Posts Tagged MACRA

Understanding MACRA: New MACRA Lectures Announced

Understanding MACRA: New MACRA Lectures Announced

The Medical Association of the State of Alabama and Warren Averett CPAs and Advisors in conjunction with the several county medical societies will be hosting an in-depth education session on MACRA.

CMS has outlined phases for MACRA’s payment models to go into effect, and the first proposed performance reporting period began Jan. 1. This is just the beginning.

This is an educational opportunity for physicians and staff to learn details regarding the new MACRA law and how it will affect your practice. The session will provide physicians with important information you need to know to be in compliance with new MACRA requirements so your practice can maximize your Medicare reimbursement potential and avoid penalties.

Below is a list of the dates for the Understanding MACRA series:

  • Baldwin County – February 21
  • Houston County – March 9
  • Covington County – March 14
  • Jefferson County – March 16
  • Lee County – March 21
  • Montgomery County – April 18
  • Colbert County – April 20
  • Huntsville – April 25
  • Fayette – May 2
  • Gadsden – May 4
  • Mobile – TBA
  • Anniston – May 23

If other county societies would like to host an Understanding MACRA series, please contact Mark Jackson for more information.

The Medical Foundation of Alabama designates this live activity for a maximum of 1.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Medical Association of the State of Alabama through the joint providership of the Medical Foundation of Alabama and the Medical Association of the State of Alabama. The Medical Foundation of Alabama is accredited by the Medical Association of the State of Alabama to provide continuing medical education for physicians.

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Opinion: All Americans Need Access to Affordable, Quality Care

meigsEditorial contributed by John Meigs Jr., M.D., president of the American Academy of Family Physicians, member of the Medical Association Board of Censors, and a family physician in Centreville, Ala. Editorial reprinted by permission.

Since Election Day, health care analysts have tried to forecast the fate of our health care system. Much remains uncertain, but what is undisputed is the goal that all Americans must be able to obtain affordable, high-quality and efficient health care. This must be at the center of any national health care strategy. That’s why America’s family doctors are starting this new year by encouraging the Trump administration and the 115th Congress to focus on this essential priority.

The American Academy of Family Physicians has long supported and advocated for meaningful patient-centered health care for all, an underlying tenet of many health care reform proposals, including the 2010 Affordable Care Act. We recognize that our current health care system is not perfect and new approaches can certainly improve the law. However, the nearly 200 million Americans who currently have health care coverage through the individual, small group and employer-based markets — as well as Medicaid — should not have their coverage and insurance protections jerked out from underneath them.

Within any changes, the overarching policy must ensure everyone has access to health care. Because America’s family doctors see more than half a million patients a day, we know what policies and programs ensure access to consistent, comprehensive and preventive care, particularly for low-income individuals and families. Financial barriers to care have crumbled as a result of Medicaid, the Children’s Health Insurance Program and Medicare. Medicaid and CHIP currently enroll nearly 73 million children and low-income Americans. Medicare preserves access to care for nearly 56 million elderly and disabled people. Equally important, patients who have privately purchased health insurance — particularly those with high-deductible plans — must not have to overcome financial obstacles to receive care.

Patient-centered care is at the heart of health care reform, which is why we must have a payment system that rewards the value of care over the volume of services provided. Our nation’s policy must build on the Medicare Access and CHIP Reauthorization Act — or MACRA — to ensure family physicians in all practice settings can continue to practice patient-centered care.

Our lawmakers also must commit to building a physician workforce that can meet the growing demand for primary care. They must support efforts to maintain a steady pipeline of primary care physicians through graduate medical education reforms and extension of the community-based Teaching Health Center program that attracts students to family medicine.

Health care is a personal matter, which is why primary care is the foundation of our health care system. Time and time again, primary care physicians have been counted on to provide care to millions of Americans from all parts of the country — for they have proven their expertise to improve health outcomes while lowering costs.

It is imperative that we have national health policies that ensure all Americans can sustain a continuous relationship with their primary care physicians. The only way we can do this is with legislation and regulations that ensure all Americans, regardless of health or financial status, can get needed health care in a timely, efficient, affordable and personalized manner. America’s family doctors pledge our support in helping to achieve this vision.

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MACRA may sound like a word jumble with terms like MIPS, APM, QPP, ACI, CPS, VBP, and so on. Unfortunately, a majority of physicians are unaware of how this new payment system will affect their practices, so making sense of these acronyms is just the beginning.

