MACRA Final Rule: What it means for episodes

CMS has released the final rule of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which will significantly change the way Medicare pays physicians under the Quality Payment Program. The new rule reflects CMS’s attempts to transition from fee-for-service to value-based payments. It is great news for physicians under CMS value-based care programs (e.g. CJR, BPCI), as they stand to earn additional bonuses from this program.

Physicians can participate in one of two payment tracks: Merit-based Incentive Payment System (MIPS), or Advanced Alternative Payment Models (APMs). Physicians who primarily use traditional Medicare Part B (fee-for-service) will participate in MIPS, where they will get a performance-based adjustment to their Medicare payment. Physicians who are participating in APMs, such as bundled payments programs or ACOs, may be covered by MIPS or may qualify for the Advanced APMs. CMS has indicated that physicians who already take risk linked to patient outcomes will qualify for Advanced APMs, suggesting that physicians under bundles are likely to be part of the models. Physicians under APMs that do not qualify for Advanced APMs will be part of MIPS APMs and be subject to MIPS reporting requirements and the MIPS payment adjustment. In either case, physicians who are participating in APMs will be scored using the APM scoring standard instead of the generally applicable MIPS scoring standard. The rule will take effect on Jan. 1, 2017 and the first physician payment will be made on Jan. 1, 2019. 

[1] On the MIPS track, physicians can earn plus or minus 4% of reimbursement in 2019. The adjustment potential grows to 9% in 2022.

[1] On the MIPS track, physicians can earn plus or minus 4% of reimbursement in 2019. The adjustment potential grows to 9% in 2022.

Initially, most physicians will start with MIPS. However, with the goal of shifting towards a value-based payment model, CMS wants more physicians to be under Advanced APMs and therefore lowered the barriers and increased incentives in the following ways:

1)      Simplified requirements To be considered as an Advanced APM, an APM must meet all three of the following criteria:

a.       Base payment on quality measures comparable to those in MIPS

b.       Require use of certified EHR technology

c.       Either (i) bear more than nominal financial risk for monetary losses OR (ii) be a Medical Home Model

2)      Reporting exemption Physicians who are under Advanced APMs, referred to as Qualifying APM Participants (QPs), are exempt from MIPS reporting requirements

3)      More bonuses Under Advanced APMs, physicians may earn incentive payments of approximately 5% for 5 years in a “lump-sum payment” every year from 2019 to 2014. And there is no penalty.

Clarify Health provides the episode analytics and workflow optimization platform to help you better understand your own performance and maximize your bonuses. For physicians under Advanced APMs, we can help track and report performance. Contact us for more information.

Check out the full final rule for the MACRA: https://qpp.cms.gov/docs/CMS-5517-FC.pdf