In the previous two editions of this column, I have written about the new Medicare Access and CHIP Reauthorization Act (MACRA) and the changes it will bring to Medicare physician payment beginning in January 2019 with the Merit-Based Incentive Payment System (MIPS). In June’s column, three of the four MIPS performance categories were outlined. Specifically, those include the Quality, Resource Use, and Electronic Health Record Meaningful Use components and encompass the Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM), Physician Quality Reporting System (PQRS), and Electronic Health Record Meaningful Use (EHR-MU) programs with which Fellows are hopefully familiar. As promised, this month I will discuss the final performance category component, namely the Clinical Practice Improvement Activities (CPIA) as well as the Alternative Payment Models program (APMs). Lastly, I wish to bring to the attention of Fellows a new web-based resource developed by the ACS Division of Advocacy and Health Policy to assist them in avoiding current law Medicare penalties.
The CPIA are designed to assess and credit surgeons according to their effort toward improving their clinical practice OR their preparation toward participating in the APMs. The menu of specific, recognized activities will be established in collaboration with the Centers for Medicare & Medicaid Services and the providers to whom the activities will be applicable. Many of the specifics are yet to be determined and will be part of the rule-making process in coming years. However, the MACRA legislation specifies that the CPIA must be applicable to all specialties and be attainable for small practices and professionals in rural and underserved areas. To support the efforts of surgeons and other providers in small or rural practice, Congress set aside $20 million dollars for each year, 2016-2020, for technical assistance to support the efforts of practices with 15 or fewer professionals to improve MIPS performance or transition to APMs.
The new law takes concerted steps to incentivize and encourage the development of and participation in APMs. As with the CPIA outlined above, the details of APMs are not yet fully clear and will be established going forward. However, in general, these programs will base payment on quality measures, not volume or intensity, and will include an element of financial risk for providers. For those surgeons who receive a significant share of their revenue from an APM, an annual 5% bonus will be available for each of the years 2019-2024. To qualify for that bonus surgeons must receive 25% of their Medicare revenue from an APM in the years 2019 and 2020, with the requirement subsequently increasing to 50% in 2021 and ultimately to 75% beginning in 2023. Providers may qualify based on a combination of private APMs and Medicare APMs as well.
In recognition of the lack of APMs in many areas or applicability for many specialties, MACRA prioritizes development of models for small practices, models that are specialty specific, and model development in conjunction with private payers as well as Medicaid-based options, all with the ultimate goal of encouraging the development of new and innovative payment models. The legislative language in MACRA is broad enough that it may allow for creation of a model based on the ACS’ Clinical Affinity Group (CAG) concept whereby providers are grouped together based on the patients or conditions that they treat, not their specialty designation.
Surgeons who meet a threshold of payment received from a qualified APM will be exempted from participation in MIPS to include most EHR-MU requirements and also receive the 5% bonus as described above. Those who participate in an APM but fail to meet the threshold necessary to receive that bonus will receive credit for such in the CPIA portion of their MIPS composite score.
Finally, even though the permanent repeal of the SGR found in MACRA represents the successful culmination of long-standing, combined advocacy efforts of the American College of Surgeons (ACS) and other medical associations toward meaningful, future Medicare physician payment reform, Fellows should be well aware that the three current law Medicare quality programs, namely the PQRS, EHR-MU, and VBM and their corresponding requirements as well as their associated penalties remain in effect until January 2019.
Surgeons who do not successfully participate in the PQRS, EHR-MU, and VBM face significant penalties on future Medicare payments. Specifically, failure to meet the requirements imposed by these three programs in 2015 could result in total penalties of up to 9% in Medicare payments in 2017.
To assist Fellows in navigating the complexities of complying with current law quality program requirements and thus avoid Medicare penalties, the ACS Division of Advocacy and Health Policy has developed a new online interactive flowchart which can be found at [WEB ADDRESS]. Fellows may wish to refer to and bookmark this page as an ongoing reference in order to familiarize themselves with current law requirements, facilitate their individual compliance with same, and thus successfully avoid penalties. As always, Fellows with questions may contact the DAHP at 202-337-2701.