HealthLaw_stethoscope2The Trump administration is considering releasing a rule to ease the burden that small practices are facing in trying to comply with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), according to a recent report in The Hill.

By way of background, MACRA consolidates a number of existing reporting programs into a two-track system under which eligible clinicians will receive incentive reimbursement payments through either the Merit-Based Incentive Payment Systems (MIPS) or through certain alternative payment models (APMs). Under MIPS, eligible clinicians can receive incentive payment (or penalties) based on their reporting of various measures. (For a detailed discussion of MACRA and these reporting requirements, see our prior post.) Alternatively, clinicians can be reimbursed under the second track if they participate in an “Advanced APM,” which include certain accountable care organizations (ACOs) and patient-centered medical homes. Continue Reading Insiders Say New MACRA Rule Likely as Providers Look to Sec. Price to Ease Burden

Last week, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services released a report analyzing CMS’ readiness to implement major parts of the Medicare Access and CHIP Reauthorization Act  of 2015 (MACRA). The report provides an inside look at the steps CMS is taking to implement MACRA’s Quality Payment Program (QPP), which is an ambitious transformation of the way in which the federal government reimbursements health care providers. The report highlights two key vulnerabilities for the MACRA transition, a process that will hopefully be smoother than the troubled roll out of HealthCare.gov.

Continue Reading OIG Report Offers Glimpse into CMS Progress Towards MACRA Implementation

On October 14, 2016, the Centers for Medicare and Medicaid Services (CMS) released the final rule for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The final rule marks the most significant reform to our health care system since the enactment of the Affordable Care Act in 2010, providing Medicare incentives to reward quality and value—not volume—through the use of alternative payment models such as accountable care organizations.  The final rule includes changes that significantly soften certain requirements from the proposed rule, with CMS emphasizing that physicians will be allowed to “pick their pace” for satisfying MACRA requirements that begin on January 1, 2017.

A MACRA Refresher

CMS issued a proposed rule in late April of this year, much of which is unchanged in the final rule.  For our previous discussion of MACRA, see our prior blog posts on: an overview of the MACRA and MIPS, Advancing Care Information, APMs, and flexible reporting requirements.

Starting in 2019, CMS will replace a number of existing reporting programs with a two track system, known as the Quality Payment Program, under which eligible clinicians will receive incentive reimbursement payments through either:

  1. The Merit-Based Incentive Payment Systems (MIPS); or
  2. Alternative payment models (APMs).

MIPS consolidates three existing Medicare programs: (1) the Physician Quality Reporting System, (2) the Physician Value-based Payment Modifier, and the (3) Medicare Electronic Health Record (EHR) Incentive Program. Under MIPS, eligible clinicians can receive incentive payment (or penalty) based on four categories of measures: quality, cost, improvement activities, and the use of EHRs. (These categories are discussed in greater detail below.) CMS will take the results and create a composite score that it will then use to increase or decrease the clinician’s reimbursement under the Medicare Physician Fee Schedule (PFS). These adjustments will begin on January 1, 2019, and will be based on data collected in 2017.  Clinicians scoring below a certain threshold will incur a negative adjustment in their payments starting with a maximum penalty of 4% in 2019 and increasing to a maximum penalty of 9% in 2022 and beyond. Those scoring above the threshold can receive up to a 4% increase in 2019, with a maximum increase of 9% in 2022. High achievers will be eligible for an additional upward adjustment.

The second track is for clinicians participating in an “Advanced APM,” including certain accountable care organizations (ACOs) and patient-centered medical homes. Advanced APMs essentially operate as more generous incentive programs that are exempt from the MIPS requirements.  Those on the Advanced APM track can earn bonuses of up to 5% of their PFS payments in 2019. However, as discussed in further detail below, only ACOs accepting some amount of downside financial risk can qualify for the MIPS exemption.

Continue Reading CMS Releases MACRA Final Rule, Easing 2017 Reporting Requirements

Continuing our blog series on CMS’s massive proposed rule for the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), we dedicate this post to examining the Advance Payment Model (APM) provisions of the proposed rule.  As our colleagues discussed on May 3rd, the proposed rule contains two key initiatives: Merit-Based Incentive Payment Systems (MIPS) and Alternative Payment Models (APMs).

Continue Reading Alternative Payment Models (APMs) Under MACRA Proposed Rule

On April 27, 2016, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would put in place key parts of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA impacts a number of laws and government initiatives that have been implemented over the past two decades affecting physician reimbursement, and in doing so, will fundamentally change the way that Medicare reimburses physicians.

The MACRA Proposed Rule contains two key initiatives: Merit-Based Incentive Payment Systems (MIPS), which partially repeals the meaningful use program for electronic health records, and alternative payment models (APMs). In this first of three blogs we discuss the MACRA Proposed Rule generally and provide an overview of MIPS.

BACKGROUND AND OVERVIEW

Elimination of the Sustainable Growth Rate

One of MACRA’s most notable features is its elimination of the Sustainable Growth Rate (SGR) formula which was introduced in 1997 in an attempt to rein in the skyrocketing costs of physician services. Under the SGR, Medicare payments for physician services were supposed to be adjusted annually based in part on changes in the United States gross domestic product. Over the past several years, application of the SGR formula would have resulted in annual decreases to physician payments were it not for recurring legislative “patches” that implemented temporary delays in the application of the SGR formula.  MACRA permanently repeals the SGR formula and replaces it with modest increases in Medicare physician fees. The additional cost to Medicare resulting from the repeal of the SGR is to be offset in part by the increased reliance on APMs and on the implementation of other cost-saving measures.

The Current Physician Reimbursement System

Physician services furnished to Medicare beneficiaries are generally reimbursed on the basis of the lesser of actual charges or the amount determined under the Medicare Physician Fee Schedule. Currently and through 2018, physician reimbursement under this system depends on the physician’s participation in, and performance under, three separate programs: (1)  the Physician Quality Reporting System (PQRS), under which eligible physicians who do not satisfactorily report required quality measure data are subject to a reduction in their Medicare fees; (2) the Medicare Electronic Health Record (EHR) Incentive Program (also known as the “meaningful use” program), under which physicians who fail to achieve meaningful use of EHR systems will incur a reduction in their Medicare fees and (3) the Value-based Modifier Program, which provides incentive payments to physicians based on the quality of care they furnish compared to their cost of care during a performance period. Continue Reading CMS Releases Proposed Rule for MACRA Implementation – Overview and Merit-Based Incentive Payment Systems (MIPS)

For some health care providers, a pair of recent announcements made by the Obama Administration to implement mandatory alternative payment models (APMs) for home health value-based purchasing and bundled payments for hip and knee episodes of care will come as a shock.  For others who have participated as APM early adopters, the news may have a far lesser impact.

The Centers for Medicare and Medicaid Innovation (CMMI) will run both the home health and orthopedic bundled payment models under the Affordable Care Act Section 3021 authority.

Home Health Value-Based Purchasing

Akin to the Hospital Value-Based Purchasing Program and other VBP models, the Home Health Value-Based Purchasing (HH-VBP) model, which is scheduled to begin on January 1, 2016, will apply an annual payment reduction (or increase) to home health agencies (HHAs) of 5% initially, and up to 8% in later years, based on performance against a set of quality measures predominantly drawn from the current Outcome and Assessment Information Set (OASIS). Continue Reading Delivery System Reform 2.0: Scaling Alternative Payment Models is the New Normal