Medicare Access and CHIP Reauthorization Act of 2015:

  The Future of Medicare Reimbursement -  
The Merit-Based Incentive Payment System 

 

By: R. Bruce Crelin, Esq.

 
When the Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”) goes into effect, most participating physicians will fall under the Merit-Based Incentive Payment System (“MIPS”).  MIPS was originally scheduled to go into effect on January 1, 2019, but its first “performance period” was to begin on January 1, 2017, as assessments in 2019 were to be based upon a two-year “look back” period; thus, payment adjustments in 2019 were to be based upon the performance factors as applied beginning in 2017.  However, on July 13, Andy Slavitt, the Acting Administrator of the CMS, testified before the Senate Finance Committee that implementation may have to be delayed, due to fears of an adverse impact upon small and rural practices, so it now appears these timelines will be modified.  There are three exceptions from participation in MIPS: 1) a physician who is participating in Medicare for the first time is exempt from MIPS for the first year of participation; 2) a physician who sees a small number of Medicare patients and falls below the volume threshold established for participation; and 3) a physician who participates in an eligible Alternative Payment Model (“APM”) and qualifies for incentive payments through that program (the APM exception will be discussed in a later article in this series).

MIPS 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.  Provider performance will be analyzed under four factors: 1) 50% of the score is based upon “Quality” (replacing the Physician Quality Reporting System (“PQRS”) and Value-based Payment Modifier (“VM”)); 2) 25% on “Advancing Care Information” (replacing EHR Meaningful Use); 3) 15% on “Clinical Practice Improvement” (“CPIA”); and 4) 10% on “Resource Utilization.”  The percentages for Advancing Care Information and Clinical Practice Improvement are to stay the same for 2019, 2020 and 2021, while Quality goes down to 45% in 2020 and 30% in 2021, while Resource Utilization goes to 15% and 30%, respectively, for those years.  Based upon a composite performance score in each of these four categories, physicians will receive either a positive, or a negative, adjustment in compensation.

According to the proposed regulations, these four factors will be assessed as follows, with different reporting mechanisms depending upon whether the eligible clinician is an individual or a member of a group practice:
  • Quality: For most MIPS eligible clinicians, CMS proposes to include a minimum of six measures with at least one cross-cutting measure (for patient-facing MIPS eligible clinicians) and an outcome measure if available; if an outcome measure is not available, then the eligible clinician would report one other high priority measure (appropriate use, patient safety, efficiency, patient experience, and care coordination measures) in lieu of an outcome measure.  MIPS eligible clinicians can meet this criterion by selecting measures either individually or from a specialty-specific measure set.  For individual practitioners, the reporting mechanisms are to be claims, Qualified Clinical Data Registries (“QCDRs”), qualified registry, Electronic Health Records (“EHR”) and administrative claims (which need not be submitted).  For group practices, it will be QCDRs, qualified registry, EHR, CMS Web Interface (for groups of 25 or more), CMS-approved survey vendor for Consumer Assessment of Healthcare Providers and Systems (“CAHPS;” reported in conjunction with another data submission mechanism) and administrative claims (which need not be submitted).
  • Resource Use: Continuation of two measures from the VM: total per capita costs for all attributed beneficiaries and Medicare Spending per Beneficiaries (MSPB) with minor technical adjustments.  In addition, episode-based measures, as applicable to the MIPS eligible clinician.  For both individual providers and group practices, the reporting mechanisms are to be administrative claims (which need not be submitted).
  • CPIA: CMS generally encourages, but is not requiring, a minimum number of CPIAs.  For individual practitioners, the reporting mechanisms are to be attestation, QCDR, qualified registry and administrative claims (if technically feasible, no submission required).  For group practices, it will be attestation, QCDR, qualified registry, EHR, CMS web interface (for groups of 25 or more) and administrative claims (if technically feasible, no submission required).
  • Advancing Care Information: Assessment based on advancing care information measures and objectives.  For individual practitioners, the reporting mechanisms are to be attestation, QCDR, qualified registry and EHR.  For group practices, it will be attestation, QCDR, qualified registry, EHR, CMS web interface (for groups of 25 or more) and administrative claims (if technically feasible, no submission required).

    The program is intended to be “budget neutral,” so there will be equal numbers of negative and positive adjustments. Both negative and positive adjustments are capped at 4% in 2019, 5% in 2020, 7% in 2021 and 9% in 2022 and beyond, while positive adjustments must be paid out in an amount equal to the total negative payment adjustments among all providers.  Unfortunately, according to CMS’ own estimates, these negative adjustments are likely to disproportionately affect solo practitioners and those in smaller practices, with 86% of solo practices, 69.9% of practices of 2 – 9 eligible clinicians, 59.4% of practices of 10 – 24 clinicians, and 44.9% of practices of 25 – 99 clinicians likely to be penalized, with only 18.3% of practices of 100 or more eligible clinicians likely to be penalized in 2019.

Physicians scoring in the lowest quartile will automatically be adjusted down to the maximum penalty for the performance year.  Physicians scoring at the threshold will receive no adjustment.  Physicians scoring in the highest quartile are eligible for a potential positive payment adjustments up to the maximum outlined above.  The highest performers will receive proportionally larger incentive payments, up to three times the maximum positive adjustment for the year.  For years 2019-2024, the law establishes a $500 million bonus pool designed to provide additional incentives of up to 10 percent for “exceptional performers;” however, the law does not provide a definition of “exceptional performer.”

 
 
Kern Augustine, P.C., Attorneys to Health Professionals, DrLaw.com, is solely devoted to the representation and defense of physicians and other health care professionals. R. Bruce Crelin may be contacted at 1-800-445-0954 or via email at BCrelin@DrLaw.com.