CMS Issues MACRA Proposed Rule on Quality Payment Program for Physicians and Other Clinicians

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On April 27, 2016, CMS issued a Proposed Rule that would implement certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”) to modify the payment system for physicians and other clinicians.  Under the Proposed Rule, CMS would establish a two-track “Quality Payment Program” where clinicians could elect to participate in either the Merit-Based Incentive Payment System (“MIPS”) or Advanced Alternative Payment Models (“Advanced APMs”).

According to an HHS press release on the Proposed Rule, the agency was “guided by the same principles underlying [MACRA]: streamlining and strengthening quality-based payments for all physicians; rewarding participation in Advanced Alternative Payment Models that create the strongest incentives for high-quality, efficient and coordinated care; and giving doctors and other clinicians flexibility regarding how they participate in the new payment system.”  Comments on the Proposed Rule must be submitted by 5:00 p.m. on June 27, 2016. 

CMS anticipates that most clinicians will initially participate in the Quality Payment Program through MIPS.  MIPS would consolidate components from three existing programs – the Physician Quality Reporting System, Physician Value-Based Payment Modifier and the Medicare Electronic Health Record (“EHR”) Incentive Program for Eligible Professionals.  Under MIPS, clinicians would choose measures and activities in the following four performance categories:

  • Quality (50 percent of total score in year one): six measures chosen from a range of options that accommodate differences among specialties and practices;
  • Advancing Care Information (25 percent of total score in year one): customizable measures that reflect how clinicians use technology in their day-to-day practice, with particular emphasis on interoperability and information exchange;
  • Clinical Practice Improvement Activities (15 percent of total score in year one): selected activities from a list of 90 possible options that match the clinician’s practice goals, with a focus on rewarding clinical practice improvements (e.g., care coordination, beneficiary engagement, patient safety); and
  • Cost (10 percent of total score in year one): claims-based measure using 40 episode-specific measures to account for differences among specialties.

CMS would begin measuring clinicians’ MIPS performance in 2017, with payments based on those measures beginning in 2019.  

Clinicians participating to a sufficient extent in Advanced APMs would be exempt from MIPS reporting requirements and would qualify for a five percent Medicare Part B incentive payment.  Under the Proposed Rule, to be an Advanced APM, the model generally must require participants to bear a certain amount of financial risk; base payments on quality measures comparable to those used in the MIPS quality performance category; and require participants to use certified EHR technology.  According to CMS, models that would qualify as Advanced APMs include Tracks 2 and 3 of the Medicare Shared Savings Program, Next Generation ACO Model and Comprehensive Primary Care Plus model.  The Proposed Rule requires CMS to post the list of qualifying Advanced APMs on its website no later than January 1, 2017, and to update that list no less than annually.  Beginning in 2019, clinicians could qualify for incentive payments based in part on participation in Advanced APMs developed by non-Medicare payors (e.g., private insurance, state Medicaid programs).

The Proposed Rule is scheduled to be published in the Federal Register on May 9, 2016.  For a public inspection copy of the Proposed Rule, please click here.  For the HHS press release, please click here.  For more information on the Proposed Rule, including a fact sheet, please click here.  

Reporter, Kerrie S. Howze, Atlanta, +1 404 572 3594, khowze@kslaw.com.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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