MACRA did more than replace the Sustainable Growth Rate formula. It will soon introduce a new framework for rewarding physicians who provide higher-value care. And, it will also introduce a number of new terms physicians and their staff should become more familiar with. Following is a short list of terms every physician should know before the new payment rules take effect Jan. 1.

QPP: The Quality Payment Program. This is that new payment framework. It offers two tracks for payment: MIPS and APMs, both discussed below.

MIPS: The Merit-based Incentive Payment System. MIPS aims to align three currently independent programs — quality reporting (what physicians know now as PQRS), Advancing Care Information (now known as EHR Meaningful Use), and cost (now known as the value-based modifier) — and adds a fourth component, Improvement Activities, designed to promote practice improvement and innovation. Some physicians will be exempt from MIPS through the low-volume threshold, defined below.

APMs: Alternative payment models. Few physicians will choose this track, as many APMs are not yet available in all states. APMs typically have shared savings, flexible payment bundles and other desirable features. There are two APM participation classifications—Advanced APMs, which have their own reporting requirements and are exempt from MIPS reporting, and MIPS APMs. Read more about APMs.

Pick Your Pace: This refers to the four participation options available in the transition year, which starts Jan. 1. Physicians may elect for MIPS testing, partial MIPS reporting, full MIPS reporting or Advanced APM participation. Read more about the four options.

Low-Volume Threshold: Physicians with less than $30,000 in annual Medicare revenue or fewer than 100 Part B-enrolled Medicare beneficiaries will be exempt from all MIPS reporting. Read more about accommodations for small practices.

ACI: Advancing Care Information. This replaces Meaningful Use. It features more reasonable reporting features, including base and performance scoring, fewer measures and 90-day reporting periods. Learn more about the two ACI options.

Improvement Activities: This new component, a feature of MIPS, is intended to provide credit for practice innovations that improve access and quality of care. It features more than 90 activities across eight categories. These too make accommodations for small practices. View a full list of activities.

Reporting Option: Physicians will need to decide whether to report as an individual or as part of a group. A group is defined as two or more eligible clinicians. A physician in a group may choose to participate as an individual under MIPS.

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The Impact of MACRA

The Impact of MACRA

*Editor’s Note: Article contributed by Adele Allison, director of Provider Innovation Strategies, DST Health Solutions. Ms. Allison will be a presenter during the Medical Association’s 2017 Annual Meeting and Business Session on  April 14-15 in Montgomery.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) accelerates the pace of change in the movement toward value-based payment (VBP).1 With an effective date of Jan. 1, 2019, MACRA requires Medicare providers to choose from two defined reimbursement paths that link quality to payment: the Merit-Based Incentive Payment System (MIPS) or advanced Alternative Payment Models (APMs).2 After considering more than 4,000 comments to the proposed rule considered, CMS released the final rule on Oct. 14,3 officially rolling out the Quality Payment Program (QPP).

CMS has outlined phases for MIPS and APMs to go into effect over a timeline through 2021 and beyond. The first CMS-proposed performance reporting period begins Jan. 1, 2017 (for payment adjustments starting in 2019). Under MACRA, Medicare revenue may be adjusted upward or downward by as much as 4 percent in 2019 (based on performance in 2017) and up to 9 percent in later years.4 To respond to the rapid program launch, CMS announced in the final rule a “Pick-Your-Pace” option for 2017, allowing a range of provider quality reporting choices to comply with MACRA.5 Nevertheless, MACRA heralds a new era in provider payment where effectiveness, efficiency and performance data will determine each clinician’s economic viability. This article will explore the essential strategies providers should consider to evolve their culture and technologies towards these new value-based payments.

Impact of MACRA: The Timing

MACRA is a Medicare cost containment law grounded in quality performance. It seeks to move health care systems and providers to advance alternative payment arrangements over time, but as quickly as the industry will allow. In the mature stages, physician practices will be expected to understand and manage the risk of care associated with attributed patient populations. While population-based payment, the most advanced phase, is the desired destination, few of today’s providers are expected to be ready to assume this level of risk. Since most providers aren’t ready to take on risk, CMS expects MIPS to be the path initially most traveled by providers – predicting 761,342 clinicians to be precise.6 Yet, even MIPS is being recognized by CMS as a lofty goal in 2017.

Milestones Toward Increasing Levels of Risk-Bearing

The path forward to align value-based payment models across private and public health plans and health systems has been laid out by the recently formed Health Care Payment Learning and Action Network (HCPLAN). The HCPLAN is a public-private collaboration of health plans, providers, patients, employers, consumers, states, federal agencies and other partners seeking to accelerate the adoption of alternative payment models that reward quality and value in health care.

