CMS Changes for 2017: MACRA and APMs

In the last Vetters Enterprises blog, we discussed the Centers for Medicare & Medicaid Services (CMS) changes for 2017 regarding the model by which physicians are reimbursed for care. The Medicare Access & CHIP Reauthorization Act (MACRA) was implemented to streamline reporting of quality care and emphasize consequence for those performing poorly. The main goal is simple – make patients healthier by rewarding high quality care. The Quality Payment Program (QPP) under MACRA that we discussed in our last blog consists of two tracks physicians can choose from: MIPs and APMs. Let’s break down APMs.

Quality Payment Program: What are APMs?

CMS defines Advanced Alternative Payment Models (APMs) as new approaches to paying for medical care through Medicare that incentivize quality and value. The QPP offers additional incentives for Qualifying Professionals (QPs) who participate in APMs. MACRA states that APMs include: CMS Innovation Center model, Medicare Shared Savings Program (MSSP), Demonstration under the Health Care Quality Demonstration Program, and Demonstration required by federal law.

How Do You Qualify for APMs?

Most physicians will be subject to the MIPS track based on eligibility requirements. The following three groups will be excluded from the MIPS track: first year of Medicare Part B participation, certain participants in advanced alternative payment models, and those below the low patient volume threshold – meaning those who provide care for 100 or fewer Medicare patients and whose Medicare billing charges are less than or equal to 10k annually. To qualify as an Advanced APM and be excluded from MIPS, the following criteria (as defined by MACRA) must be met:

  • The APM requires at least 50% of the participants are required to use certified EHR technology; after year one, this threshold increases to 75%
  • The APM payments are based on quality measures comparable to those in the MIPS Quality of Care performance category
  • The APM entities bear more than nominal financial risk for monetary losses OR the APM is a Medical Home Model expanded under CMMI authority

Qualifying APM participants are eligible for a 5% lump sum bonus each year from 2019-2024 if the APM revenue is met, as well as annual updates of .75% after 2026. In layman’s terms, the MIPS track consists of fixed funds, regulations, restrictions, and penalties; whereas the AMP track consists of a significant share of provider revenue, two-sided financial risk, financial incentives, and exemption from MIPS. Want more useful information? Visit our blog again!

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CMS Changes for 2017: MACRA and MIPS

The Centers for Medicare & Medicaid Services (CMS) changes for 2017 are centered on changing the way physicians are reimbursed for care so that they can focus on giving quality care and making patients healthier. Let’s break down MACRA and MIPS as it may relate to you.

What is MACRA?

In April 2016, CMS published a proposed regulation to implement MACRA, the Medicare Access & CHIP Reauthorization Act. MACRA replaces the contentious Sustainable Growth Rate (SGR) model and provides new tools, models, and resources to help physicians give their patients the best possible care. MACRA created the Quality Payment Program (QPP), the framework through which physicians are paid for the value of the care they provide as opposed to being paid for the quantity of care they provide on a fee-for-service payment model. The QPP consists of two tracks physicians can choose from based on practice size, specialty, location, or patient population: MIPS and APMs.

What is MIPS?

MIPS, the Merit-based Incentive Payment System, is a single incentive program that consolidates three current pay-for-performance programs within in: the Physician Quality Reporting System (PQRS), Value Based Payment, and the Medicare EHR incentive program for eligible professionals (aka Meaningful Use). MIPS will go into effect in 2018 and begin adjusting payments in 2019. Physicians will be ranked on quality and cost of care vs. their peers based on four performance categories that will make up a composite performance score (CPS) of a potential 100 points. The categories and how they weigh into the score are as follows:

  • Quality of Care – 50%
  • Resource Use/Cost – 10%
  • Clinical Practice Improvement Activities – 15%
  • Advancing Care Information – 25%

Physicians may submit their individual score or a score for their entire group practice, which will be published by CMS on Physician Compare. After a year’s worth of data in 2017 is reported to CMS, a national threshold will be calculated to determine an appropriate pay adjustment for those physicians performing above/below average. For every physician that earns more through MIPS, there will be one who earns less – rewarding quality over quantity. Those performing poorly may see their payments cut by up to 9%, whereas those performing well may receive an adjustment up to 4% in 2019, increasing to 9% by 2023. Please note that note that MIPS does not apply to hospitals, meaning the EHR incentive program for hospitals will continue.

In the next Vetters Enterprises blog we will discuss Advanced Alternative Payment Models, or APMs.