A guide for healthcare information professionals about new reimbursement options based on quality of care.
HHS and CMS released the long-awaited, finalized MACRA rule on October 14, 2016. MACRA, or the Medicare Access and CHIP Reauthorization Act of 2015, replaces the prior Sustainable Growth Rate (SGR) payment formula with a new, quality-focused payment system for managing physician reimbursement. The updated system, known as the Quality Payment Program, offers two tracks for providers to choose from, the Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS).
The full text of the new rule, which is over 2,200 pages long, is available in PDF format here. HHS will accept comments for 60 days after the final rule’s release date.
Read on for key provisions of the new rule and a resource list with further information.
The new MACRA rule contains several key pieces of information and introduces some important new guidelines. Here are 5 key takeaways for information professionals seeking to understand the final rule and its impact on Medicare reimbursement in the US.
- Reimbursement is based on quality of care, managed via two payment tracks. Physicians under the new program will be paid according to the quality of care they deliver. The two payment tracks allow reimbursement for providers in different scenarios, as Healthcare Informatics explains: “The MIPS path is designed for providers in traditional, fee-for-service Medicare, and who can thus ease their way in. The advanced APM track is designed for providers who are participating in specific value-based care models already.” Additional payment tracks and models are being planned for the future to further broaden opportunities for clinicians.
- The new rule expands exemptions and flexibility. Nearly a third of physicians could be exempt under the merit-based incentive payment system (MIPS), which raises the low-volume threshold so that providers with less than $30,000 in Medicare payments or fewer than 100 Medicare patients are released from reporting requirements. The rule also comes with broader opportunities for physicians to enjoy bigger rate increases and bonuses.
- The final rule changes the definition of financial risk. As Health Data Management explains, the final rule makes financial risk “more two-sided—with Medicare and physicians assuming risk, and not everything falling on the physicians.” This approach to risk makes it more feasible for ACOs (Accountable Care Organizations) to participate in the program, and also imposes less financial risk on physicians than the proposed rule issued earlier this year.
- CMS addresses provider concerns and comments about the program. In a blog post issued alongside the new MACRA rule last week, CMS expressed support for Medicare clinicians and emphasized plans to focus “on allowing clinicians to transition at their own pace, continuing to get feedback from the field, providing meaningful support, and improving the program over time.” Additionally, CMS identified its priorities in designing the new quality-based program, which it calls “the first step in a multi-year journey.” These priorities include: focus on the patient; start out gradually; more pathways to participate in Advanced Alternative Payment Models (APMs); adapt for small and rural practices; simplified reporting and scorekeeping in MIPS.
- Transitions are built into the program. The new MACRA rule is designed to treat 2017 as a transition year to give clinicians time to ramp up to the new payment models. This means that 2018 payments will not be affected by 2017’s performance. Further, the CMS blog post explains that, aside from a 0.5% fee schedule update in 2017 and 2018, “there are very few changes when the program first begins in 2017. … The first couple of years are aimed at getting physicians gradually more experienced with the program and vendors more capable of supporting physicians.”
Resources & Further Reading
The following resources provide additional information about the new MACRA rule and its implementation.
The American Medical Association’s Medicare Payment Reform page offers a number of MACRA resources, including information about payments and penalties, preparation guidelines, and AMA’s reform efforts.
MedPageToday details the history of the new MACRA rule, CMS’s plans for its rollout, and the ins and outs of the two payment tracks.
Health Data Management explains the importance of health IT, including electronic health information, to MACRA. PatientEngagementHIT considers the potential impact on patient engagement and care coordination.
Advisory offers a MACRA Q&A addressing payment tracks, timelines, qualifications and more.
EHR Intelligence provides a summary of the rule and a rundown of statements and responses by various industry groups.
The newly-released MACRA rule introduces new reimbursement options based on quality of care, expands exemption and bonus opportunities for participating physicians, redefines financial risk, and offers a gradual transition for new and existing providers. The new system’s two payment tracks are intended to maximize flexibility, and CMS plans additional changes and opportunities to further expand participation in the future.
Although Medicare reimbursements are complex and any large-scale change in physician reporting and payments is bound to come with some growing pains, the new MACRA guidelines are intended to remedy unpopular aspects of previous reimbursement programs, while also allowing for flexibility, growth and clinician input.
For healthcare information professionals, life science intelligence professionals, patients, clinicians and other stakeholders throughout the healthcare industry, a sea change in Medicare is worthy of attention and consideration, as each piece of the increasingly complex healthcare puzzle influences the dynamic whole.
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