The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rule was finalized on October 14, 2016 replacing the Sustainable Growth Rate by the new Quality Payment Program (Medicare Payment Reform).
Full rule and an executive summary can be found at the new CMS page: The Quality Payment Program page at www.qpp.cms.gov/education.
The Quality Payment Program has two paths: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs)
MIPS INCLUDES FOUR CATEGORIES:
- Quality (formerly PQRS): 60% of total score in year 1
- Advancing Care Information (formerly EHR Meaningful Use): 25% of total score in year 1
- Improvement Activities (new category): 15% of total score in year 1
- Resource Use (based on claims data): 0 % of total score in year 1, counted starts in 2018, no data submission required.
Learn more about MIPS categories criteria.
Who will participate in MIPS (Eligible Clinician or EC)?
For year 1 and 2 (performance year 2017 and 2018 / payment adjustment year 2019 and 2020)
- Physicians (MD, DO, DDS)
- Physician Assistant (PA) -> do not report to Advanced Care Information/MU
- Nurse Practitioner (NP) -> do not report to Advanced Care Information/MU
- Certified Nurse Specialist (CNS)
- Certified Registered Nurse Anesthetics (CNRA)
For year 3+ onward (performance 2019 onward / payment adjustment year 2021 onward)
All of the above PLUS:
- Physical and Occupational Therapist
- Speech language Pathologist and audiologist
- Nurse Midwife
- Clinical social Worker and Clinical Psychologist
- Dietitian and Nutritionist
Who will NOT participate in MIPS?
- Providers billing Medicare Part B for the first time or first year participation
- Providers below low patient volume threshold = bill less than $30,000 to Medicare, and provide care to less than 100 Medicare patients per year
- Qualified Professionals (QPs) participating in an Advanced APM
- Hospital and Facilities
ALTERNATIVE PAYMENT MODELS (APM)
APMs must meet the following requirements:
- Use of a certified EHR technology or CEHRT (at least 50% of the clinicians participating in an AMP entity)
- Receive payment based on quality measure (at least 1 measure, and at least 1 outcome measure)
- Bear “more than nominal financial risk” in other words involve the assumption of financial risk of 4% of expected expenditures meaning that the losses must be at least 30% of excess over expected expenditures (marginal risk) or be a Medical Home Model expanded.
All Advanced APMs will be exempt from MIPS reporting requirements and qualify for the 5% bonus payment to those fulfilling all qualifications. In other words, If you receive 25% of Medicare covered professional services or see 20% of your Medicare patients through an Advanced APM in 2017, then you earn a 5% Medicare incentive payment in 2019.
These models are considered Advanced APMs:
• Comprehensive Primary Care Plus (CPC+)
• Comprehensive ESRD (End-Stage Renal Disease) Care Model - Medical Home Model
• Next Generation ACO
• Medicare Shared Savings Program Track 2 and 3 (MSSP)
• Oncology Care Model (OCM)
For 2018 CMS anticipates adding the following Advanced APMs:
• Advancing Cardiac Care Coordination Episode Payment Models (Cardiac and Joint Care/Orthopedic Model)
• ACO Investment Model (AIM)
• New Voluntary Bundled Payment Model
CMS Comprehensive List of APMs
Get started and learn more about the Quality Payment Program and review the educational resources including Fact Sheets, downloads and webinars at https://qpp.cms.gov/resources/education.