According to CMS, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) “makes three important changes to how Medicare pays those who give care to Medicare beneficiaries. These changes create a Quality Payment Program (QPP):
• It ends the Sustainable Growth Rate (SGR) formula for determining Medicare payments for healthcare providers’ services.
• It creates a new framework for rewarding healthcare providers for giving better care not more just more care.
• It combines existing quality reporting programs into one new system.”
Issued April 27, 2016, the proposed rule establishes a new Quality Payment Program (“QPP”), which would give providers a choice of two forms of reimbursement: (1) Alternative Payment Models (APMs); or (2) the Merit-based Incentive Payment System (MIPS). “MIPS would 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 (EPs), and would continue the focus on quality, resource use, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies.” The APMs, by way of contrast, provide CMS with new ways to pay healthcare providers. For example: (1) for the five-year period between 2019-2024, pay select participating providers a “lump-sum” incentive payment; (2) heightened transparency of physician-focused payment models; and (3) beginning in 2026, offer certain participating healthcare providers higher annual payments. Current APM models that fall under these new payment methods are: Accountable Care Organizations (“ACOs”), Patient Centered Medical Homes and bundled payments. Given that this proposed rule impacts reimbursement for physicians and hospitals alike, it is important to read these rules, especially Part II, closely and submit comments to CMS by June 27, 2016.
For providers, the key takeaways are:
• Consider your patient population. Are they educated, do they have a high utilization of prescription pain medications, and can these two issues lead to lower patient satisfaction scores and, also, have an effect on the proposed group practice reporting option (“GPRO”)?
• Look to see how long you need to be enrolled in Medicare to qualify as an APM participant.
• Make a chart of the different options available and the “pros and cons” of participating in each one.