Issue link: http://viewer.e-digitaledition.com/i/709194
WHEN CONGRESS FINALLY ELIMINATED THE SGR, WHICH WAS THE MEDICARE PAYMENT FORMUL A FOR PHYSICIAN SERVICES THAT CAUSED MUCH ANXIET Y AND FRUSTRATION FOR PHYSICIANS EVERY DECEMBER, IT SET THE STAGE FOR A MASSIVE SHIFT IN THE WAY MEDICARE PAYS PHYSICIANS FOR THEIR SERVICES. THE MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT «MACRA¬ REQUIRES MEDICARE TO BEGIN PAYING PHYSICIANS BASED IN PART ON THE "VALUE" OF THE SERVICES THEY PROVIDE. MANY BELIEVE THIS IS THE END OF TRADITIONAL FEEšFORšSERVICE, VOLUMEšBASED PAYMENTS. MACR A'S OVER ALL GOAL is to establish a system of Medicare physician fee pay- ments focused on better care, smarter spending and healthier people. To help achieve this goal, CMS recently released a proposed rule implementing MACR A. This proposed rule sheds light on the specifics and details of MACR A's new physician payment system. Here are some highlights of the MACR A proposed rule: + The Medicare physician fee sched- u le w i l l i ncr e a s e 0. 5% a n nu a l ly through 2019; + There are two distinct payment meth- ods — MIPS (Merit-Based Incentive Payment System) and APM (Alternative Payment Model); + The APM method o¥ers the most upside potential, at least initially; + For those physicians who qualify for the APM method, they receive an upfront, lump sum annua l payment of 5% of their previous year's Medicare Part B payments through 2019; + Under APM, physicians must currently participate in a PCMH-accredited orga- nization or an arrangement whereby the physicians assume more than nominal downside risk; + CMS indicated that participation in the CPC+ initiative, the Medicare Shared Savings Program (Track 2 or 3 only), or a next generation ACO would qualify physicians for APM; and + Most physicians will default to MIPS (according to CMS, only 5% of all physi- cians will qualify for APM, leaving the remainder in MIPS); + MIPS is a combination of various exist- ing incentive arrangements — PQRS, value-based modifier and meaningful use (these incentive arrangements will sunset December 31, 2016); + Under MIPS, physicians will receive payment adjustments (incentives or penalties) based on their performance in four categories — Quality (formerly, PQRS), Advancing Care Information (formerly, meaningful use), Clinical P ra ct ice Improvement Act iv it ies (CPIA), and Resource Use (formerly, value-based modifier); + The amount of the payment adjustment will depend on the physician's overall composite score and can be as high as 37% (depending on budget neutrality) or as low as -4%; and + CMS will establish the benchmark score and payment adjustments will be sca led accordingly — the more a physician exceeds the benchmark, the higher the adjustment, etc. The most important concept to keep in mind now is the timing aspects associated with MIPS and APM. While the payment adjustments will not appear until 2019, each physician's performance year starts with 2017. Payment adjustments in 2019 will be based on 2017 performance. On top of this, CMS is not expected to release the final MACR A Rule until November. This doesn't leave much time to plan and prepare. Physicia ns a nd their advisors must immediately sta r t to critica lly a ssess t he pat hway for 2017. If a physicia n wants to participate in A PM, the physi- cian may need to ma ke arrangements in the nex t few months to join a qua lif ied ACO or other a rra ngement. Likewise, for physicia ns who pla n or defau lt to MIPS, they should sta r t gathering a nd critica l ly a ssessing PQ R S, mea ning- f u l u s e , a n d v a lue - b a s e d m o d i f ier information to gauge their projected performa nce in MIPS. The M ACR A Rule is heav y and the MIPS and APM methods are complicated, especially since the result is a dramatic change to the physician reimbursement landscape. Time is of the essence. Change is coming. Anyone who delays seeking an in-depth working knowledge of the MIPS and APM methods will be making a strategic mistake. J. Ryan Williams is Partner in the Health Care Practice Group of Brouse McDowell in Akron, Ohio. ■ Moving From Volume to Value — An Overview of the Payment Methods under the Proposed MACRA Rule BY J. RYAN WILLIAMS 2 2