Will MACRA Help Providers Increase Medicare Payments in the Future?


MACRA was enacted after several years of short-term “fixes” to prevent payment cuts under the previous sustainable growth rate (SGR) formula. The legislation was a bipartisan, bicameral effort to move towards Medicare payment based on value, rather than volume. This legislation passed with the support of many health care stakeholder organizations, which will now watch carefully as the Centers for Medicare and Medicaid (CMS) implements this massive change to Medicare Part B payment to ensure a smooth transition and optimum outcomes of participation for as many clinicians as possible.

MACRA repeals the Medicare SGR and replaces it with the Quality Payment Program (QPP), a two track system including:

  1. A Merit-based Incentive Payment System (MIPS) for eligible professionals under the Physician Fee Schedule (PFS); and
  2. Optional participation in Advanced Alternative Payment (APM) models. The implementation of these programs will impact not only clinicians, but also the facilities and networks they practice within.

The majority of Medicare doctors will participate, at least at first, in MIPS, as indicated by HHS. That program permits Medicare clinicians to be repaid by demonstrating achievement in four categories: quality, cost, advancing care information, and clinical practice improvement activities.

Under the MIPS proposed rule:

  • Quality represents half of a total score in year one of the program. Clinicians would report six measures from among a scope of options that suit differences among specialties and practices.
  • Cost represents 10 percent of total score in year one. The score would be based on Medicare claims, which means no reporting requirements for clinicians, HHS brings up. This category would utilize 40 episode-specific measures to account for contrasts among specialties.
  • Advancing Care Information means 25 percent of total score in year one. Here, clinicians report adjustable measures mirroring their utilization of technology in everyday practice – with a specific accentuation on interoperability and data trade. HHS underlines that, dissimilar to current reporting program, this classification would not require all-or-nothing EHR measurements or redundant quality reporting.
  • Clinical Practice Improvement Activities count for 15 percent of total score in year one – remunerating clinical practice improvements, for example, activities concentrated on care coordination, recipient engagement, and patient safety. Clinicians may choose activities that match their practices’ objectives from a list of more than 90 options.

CMS would start measuring execution for specialists and different clinicians through MIPS in 2017, with payments based on those measures starting in 2019.

Under the APM proposed standard:

  • For services furnished during 2019 through 2024, physicians participating in APMs receive annual lump sum bonus payments equal to 5% of their covered Medicare professional services
  • To be eligible for these payments, physicians’ level of participation in the qualified APMs must reach certain threshold levels, starting with 25% of either revenues or patients in 2019-20 and growing to 75% by 2023
  • Physicians who are close to these thresholds can “partially qualify”
  • For purposes of calculating the percentage of a physician’s revenue that is attributable to an APM, CMS can take the revenue percentage for part of a year and extrapolate to the whole year.
  • To qualify for these payments, the “alternative payment entity” must require use of a certified EHR, have quality measures in place, and bear “more than nominal financial risk”
  • APMs include Medicare Shared Savings Program ACOs, all CMS Innovation Center initiatives except Health Care Innovation awards, and certain demonstration programs.

To better understand the MACRA legislation and get strategies to win Medicare incentives and avoid penalties in 2016, join expert speaker Jeanne Chamberlin in a live webinar on Tue, June 21, 2016. During the session, Jeanne will clarify what to expect from Medicare in 2016, with regards to penalties and incentives. She will also discuss the details of changes to the Medicare PQRS, Value-Based Modifier and Meaningful Use programs for the 2016 reporting year.

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