The Medicare Access and CHIP Reauthorization Act (MACRA) and Delivery Reform

On April 27, 2016, the Department of Health and Human Services issued a Notice of Proposed Rulemaking to implement key provisions of the Medicare Access and CHIP Reauthorization Act (MACRA), bipartisan legislation that replaced the flawed SGR formula with a new approach to paying clinicians for the value and quality of care they provide. The proposed rule implements these changes through the unified framework called the “Quality Payment Program,” which includes two paths: the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APMs).

The registry community also recently received clarification from the HHS Office for Human Research Protections regarding applicability of the Common Rule to various registry activities.

The Merit-based Incentive Payment System (MIPS)

Currently, Medicare measures the value and quality of care provided by doctors and other clinicians through a patchwork of programs, including PQRS, the VBM, and the Medicare Electronic Health Record (EHR) Incentive Program. Through the law, Congress streamlined and improved these programs into one new system called MIPS. Most Medicare clinicians will initially participate in the Quality Payment Program through MIPS.

Consistent with the goals of the law, the proposed rule would improve the relevance and depth of Medicare’s value and quality-based payments and increase clinician flexibility by allowing clinicians to choose measures and activities appropriate to the type of care they provide. MIPS allows Medicare clinicians to be paid for providing high quality, efficient care through success in four performance categories: Cost (10%), Quality (50%), Clinical Practice Improvement Activities (CPIAs) (15%) and Advancing Care Information (25%). Clinicians’ MIPS scores would be used to compute a positive, negative, or neutral adjustment to their Medicare payments. In the first year, depending on the variation of MIPS scores, adjustments are calculated so that negative adjustments can be no more than 4 percent, and positive adjustments are generally up to 4 percent, with additional bonuses for the highest performers. The maximum negative adjustment in 2020 is 5 percent, 7 percent in 2021, and 9 percent in 2022 and thereafter.

Advanced Alternative Payment Models (APMs)

APMs are the CMS Innovation Center models, Shared Savings Program tracks, or statutorily-required demonstrations where clinicians accept both risk and reward for providing coordinated, high-quality, and efficient care. These models must also meet criteria for payment based on quality measurement and for the use of EHRs. From 2019 through 2024, Qualifying APM Professionals (QPs) would receive a lump sum payment equal to 5 percent of the estimated aggregate payment amounts for Part B services. Clinicians participating in APMs are excluded from MIPS.