The Nitty-Gritty of MACRA 2017


Info Services, Inc. Compliance Services

MACRA (Medicare Access and CHIP Reauthorization Act of 2015) basically repealed the SGR formula for determining Medicare Fee for Service payments. This act also included a replacement where Congress directed CMS to implement the Medicare Incentive Payment System (MIPS) as a new physician payment system that incentivizes quality and efficiency rather than volume. MIPS rolls the existing PQRS, Value Based Modifier and Meaningful Use into one program. The previous programs were merely baby steps to implement MACRA.

If you are a Medicare provider who is not newly enrolled and bills Medicare charges of $30,000 or more on behalf of 100 or more Medicare Part B beneficiaries per year, you are covered under MACRA and will receive either a positive or negative adjustment based on your performance under MACRA. The inclusion in MACRA is a phase-in process. For years 1-2 it covers these providers: MD, DO, DMD, DDS, PA, NP, CNS and CRNA. Years 3 and forward add PT, OT, SP, LCSW and others.

There are two paths to participation in MACRA. The Gold-standard with the greatest benefit is for the provider to participate in an Alternative Payment Model (APM). Those qualifying receive a 5% APM incentive payment in 2019 for 2017 participation. Those not qualifying for an APM must participate in MIPS receiving a positive or negative adjustment based on your score in different areas of focus. There is no official “election” where you sign up to do one or the other- the provider just reports the appropriate measures by March 31, 2018. The significance of the recordkeeping will require providers to know before January 2017 what your plan of action will be. The result of participation in 2017 will affect 2019 either positively or negatively. The budget neutral adjustments range from +/- 4% in 2019 to +/_ 9% in 2022.

If an APM is the Gold-Standard- How Does a Provider Participate?

An Alternative Payment Model is a payment approach, developed in partnership with the clinician community, that provides added incentives to clinicians to provide high-quality and cost-efficient care. Advanced APMs are a subset of APMs and let practices earn more for taking on some risk related to patients’ outcomes. Advanced APMs must meet the following requirements:

  • Be CMS Innovation Center models, Shared Savings Program tracks, or certain federal demonstration programs

  • Require participants to use certified EHR technology

  • Base payments for services on quality measures comparable to those in MIPS

  • Be a Medical Home Model expanded under Innovation Center authority or require participants to bear more than nominal financial risk for losses.

To qualify for the 5% APM incentive payment, the provider must receive a certain percentage of payments for covered professional services or see a certain percentage of patients through the Advanced APM during the associated performance year.

For 2017 the Advanced APMs are:

  • Comprehensive End Stage Renal Disease Care Model (Large Dialysis Organization arrangement)

  • Comprehensive End Stage Renal Disease Care Model (non- Large Dialysis Organization arrangement)

  • Comprehensive Primary Care Initiative (CPC+)- Currently only available in Arkansas, Colorado, New Jersey, New York (Capital District-Hudson Valley Region), Ohio and Kentucky (Cincinnati-Dayton Region), Oklahoma (Greater Tulsa Region) and Oregon.

  • Medicare Shared Savings Program Accountable Care Organization – Track 2

  • Medicare Shared Savings Program Accountable Care Organization – Track 3

  • Next Generation Accountable Care Organization

  • Oncology Care Model (OCM): two-sided risk arrangement

For 2018 the Advanced APMs anticipated additions are:

  • Accountable Care Organization Track 1 +

  • New Voluntary Bundled Payment Model

  • Comprehensive Care for Joint Replacement Payment Model (CEHRT)

  • Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT)

  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer Accountable Care Organization

Ok, So I Don’t Qualify for an APM- Now What?

If a provider cannot participate or decides not to participate in an official Alternative Payment Model and wishes to avoid a payment penalty or possibly receive a positive adjustment, he or she must participate in MIPS. There is some flexibility in reporting MIPS for the 2017 data but only for 2017.

Info Services, Inc. MACRA 2017 Scenarios

MIPS measures are a combination of PQRS (Physician Quality Reporting System), the Value-Based Payment Modifier and Medicare Meaningful Use. Providers who participated in these programs in the past or currently have an advantage in MIPS because the requirements should be familiar.

4 MIPS Categories Used to Score Providers for 2017:

Category 1: Quality (Replaces PQRS)

2017 Score Weight: 60%

What is Required: Report up to 6 quality measures including an “Outcome” measure

Look up Measures: HERE