The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is one of the most newsworthy items grabbing healthcare headlines in recent weeks and for good reason. According the 24-page executive summary of the regulation, MACRA repeals the Medicare Sustainable Growth Rate (SGR) and replaces it with a new approach to payment called the Quality Payment Program, which rewards the delivery of high-quality patient care.

The Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) mean eligible clinicians or groups may pursue incentives for participation in certain APMs and includes the criteria for use by the Physician-Focused Payment Model Technical Advisory Committee (PTAC). Also, APMs can apply to a specific clinical condition, a care episode or a population.

The creation of MIPS will consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM) and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals, and it "will continue the focus on quality, cost and use of certified EHR technology."

CMS said it received more than 4,000 comments and had more than 100,000 physicians and other stakeholders attend its outreach sessions. Through the outreach, officials created six objectives to drive progress and improvement:

  • To improve beneficiary outcomes and engage patients through patient-centered Advanced APM and MIPS policies
  • To enhance clinician experience through flexible and transparent program design and interactions with easy-to-use program tools
  • To increase the availability and adoption of robust Advanced APMs
  • To promote program understanding and maximize participation through customized communication, education, outreach and support that meet the needs of the diversity of physician practices and patients, especially the unique needs of small practices
  • To improve data and information sharing to provide accurate, timely and actionable feedback to clinicians and other stakeholders
  • To ensure operational excellence in program implementation and ongoing development

"We believe that by setting ambitious yet achievable goals, eligible clinicians will move with greater certainty toward these new approaches of delivering care," CMS noted in its executive summary. "To these ends, and to ensure this program works for all stakeholders, we further recognize that we must provide ongoing education, support and technical assistance so that clinicians can understand program requirements, use available tools to enhance their practices, and improve quality and progress toward participation in Alternative Payment Models if that is the best choice for their practice."

This rule finalizes policies to improve physician and other clinician payments by changing the way Medicare incorporates quality measurement into payments and by developing new policies to address and incentivize participation in APMs. These unified policies to promote greater value within the healthcare system are referred to as the Quality Payment Program.

Under the final rule, 2017 will be a transition year that eligible clinicians can select from multiple attestation options. Clinicians can choose their course of participation in this year with four options:

  • Report to MIPS for a full 90-day period or, ideally, the full year, and maximize the MIPS eligible clinician's chances to qualify for a positive adjustment. In addition, MIPS eligible clinicians who are exceptional performers in MIPS, as shown by the practice information that they submit, are eligible for an additional positive adjustment for each year of the first six years of the program.
  • 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 and report more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information performance category in order to avoid a negative MIPS payment adjustment and to possibly receive a positive MIPS payment adjustment.
  • 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 MIPS payment adjustment. Alternatively, if MIPS eligible clinicians choose to not report even one measure or activity, they will receive the full negative 4 percent adjustment.
  • MIPS-eligible clinicians can participate in Advanced APMs, and if they receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM, they will qualify for a 5 percent bonus incentive payment in 2019.

According to CMS:

"For the 2017 performance period, we estimate that more than half of clinicians — approximately 738,000 to 780,000 billing under the Medicare PFS will be excluded from MIPS due to several factors, including the MACRA itself. We estimate that nearly 200,000 clinicians, or approximately 14.4 percent, are not one of the eligible types of clinicians for the transition year CY 2017 of MIPS under section 1848(q)(1)(C). The largest cohort of clinicians excluded from MIPS is low-volume clinicians, defined as those clinicians with less than or equal to $30,000 in allowed charges or less than or equal to 100 Medicare patients, representing approximately 32.5 percent of all clinicians billing Medicare Part B services or over 380,000 clinicians. Additionally, between 70,000 and 120,000 clinicians (approximately 5-8 percent of all clinicians billing under the Medicare Part B) will be excluded from MIPS due to being QPs based on participation in Advanced APMs. In aggregate, the eligible clinicians excluded from MIPS represent only 22 to 27 percent of total Part B allowed charges."

The provisions of this final rule with comment period are effective on Jan. 1, 2017. The final rule, currently under public comment period, was nearly 2,400 pages.