Providers are urged to prepare quickly to meet the new Medicare reimbursement requirements mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
“The first measurement year starts Jan. 1, 2017, so providers need to prepare quickly,” emphasizes William F. Harvey, MD, MSc, Government Affairs Committee chair, American College of Rheumatology (ACR).
2 Payment Pathways
Under MACRA, physicians are required to choose between one of two Medicare reimbursement payment pathways. This is due to the effort made by Medicare to move toward a value-based healthcare system that focuses on delivering high-quality, affordable care.
Physicians can choose either a Merit-Based Incentive Payment System (MIPS) or an Alternative Payment Model (APM).
MIPS is a new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-Based Payment Modifier) and the Medicare electronic health record (EHR) incentive program into a single program in which eligible professionals (EPs) will be measured on:
- Quality;
- Resource use;
- Clinical practice improvement; and
- Meaningful use of certified EHR technology.
The APMs pathway incentivizes providers on quality, outcomes and cost containment. Examples of APMs include accountable care organizations (ACOs), bundled payment models and medical homes.
“This is not optional,” says Dr. Harvey. Providers who fail to choose a reimbursement pathway will default to MIPS.
A 2-Year Lag
Although the official start date for MACRA is not until 2019, the first performance period for elements of MIPS begins Jan. 1, 2017.
According to the ACR website, it’s important for members to understand that some of the assessments about MIPS made at the effective date of 2019 will be based on the 2017 submitted data.1 In other words, the performance measures submitted in 2017 will be used to determine whether or not a penalty or bonus will be granted in 2019. In 2020, penalties will be based on performance in 2018, and so on. “There is a two-year lag between the performance and the payment adjustment,” says Dr. Harvey.
The MACRA Roadshow
To help educate providers about MACRA, the ACR has developed a slide presentation that members are presenting to rheumatologists around the country at state and local meetings. Called the MACRA “roadshow,” it contains information to help providers select a type of reimbursement structure and discusses important timelines for implementation.
More on MIPS
Clarifying that MIPS is a single program that combines older programs, Dr. Harvey says providers can review their Quality and Resource Use Report (QRUR) for a “good clue as to how they will fare in MIPS.”
Rheumatologists who choose MIPS should also join the ACR’s Rheumatology Informatics System for Effectiveness (RISE) Registry, which will meet the MIPS Qualified Clinical Data Registry requirement.
More on APMs
Providers who choose APMs as their reimbursement pathway will be exempt from MIPS if they receive significant revenue from qualifying APMs. As an incentive to choosing this reimbursement pathway, they will receive a 5% bonus in 2019–2024. Currently, all APMs are payer designated and are accountable for total spending, with no fundamental change in how much and for what physicians are paid (i.e., shared savings plus fee-for-service).
The ACR is interested in creating a physician-focused APM, which includes identifying areas for reduced cost or better care, identifying barriers in the current model (e.g., no payment-for-care coordination) and designing the APM to remove barriers and make provisions to ensure quality and/or reduce cost.
Mary Beth Nierengarten is a freelance medical journalist based in Minneapolis.
Resource
- American College of Rheumatology. http://www.rheumatology.org/MACRA.