Among other things, the HCPLAN has defined a framework of four categories as milestones along a payment continuum. Each category moves toward increasing levels of risk-bearing, value-based care, and payment innovation (see Figure 1).7 Physicians and other clinicians can use this framework to evaluate the status of their current payer agreements in this journey. They can also use this framework to begin developing plans to evolve further along this continuum.

Four Categories of Value-Based Payment

Category 1  Traditional fee-for-service (FFS) with no link to quality or value. Category 1 represents traditional payment models typically built on fee schedules and diagnostic related groups (DRGs).

Category 2  FFS linked to measures of quality and value. Providers are paid differentially based on measures of quality, yet providers continue to receive a fee for each service. MIPS is a Category 2 payment arrangement as is the Blue Cross and Blue Shield of Alabama Quality Management Program.8

Category 3  Alternative payment built on an FFS infrastructure. Providers begin taking limited risk with alternative payment models that span across the continuum of care. A retrospective bundled payment fits in this category, as does shared savings under an Accountable Care Organization (ACO). Category 3 arrangements that include “significant but not excessive” risk-bearing qualify as advanced APMs under MACRA. Qualified participants in CMS advanced APMs will not be subject to MIPS and will be eligible to receive a 5 percent incentive payment. Available in 14 regions, CMS has elevated the expanded medical home, a risk-sharing PCMH known as the Comprehensive Primary Care Plus (CPC+), as an example of a qualifying advanced APM under MACRA.9

Category 4  This is a population-based payment. Under Category 4, payment is not triggered by clinical service delivery, but rather the payer makes a population-based payment to the provider to assume responsibility over a defined period of time. Category 4 clinicians embrace advanced risk-bearing models often across the care continuum; shared risk for an attributed patient population that may be condition-specific or global. Like more than nominal risk arrangements under Category 3, CMS will recognize Category 4 providers as QPs under advanced APMs and not subject to MIPS.

PowerPoint Presentation

CMS Outline of a “Pick-Your-Pace” Plan

Since the first MIPS performance period is set for Calendar Year 2017 and the final rule governing the details of MACRA was not released until Oct. 14, 2016, providers will have very little time to plan, prepare and implement necessary changes to succeed. In response to industry concerns and comments, CMS will allow MACRA providers to “Pick Your Pace” in 2017 under the following structure in Figure 2.10

Microsoft Word - MASA article Overview of MACRA for Providers 10

Leveraging Data for Population Health Management

Through MACRA, CMS is leading change in payment reform that will permeate to other segments of health care. Providers need to think strategically about alignment with emerging quality measures and payment structures. Today is an opportune time for providers to begin collaborating more fully with each other and health plans to achieve higher levels of measurable care and payment; and, measurement is driven by data. Providers must begin thinking about assuming collective responsibility for attributed patient populations across the health delivery system as this is where payment is heading.

To do this, practitioners should leverage combined data for population health management as a provider community. The Meaningful Use programs provided physicians and other clinicians with growing visibility into their individual patient populations. Where the payer-provider relationship is one-on-one, such as under traditional fee-for-service (FFS) contracts, individual provider technical capabilities may be sufficient to meet preliminary demands for managing patient populations. Under a growing plethora of PBP models, many different types of clinicians (primary care physicians, specialists, physician assistants, nurse practitioners, nurse specialists, dentists, physical therapists, and others) may be paid as part of a collective for a shared patient. This will be driven by composite measurements that require a view of data beyond the four walls of the individual provider enterprise.

Payers have had this aggregated data view for decades through the most foundational data-source in the U.S. – claims data. Your claims process is not just a means of getting paid. Claims are a reporting vehicle where the nuances of your patient population are communicated and assessed by a payer. More and more, payers are beginning to share this aggregated population data with providers to assist with resource management, assessment of disease burden and outcomes measurement across the care continuum.

MIPS Scoring Explained

Given that nearly 90 percent of clinicians are expected to fall under a MIPS payment arrangement, it is important to understand how scoring will occur. Essentially, a single composite score for MIPS will be based on weighted performance in four categories: quality, cost, advancing care information, and clinical practice improvement activities (see Figure 3). Ultimately, MIPS rewards and penalties will be tied to a clinician’s composite performance score, and payment will wash from low-performing to high-performing providers in a budget-neutral fashion. Maximum points can be earned under the Clinical Practice Improvement Activities (CPIA) category for official medical home status under NCQA, The Joint Commission, URAC or AAAHC; or, NCQA patient-centered specialty practice (PCSP) achievement. Additionally, the formerly known CMS Electronic Health Records (EHR) Meaningful Use program is now represented under MIPS by the Advancing Care Information composite performance score category.

