The Centers for Medicare and Medicaid Services (CMS) April 27 released the proposed rule on the Medicare Access CHIP Reauthorization Act (MACRA) payment system for physicians, which will be effective beginning Jan. 1, 2019. The new system is also referred to as the Quality Payment Program (QPP) and involves two payment options: the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs). CMS has previously estimated that 90 percent of physicians will participate in MIPS in the first year of the QPP.
Under MIPS, physicians’ performance will be assessed under four domains: Quality; Advancing Care Information (ACI), which replaces the current meaningful use program for Eligible Professionals; Clinical Practice Improvement Activities (CPIA); and Cost. These domains will replace the Physician Quality Reporting System, Value-Based Payment Modifier, and Electronic Health Records Meaningful Use Incentive Program. Clinicians will continue having the option to report data as an individual or as a group.
For the first year of MIPS, the requirements of the four domains are as follows:
- Quality: 50 percent of total score, six measures required;
- ACI: 25 percent of total score, 11 customizable measures required;
- CPIA: 15 percent of total score, physicians will choose among 90 different options for this category; and
- Cost: 10 percent of total score, 40 episode-specific claims measures included
CMS acknowledges these domains will not be applicable and available to every type of clinician reporting under MIPS. CMS proposes additional ways to re-weight the MIPS performance categories to specifically accommodate non-patient facing providers and other clinicians.
Under MIPS, clinicians will be assessed on their performance in 2017 with payments starting in 2019. A total of four percent of a clinician’s Medicare payments is at risk in 2019, gradually increasing to 9 percent in 2022. The highest performers will have the opportunity to achieve additional payments.
Clinicians who qualify for the APM track will receive a five percent bonus and do not need to meet the requirements of MIPS. Under the QPP, CMS proposes two types of APMs: Advanced APMs and Other Payer Advanced APMs, which will include commercial APMs. Initially, the payment system will be focused on physicians’ services in fee-for-service (FFS) and the All-Payer-Combination option will be available beginning calendar year (CY) 2021.
Examples of advanced APMs include the Comprehensive Primary Care Plus (CPC+) model, the Next Generation ACO model, and the Comprehensive ESRD Care model. The Bundled Payment for Care Improvement (BPCI) models and Track 1 of the Medicare Shared Savings Program would not count as APMs under the proposed rule.
CMS also outlined three standards to determine whether clinicians are undertaking nominal financial risk, a key requirement to determine eligibility for APMs. CMS proposes to notify the public of which APMs will be Advanced APMs prior to each performance period, starting no later than Jan. 1, 2017.
The proposed rule also includes proposed criteria for use by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) in making recommendations on physician-focused payment models (PFPMs). The PFPM’s criteria will be established into three categories including: payment incentives, care delivery, and information availability.
Comments on the proposed rule are due June 27. The AAMC will be hosting a webinar on the proposed rule and will be submitting comments.