Last week, the Centers for Medicare & Medicaid Services (CMS) took its first step forward to implement several critical provisions of The Medicare Access and CHIP Reauthorization Act of 2015 (aka MACRA) with the release of a proposed regulation titled, “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models.”  

Many of you may have seen news of the rule’s release or even read an article or two highlighting some of its key provisions.  Weighing in at 962 pages, this rule is not only long (trust me on this one, I read every word of it!), but extremely complex, and at times difficult to understand.  Perhaps for good reason this time: This regulation proposes the most fundamental changes to how physicians are paid that we’ve seen in decades, and it is likely to have a greater impact on the way physicians practice medicine than The Patient Protection and Affordable Care Act (aka Obamacare)!

With that being said (and now that I’ve got your attention!), while this rule certainly can’t be summarized in a blog post, here are my top five initial takeaways from CMS’ proposed MACRA rule:

  1. MIPS will begin January 1, 2017 with a full-year reporting period. The rule confirms that the first performance period for the new Merit-Based Incentive Payment System (MIPS) will run January 1, 2017 – December 31, 2017. MIPS sunsets the financial penalties tied to the Meaningful Use EHR Incentive Program (MU), Physician Quality Reporting System (PQRS), and Physician Value-Based Payment Modifier (VBM) after the 2018 payment period (which is tied to the 2016 performance period) and will adjust physician’s payments based on performance in four categories: (1) quality; (2) cost; (3) advancing care information; and (4) clinical practice improvement activities. With January 1, 2017 only eight months away, MIPS will be here before we know it.
  2. The Meaningful Use program has been rebranded “Advancing Care Information,” but you’ll likely still recognize it as your old friend MU. While much discussion by CMS and the media has focused on “the end of meaningful use,” MU is not ending. MACRA explicitly requires CMS to measure a physician’s “meaningful use of a certified EHR” as one of four MIPS performance categories. And while CMS has chosen to rebrand the program and scale back some of its reporting requirements, the core structure of the program remains with requirements very similar to those included in the MU Stage 3 rule CMS released last fall. Also, the rule does not propose changing the 2016 MU reporting requirements or any future changes to the hospital or Medicaid MU programs (only Medicare for eligible professionals).
  3. CMS has made an effort to reduce the reporting burden, streamline reporting requirements, and offer physicians more flexibility in these programs. By scaling back certain reporting requirements and offering flexible reporting options for the different MIPS performance categories, CMS has made a noticeable effort to reduce the burden of participating in these programs. Notably, whereas this year PQRS requires most physicians to report on nine quality measures, the quality category in MIPS proposes six measures next year.  Other provisions would allow physicians participating in alternative payment models (APMs) to report their MIPS quality measures through the APM structure instead of as an individual or group practice.
  4. Physicians participating in the Shared Savings ACO Track 3, Next Generation ACO, and CPC+ alternative payment models are eligible for advanced APM incentive payments in 2017. Physicians participating in “Advanced Alternative Payment Models” are exempt from MIPS adjustments and eligible for a 5% bonus payment starting in 2019, based on 2017 performance.  Because of some ambiguities in the law’s definition of the requirements for this category, it had been unclear which APMs would qualify for these bonus payments.  While the proposal to exclude most Medicare APMs from this category (including the several hundred Shared Savings ACO Track 1 and 2 participants) disappoints many, interest in the newly announced Comprehensive Primary Care Plus (CPC+) model should spike given its inclusion as a qualifying advanced APM in the proposed rule.
  5. All roads lead to value-based care. Congress passed MACRA into law with the intent to repeal the flawed sustainable growth rate (SGR) formula and replace it with a system for physician payment that rewards cost control, improved quality, and better outcomes. With this first proposed rule, CMS has clearly taken the baton from Congress and done its part to accelerate the shift toward value-based care and reimbursement.  As noted in the rule’s Executive Summary: “This rule is needed to propose policies to improve physician payments by changing the way Medicare incorporates quality measurement into payments and by developing new policies to address and incentivize participation in alternative payment models.”  As a result, nearly every proposal in this rule reflects the shift towards value.

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