In 2017, physicians across the country will be revamping the way they deliver care as a result of legislation passed last year, the Medicare Access & CHIP Reauthorization Act of 2015, or MACRA. In addition to Medicare, this important legislation shapes the future of the U.S. healthcare system. 

So what will MACRA mean for providers and patients? This simplified Q&A covers the basics, and provides commentary from Telligen experts who understand quality reporting inside and out. Be sure to check back for the latest updates and resources that will help providers make the MACRA transition a smooth one.

What is MACRA?

In short, MACRA (Medicare Access and CHIP Reauthorization Act of 2015) is Medicare payment reform law that impacts Medicare providers in significant ways:

  • It eliminates a payment formula (SGR) that plagued physicians with repeated threats of severe payment cuts
  • It creates a Medicare payment program that rewards doctors based on the quality of care they provide, not the quantity of care they provide

The proposed rule implements these changes through the unified framework called the “Quality Payment Program”, QPP, which includes two paths:

  1. Merit-Based Incentive Payment System (MIPS)This option streamlines the three existing Medicare incentive programs — Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VM) and Meaningful Use (MU) — into one quality program. Physicians will potentially receive a bonus or penalty based on how they perform on measures of quality, resource use, advancing care information and clinical practice improvement activities.
  2. Alternative Payment Models (APMs) — Under this option, providers go a step further to provide high-quality, coordinated care by participating in an advanced APM (like Accountable Care Organizations or Patient Centered Medical Homes). Choosing the APM route means taking on greater financial risk, but also the potential to achieve greater financial reward.

Why should I care?

MACRA QPP presents one of the most significant payment reform pieces of legislation in decades. Unlike previous quality initiatives, MACRA-QPP does not offer the option for providers to opt-out of participation. This means that any provider who accepts Medicare patients — physicians, physician assistants, nurse practitioners, clinical nurse specialists and nurse anesthetists — and bills Part B will be required to report one of the two paths in 2017.

For now, only physician offices — not hospitals — are governed by MACRA rules. In addition, this program only applies to payments physicians receive from Medicare Part B. Medicaid is not included.

Why is this happening?

The shift from paying for value rather than volume represents a significant change, but it’s one that has been years in the making. Since the Affordable Care Act was passed, the federal government has been transitioning from fee-for-service to a model that delivers high-quality care while lowering costs. The overall goal is summed up by the broad aims of the National Quality Strategy — better care, smarter spending, and healthier people, healthier communities.

Which path should my practice pick?
Most physicians will participate in MIPS until more advanced APMs become available. That information will then be used by CMS to determine which providers are eligible for the APM path. The proposed rule offers flexibility to move between the components of the MIPS path to the Advanced APM path with a goal to transition most eligible clinicians to the Advance APM path.   

What’s an APM?

APMs represent a payment approach that shifts away from the traditional fee-for-service system that encourages quantity of services provided towards payment models that promote high-quality, cost-effective care. APMs comprise a variety of forms — Accountable Care Organizations, Patient-Centered Medical Homes and bundled payments — not all of which will be eligible for the APM path.

Which APMs are eligible?

CMS refers to payment models eligible for the APM paths as “Advanced APMs.”

Advanced APMs meet the base definition of APM and also meet the following criteria:

  • Use certified-EHR technology.
  • Base payment on quality measures comparable to those in MIPS
  • The entity(ies) participating in the APM:
  • Bear more than nominal financial risk for monetary losses; or
  • Is a medical home model expanded under CMMI

Does MACRA signal the end of meaningful use?

According to a CMS blog post, MACRA is an opportunity to adjust EHR payment incentives, but it doesn’t eliminate them overnight. Under MIPS, physicians will be required to report EHR data, under the Advancing Care Information category. This category would no longer require the all-or-nothing EHR measurement and quality reporting. The current meaningful use Modified Stage 2 and Stage 3 requirements are still in effect for hospitals and Medicaid eligible clinicians

How will this impact a small and/or rural practice?

From 2016–2020, CMS will provide $20 million in annual funding to offer technical assistance to small practices (15 or fewer professionals) and practices in rural areas to deal with the demands of the MIPS and remove barriers from participating in APMs.

MACRA doesn’t go into effect until 2019, so why worry now?

Don’t let the 2019 date give you a false sense of security. Remember the data used to make payment adjustments to eligible clinicians in 2019 will be derived from performance in 2017 (less than six months away). Providers have big decisions to make, and now is the perfect time to assemble a plan for success.

What can I do now to prepare?

Get Educated — Navigating MACRA’s requirements will require a basic understanding of value-based programs, MACRA/MIPS/APMs and their impact on the healthcare industry.

Get Involved — Networking with peers, talking with experts, and having a voice in how MACRA develops will help clinicians assemble a plan.

Get Ready — In the coming months, Telligen will dive deeper into MIPS and APMs and provide resources to get your practice educated, involved and ready for MACRA.