On October 15, 2016, the Department of Health and Human Services (HHS) released the final rule outlining its implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP). The QPP applies to clinicians or groups with more than $30,000 in Medicare Part B allowed charges and more than 100 Medicare patients. Clinicians or groups under either threshold or who are participating in Medicare for the first time in 2017 are exempted.
The QPP rewards value and outcomes via two tracks: Merit-based Incentive Payment Systems (MIPS) or Advanced Alternative Payment Models (Advanced APMs).
MIPS consolidates several existing programs that will be retired. Under MIPS, clinician performance will be measured on a 100 point scale in one or more of the following performance categories:
Clinicians scoring above a designated threshold may receive higher Medicare payments and those below the minimum threshold will experience a reduction in Medicare payments. Clinicians qualifying for services delivered through an Advanced APM are exempt from MIPS, will avoid payment penalties and will receive increased Medicare payments. The final list of qualifying Advanced APMs will be published by January 1, 2017.
Transition Options for 2017
Depending on their level of participation in 2017, MIPS eligible clinicians will be subject to negative or positive payment adjustments beginning January 1, 2019. Clinicians have until March 31, 2018 to submit data collected. The possibilities for clinicians are as follows:
No MIPS or Advanced APM Participation – MIPS eligible clinicians who do not report any data for 2017 and do not participate in an Advanced APM will be subject to a negative 4% payment adjustment.
Minimum MIPS Participation – To avoid a negative payment adjustment, clinicians must report one of the following for at least a full 90-day period in 2017: (1) one measure in the quality category, (2) one activity in the improvement activities category, or (3) the required measures of the advancing care information category.
Greater MIPS Participation – Clinicians who chose to report more than the minimum data will be eligible for a positive payment adjustment. Clinicians who are exceptional performers in MIPS (ideally reporting data in all three categories for the entire year and achieving a score of 70 or higher) are eligible for an additional positive payment adjustment for the first six years of the program.
Advanced APM Participation – Qualified Providers (QPs) are Clinicians who receive 25% of Medicare payments or see 20% of Medicare patients through an Advanced APM. QPs are excluded from MIPS and qualify for a 5% bonus incentive payment in 2019. Clinicians participating in an Advanced APM must submit the quality data as required by the Advanced APM. The Final Rule offers the potential for additional Advanced APMs and services provided at certain CAHs, RHCs, and FQHCs may be included in determining the threshold under the patient count method.
Small and Rural Practices – Clinicians practicing in small (≤ 15 clinicians) or in rural shortage areas have a reduced reporting burden and will receive increased technical assistance from HHS. Clinicians or groups with a low Medicare volume (≤ $30,000 or 100 Medicare patients) are excluded from the MIPS payment adjustment. HHS is also examining financial risk sharing options to better support small and rural practices. Special rules for the medical home Advanced APM apply. In addition, HHS has committed $20 million annually for the next 5 years to provide training and assistance specific to small and rural clinicians.
For 2017 MACRA reporting, HHS has provided clinicians with greater flexibility in meeting the reporting requirements by lowering the minimum reporting threshold, reducing the number of measures and permitting a 90-day reporting period for 2017. HHS has also accelerated the time-line for assessing whether clinicians meet the Advanced Alternative Payment Model (Advance APM) prior to the end of the MIPS reporting period. HHS expects that this transitional period should give clinicians the opportunity to develop a plan for moving toward accountable care models or revising care delivery practices enabling clinicians to generate higher Medicare payments in future years.
Thank you to Keith Maune, Belmont University College of Law, for his assistance in preparing this article.