After reviewing more than 4,000 comments, the Centers for Medicare & Medicaid Services released the final rule Oct. 14 for the Medicare Access and CHIP Reauthorization Act, the Medicare payment system that replaces the sustainable growth rate formula for physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists.

“It’s time to modernize the Medicare physician payment system to be more streamlined and effective at supporting high-quality patient care. To be successful, we must put patients and clinicians at the center of the Quality Payment Program,” said Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services. “A critical feature of the program will be implementing these changes at a pace and with options that clinicians choose. Today’s policies are designed to get all eligible clinicians to participate in the program, so they are set up for successful care delivery as the program matures.”

NN&I’s Roundtable on MACRA is available for replay

Adam Weinstein, MD, and Diana Strubler, Policy and Standards Senior Manager at Acumen Physician Solutions will help you understand how to navigate this complex payment system.

The agency is calling 2017 a transition year, and is allowing clinicians to begin collecting performance data any time between Jan. 1, 2017 and Oct. 2, 2017. Performance data must be submitted to CMS by March 31, 2018, regardless of start time. The first payment adjustments based on performance go into effect on Jan. 1, 2019.

“We envision that it will take a few years to reach a steady state in the program, and we therefore anticipate a ramp-up process and gradual transition with less financial risk for clinicians in at least the first 2 years,” CMS wrote in the executive summary of the rule.

There are two ways to participate in the program: the Merit-Based Incentive Payment System (MIPS) is for clinicians who participate in fee-for-service Medicare, and the Advanced Alternative Payment Model (APM) is for clinicians who are participating in value-based care models, like the Comprehensive ESRD Care model.

MIPS reporting options in 2017

MIPS will make payment adjustments based on performance on a composite score in four categories­— Quality, Advancing Care Information, Clinical Practice Improvement Activities, and Cost or Resource Use.

In response to comments, CMS will not weigh the cost performance category in 2017.

The program consolidates components of three existing programs—the Physician Quality Reporting System, the Physician Value-based Payment Modifier, and the Medicare Electronic Health Record Incentive Program (Meaningful Use).

Clinicians who participate in MIPS will have three reporting options in 2017. The first option provides the highest chance to qualify for a positive adjustment, the second one allows the possibility of a positive adjustment, and the third simply allows the clinician to avoid a negative adjustment.

  • Option 1: Clinicians can choose to report on all measures for a full 90-day period or the full year, and maximize chances to qualify for a positive adjustment.
  • Option 2: Clinicians can choose to report to MIPS for a period of time less than the full year performance period 2017 but for a full 90-day period at a minimum. They must report more than one quality measure, more than one improvement activity, or more than of the required measures in the advancing care information performance category in order to avoid a negative payment adjustment and to possibly receive a positive payment adjustment.
  • Option 3: Clinicians can choose to report one measure in the quality performance category; one activity in the improvement activities performance category, or report the required measures of the advancing care information performance category and avoid a negative payment adjustment

If MIPS eligible clinicians choose to not report even one measure or activity, they will receive the full negative 4% adjustment.

Small practices

Small practices can be excluded from the 2017 requirements if they have less than $30,000 in Medicare Part B charges or do not treat more than 100 Medicare patients. This exclusion represents 32.5% of clinicians (380,000), but accounts for only 5% of Medicare spending, CMS said.

The agency said it will also provide the option for solo and small practices to join “virtual groups” and combine their MIPS reporting, but this option is not available in 2017. CMS said they expect to have more small practice participation after the transition year.

Quality measures

CMS said quality measures will be selected annually through a call for quality measures process, and a final list of quality measures will be published in the Federal Register by November 1 of each year.

Advance Alternative Payment Models

Clinicians that participate in the advanced APM can earn a 5% incentive payment starting in 2019 and avoid participating in MIPS. APMs must meet three requirements: (1) participants must use certified EHR technology, (2) participants must base payments on quality measures comparable to those in the quality performance category under MIPS, (3) and participating entities must bear risk for monetary losses or be a Medical Home Model.

Participants must also be part of one of the approved models, which currently include the following:

  • Comprehensive ESRD Care
  • Comprehensive Primary Care Plus
  • Next Generation ACO Model
  • Shared Savings Program Tracks 2 and 3

CMS estimated that 30,000 to 90,000 clinicians would qualify for the Advanced APM in 2017.