On Sept. 28, the Centers for Medicare & Medicaid Services (CMS) released its long awaited Request for Information (RFI) to seek public comment related to provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA): Merit-based Incentive Payment System (MIPS), Alternative Payment Models (APMs), and physician-focused payment models (PFPMs). The RFI will be formally published in the Federal Register on October 1. Comments are due at 5 p.m. on October 30. Rulemaking activity is expected to begin next year, with 2019 being the start of the APM/MIPS payment updates.

This is a valuable opportunity for stakeholders to participate in delivery system reform by developing and submitting their ideas.

Payment Updates 1: MIPS

MACRA consolidates and expands pay-for-performance incentives within the fee-for-service system, creating the new Merit-Based Incentive Payment System (MIPS). Under MIPS, the Physician Quality Reporting System (PQRS), EHR Incentive Program, and Physician Value-Based Modifier become part of a single payment adjustment to physician payments beginning in 2019.

MACRA creates four categories of measures that are weighted to calculate an overall MIPS score:

  • Quality (50% of total adjustment in 2019 shrinking to 30% of total adjustment in 2021)
  • Resource Use (10% of total adjustment in 2019 growing to 30% of total adjustment by 2021)
  • Clinical Improvement (15% of total adjustment)
  • EHR Use (25% of total adjustment)

The range of potential payment adjustments based on performance against MIPS measures grows each year through 2022. In 2019, providers could see adjustments ranging from -4% up to +12%. By 2022, the range reaches -9% up to +27%. The program is designed to be budget neutral, so total negative adjustments across all providers will equal total positive adjustments across all providers.
Solicitation of Comments: CMS seeks comments on quality performance categories, resource use performance categories, development of performance standards and public reporting to name a few areas for comment.

Payment Update 2: APMs

MACRA allows providers participating in "Alternative Payment Models" (APMs) to opt out of MIPS. In addition, from 2019 to 2024, providers qualifying for the APM track will receive a 5% annual lump sum bonus on PFS payments. To qualify as an APM participant, providers must meet increasing thresholds for the percentage of their revenue they receive through qualifying APMs.

The MACRA also encourages expansion of the APM options available to physicians, especially specialists, through physician focused payment models (PFPMs). The law requires the establishment of a Technical Advisory Committee that will assess PFPM proposals submitted by stakeholders and make recommendations to the Secretary about which models to consider testing.

Solicitation of Comments: CMS seeks comments on quality measures, use of certified EHR technology, definition of physician-focused payment models, and model design to name a few areas for comment.

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