Just about everyone has a family member or neighbor who participates in Medicare, the federal health insurance program for people ages 65 and older that also covers younger people with certain disabilities. There are more than 50 million Medicare enrollees in the United States, with 200,000 living in the Austin metro area.
The Centers for Medicare and Medicaid Services (CMS) has been a national leader in driving the push from paying for volume to paying for value. Many physicians who see Medicare patients already get reimbursement adjustments through existing quality payment programs, including Electronic Health Record Meaningful Use, the Physician Quality Reporting System, and the Value-Based Payment Modifier.
Clinicians may not be familiar with upcoming Medicare reimbursement changes under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This is not a surprise — the law is complex and program details for this year were only recently published. One of the biggest changes is that MACRA eliminates the Sustainable Growth Rate (SGR) formula, which connected Medicare Part B payment (outpatient services) to changes in the gross domestic product (GDP). MACRA also establishes the Quality Payment Program, which is a new framework to reward the quality of care delivery.
Quality Payment Program
There are two tracks for the Quality Payment Program:
- The Merit-Based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models (APMs)
The implementation rules for the Quality Payment Program — about 2,400 pages worth — were finalized in October. It is imperative to prepare now, though, since the first performance period begins as early as this month (January 2017) and associated payment adjustments begin in January 2019.
Merit-Based Incentive Payment System
The Quality Payment Program only applies to Part B services (outpatient care) for Medicare fee-for-service enrollees — about 160,000 in the Austin metro area. In 2017, most clinicians will fall under the MIPS track. MIPS combines three existing quality programs (Meaningful Use, Physician Quality Reporting System and the Value-Based Payment Modifier) to create a single composite score based on quality, resource use, clinical practice improvement and electronic health record use. MIPS payment adjustments start in 2019, with the potential to gain or lose as much as 4 percent depending on 2017 performance relative to peers. There is also a requirement for scores to be made public on the Medicare Physician Compare webpage. There will be additional bonuses for high achievers, and adjustments grow to as much as 9 percent by 2022.
In response to stakeholder concerns about the aggressive timeline, the final rule provides clinicians several options for participating in MIPS in 2017. They may test MIPS reporting with no payment adjustment in 2019, or may report for part of the year or the entire year to earn incentive payments. MIPS is designed to be budget neutral for the federal government. Because CMS made it easier to avoid penalties in 2019, initial incentive payments are likely to be modest (i.e., probably no more than 1 percent for most clinicians).
Advanced Alternative Payment Models
Some clinicians will qualify for the Advanced APM track, with greater potential risks and rewards. Those practicing at certain accountable care organizations and patient-centered medical homes or under bundled payment models may be exempt from MIPS and will qualify for a 5 percent Part B incentive payment from 2019-24. The initial list of Advanced APMs is fairly narrow. CMS estimates that between 10 to 20 percent of participating clinicians nationwide will be in the Advanced APM track for the 2017 performance year. Of note, at this time there are no Medicare Advanced APMs underway in the Austin area. In the final rule, CMS indicated it plans to modify some current APMs in 2017 and 2018 to increase the number of clinicians that qualify for the Advanced APM track. Work is underway to define additional APMs, including physician-focused models, that will qualify for this alternate track in the future.
MACRA provides an incentive for collaboration among community physicians and other clinicians to improve collective performance. MIPS quality payment adjustments are a zero-sum game nationally, but local communities that come together to share data, improve care coordination and focus on better patient outcomes will have a strong advantage over those that don’t. Central Texas is well positioned to serve as a model for the nation for MACRA implementation.
MACRA’s goals of rewarding quality, cost effectiveness and APMs are aligned with the Dell Medical School’s development of new models of person-centered, multidisciplinary care that reward value, measure outcomes and improve health. In early January, the Dell Medical School, Texas Medical Association and Travis County Medical Society convened a seminar to help prepare local physician practices for the new MACRA Quality Payment Program. The event made clear that future success of MACRA implementation in Central Texas will be dependent on collaboration at the local level. The commitment to improve patient outcomes demonstrated at the event should be the inspiration and driving force to such collaboration.