Microsoft Word - MASA article Overview of MACRA for Providers 10

Where can I get help and learn more?

  1. CMS Quality Payment Program interactive website. Offers a practical overview of the new program and can assist in identifying appropriate measures and activities based on your specialty. Go to:
  2. atom Alliance and the Alabama Quality Assurance Foundation (AQAF). The CMS Quality Innovation Network (QIN)-Quality Improvement Organization (QIO) for Alabama that works on data-driven initiatives. Go to:
  3. CMS Innovation Center. Provides comprehensive information about alternative payment models being implemented and tested across the country. Go to:


A fundamental change is required to move from volume to value in payment for health care services. Today, much of health care economics is still functioning under Category 1, fee-for-service, but the roadmap towards value has been laid out under MACRA. Health care providers who understand the direction CMS is driving health care economics will be better positioned to work collaboratively with their community-based peers and payers as they move along this continuum. The stage is set for a new era of value in health care.


1   Federal Register. 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. Published May 9, 2016. Accessed August 12, 2016.

2   CMS. Quality Payment Program. Accessed August 25, 2016.

3   CMS. The CMS Blog, Plans for Quality Payment Program in 2017: Pick Your Pace. Published September 8, 2016. Accessed September 12, 2016.

4   CMS. MACRA RFI Posting. Accessed August 25, 2016.

5   CMS. The CMS Blog, Plans for Quality Payment Program in 2017: Pick Your Pace. Published September 8, 2016. Accessed September 12, 2016.

6   CMS Proposed Rule, 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,, Table 63. Published May 9, 2016. Accessed August 25, 2016.

7   Health Care Payment Learning & Action Network. Accelerating and Aligning Population-Based Payment Models: Data Sharing. Published August 8, 2016. Accessed August 12, 2016.

8   BlueCross BlueShield of Alabama. Quality Management Program. Accessed September 13, 2016.

9   CMS Innovation Center. Comprehensive Primary Care Plus. Accessed September 13, 2016.

10   CMS. The CMS Blog, Plans for Quality Payment Program in 2017: Pick Your Pace. Published September 8, 2016. Accessed September 12, 2016.

11   CMS. MIPS Scoring Methodology Overview. Accessed August 25, 2016.

Strategies to Remember...

Essential Strategy 1:  Think of your claims as a reporting vehicle where the nuances of your patient population can be communicated to a payer.

Essential Strategy 2:  Assess your payer agreements to identify the category of payment in place today. This will help you understand where you currently are in the payment continuum.

Essential Strategy 3:  Recognize payers that make up the majority of your revenue. Contact provider relations and identify that payer’s PBP strategies and timelines. This will offer you a tactical roadmap for alignment.

Essential Strategy 4:  Identify essential data-points upon which measurement will be based. Is there overlap between payers? How do you “measure up” today? Critical data identification will help you position for workflow redesign for consistent data capture.

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MACRA Education from the AMA

MACRA Education from the AMA

The American Medical Association is offering several educational opportunities to help physicians understand the requirements of the new Quality Payment Program (QPP) that was created by the Medicare Access and CHIP Reauthorization Act (MACRA). The sessions have been scheduled to give physicians an understanding of what the final rule means for their practice and what they need to do as part of the QPP. All of the sessions, except Nov. 29, are open to physicians and medical society staff.  

Please take advantage and register for these additional learning opportunities and pass along the registration information to your physician members.

Tuesday, Nov. 29 @ 1 p.m. – 3 p.m. ET
Staff Train the Trainer Webinar
This session will be focused on helping medical society staff to gain a better understanding of the new regulations so you will be prepared to answer your questions.

Thursday, Dec. 1 @ 6:30 p.m. – 9 p.m. ET
Atlanta Regional Seminar (streaming and webinar)
Cobb Galleria Center in Atlanta, GA

Tuesday, Dec. 6 @ 8:00 p.m. – 9:30 p.m. ET
Physician/Staff Webinar

Saturday, Dec. 10 @ 9 a.m. – 11:30 a.m. PT
San Francisco Regional Seminar (streaming and webinar)
Marriot Marquis in San Francisco, CA

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What You Said About MACRA…

What You Said About MACRA…

Just a few weeks ago, the Department of Health & Human Services dropped the finalized Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rule – a landmark new payment system moving health care to a merit-based payment system. The rule, weighing in at almost 2,400 pages, has garnered more than 4,000 public comments since its proposal in April, is scheduled to become effective Jan. 1, 2017. With so little time to prepare, we asked some of Alabama’s physicians what they think about MACRA.


