MACRA Highlights

Key Changes, SGR v MACRA QPP

  1. SGR: Payment changes (cuts) were applied uniformly to all physicians.
    MACRA QPP: Payment increases or decreases apply to physicians based on individual group performance.  

  2. SGR: No financial incentive to improve quality. MACRA: Payment based partially on quality measurement.
    MACRA QPP: Payment based partially on quality measurement.

  3. SGR: Flawed mathematical formula written into the law, imposed by the Centers for Medicare and Medicaid Services (CMS) on physicians.
    MACRA QPP: Law, implementation, and programs developed with physicians’ input.

  4. Reporting Requirements and Penalties prior to MACRA QPP

  • Existing Reporting Programs Medicare EHR Incentive Program aka MU (electronic health records meaningful use) 3% penalty, increased to 5% in 2019, for failure to meet standards. 

  • PQRS (Physician Quality Reporting System) 2% penalty for failure to report quality measures.

  • VM (Value-based Payment Modifier): 2016, Practices with 100+ providers, 2% penalty for low VM performance score.

  • 2017, Practices with 1-9 providers, 2% penalty for non-participation in 2015 PQRS. Practices with 10+ providers, 4% penalty for low VM performance score.

  • 2018, All providers subject to possible downward adjustment. 

MACRA QPP:  Streamlines these reporting programs into one.

MACRA Payment Highlights:

  • MACRA eliminated SGR and 21.2% payment cut scheduled for 2015

  • The Physician Fee Schedule is increased by  0.5% payment from  July 2015 through 2019

  • There is no increase in the fee schedule from 2020 to 2025

  • Yearly beginning in 2026, the fee schedule for physicians in qualifying Advanced APMs increases 0.75%, while the fee schedule for MIPS and exempt physicians increases 0.25%.

Two Payment System Options:  You Choose What Works Best for Your Practice

  1. Merit-based Incentive Payment System (MIPS): fee-for-service plus streamlined reporting on quality, cost, improvement activities, and electronic health record meaningful use (known now as advancing care information)

    1. Sliding-scale bonuses or cuts based on reporting and performance in four categories: quality, resource use, advancing care information (EHR meaningful use), and clinical practice improvement activities, a new category.

  2. Advanced Alternative Payment Models (APM): No MIPS reporting requirement

    1. Advanced APMs include medical homes, accountable care organizations (ACOs), and demonstrations under the Medicare Health Care Quality Demonstration Program

    2. Physicians practicing within an APM who meet the patient or revenue thresholds will receive a 5% bonus between 2019 and 2024 and a 0.75% increase in the Physician Fee Schedule in 2026 and beyond.

      MIPS: What to Expect in MACRA’s 2017 Transitional Year
      In an effort to encourage as much participation as possible in the first year, CMS is allowing clinicians to “pick their pace” and to choose how much 2017 data to submit through MIPS. Clinicians can avoid a negative payment adjustment by submitting a minimum amount of data and earn a neutral or positive adjustment by submitting at least three months of data. CMS plans to extend the transition period into at least part of 2018 “to provide a ramp-up of the program and of the performance thresholds.” In 2017, CMS will provide guidance on the parameters for 2018 and on payment adjustments for 2020. (Access the MIPS graph below in PDF format )

      Source: Centers for Medicare & Medicaid Services’ final rule for implementing Quality Payment Program under the Medicare Access and CHIP Reauthorization Act of 2015

First Performance Period Reporting Options

In order to ensure the implementation of the Quality Payment Program is successful for as many physicians and other Medicare providers as possible, CMS has created 4 reporting options for 2017.  Choosing one of these options will ensure that physicians do not receive penalties during the first payment period.

Option 1: Physicians can submit one measure in quality, advancing care information, or improvement activities at some point in 2017 in order to avoid negative payment adjustments in MIPS.  

Option 2: Physicians can choose to submit data for at least 90 days rather than the full year.  Physicians who select this option may receive a small positive payment adjustment.  

Option 3: In practices that are ready to fully implement reporting on January 1, 2017, physicians can opt to submit data for the entire year-long performance period.  Physicians who select this option may receive a payment adjustment of up to 4 percent.

Option 4: Instead of reporting through MIPS, physicians can participate in an Advanced APM.  If they see enough Medicare patients or receive enough Medicare payments through the Advanced APM during the performance period, they can receive a 5 percent bonus.