“MACRA is a very complex law and will be a burden for many of our physicians. However, please remember that MACRA repealed and replaced the SGR, the flawed program where we all annually faced pay cuts of 20 percent and greater and were always at the mercy of Congress to provide relief that almost always came at the last minute. With MACRA, we have the stability of knowing what to expect, we have the potential of increased payments and even bonus payments along with the possibility of negative updates as well. If you participate in Pick-Your-Pace at any level of participation in 2017, you will avoid any potential penalties in 2019, the first year of MACRA implementation. The MACRA updates in 2019 start at +/- as much as 4 percent and go up slowly each year but come nowhere close to the 21 percent cuts we faced under SGR. MACRA is by no means perfect, but it does begin the Medicare transition from volume-based Fee-For-Service payments to a value-based payment system. I would encourage all physicians to participate in Pick Your Pace at whatever level you are able to accomplish in 2017 to avoid potential penalties in 2019. As we delve deeper into this law, stay tuned for future updates and recommendations.” – John Meigs Jr., M.D., Brent

“Because I see very little Medicare patients, I have not studied MACRA or MIPS other than to know it will be a burden to physicians and staff in time or expense to hire a third party to do the reporting requirements. For physicians like me that see little Medicare patients, but just enough (about 100 a year) to be required to do the reporting to be penalized, it is burdensome. I may take the penalty and then ultimately not see Medicare anymore because it isn’t cost efficient for my practice. The government is continually putting more costly regulations and requirements on physician practices pressuring the overall viability of a private practicing physician in the future. There will come a breaking point.” – McCain Ashurst, M.D., Montgomery

“They’re talking about a reduction in payments for failing to meet standards, but how do you assess that — what metric do you use? How do you assess quality? And there’s a lot of flippant interpretations of what they’ll pay.” – Clifford Black, M.D., Anniston, quoted in The Anniston Star

“We’ll just have to pay more attention to what we do … how often patients get treatment … show that patients are getting proper quality of care … if you do it enough it’ll eventually become second nature. But it is a slightly greater bureaucratic level on physicians. Generally, the quality of care is good right now … maybe there will be a 1 to 2 percent improvement.” – Todd Scarbrough, M.D., Anniston, quoted in The Anniston Star

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CMS Releases MACRA Final Rule

CMS Releases MACRA Final Rule

*Editor’s Note: The Medical Association will be studying the just-released MACRA rule and will be providing additional info as it becomes available. The Association and MGMA will co-host a free webinar, “MACRA: Essential Strategies in Economic Reform” on Nov. 7 from 12 p.m. to 1:30 p.m. Click here for more information.

On Oct. 14, the Department of Health & Human Services finalized a landmark new payment system for Medicare physicians that will continue reforming how the health care system pays for care. The rule, which since its proposal in April garnered more than 4,000 public comments, cements the two payment tracks already proposed and is scheduled to become effective Jan. 1, 2017.

First, physicians can participate in the Merit-Based Incentive Payment System track, which based payment of clinic performance, practice improvement, reporting and technology use. However, the final rule makes official the “pick-your-pace provision” allowing physicians a slower entry into the model if they are not quite prepared to handle all aspects of the program. To do that, CMS is offering physicians a flexible performance period at the beginning.

“It’s time to modernize the Medicare physician payment system to be more streamlined and effective at supporting high-quality patient care. To be successful, we must put patients and clinicians at the center of the Quality Payment Program,” said Andy Slavitt, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS). “A critical feature of the program will be implementing these changes at a pace and with options that clinicians choose. Today’s policies are designed to get all eligible clinicians to participate in the program, so they are set up for successful care delivery as the program matures.”

The rule, which weighs in at nearly 2,400 pages, is informed by a months-long listening tour with nearly 100,000 attendees and nearly 4,000 public comments. A common theme in the input HHS received was the need for flexibility, simplicity, and support for small practices. First, the new payment system creates two pathways. These paths let clinicians pick the right pace for them to participate in the transition from a fee-for-service health care system to one that uses alternative payment models that reward quality of care over quantity of services.

Clinicians will choose between two options:

  • The first path gives clinicians the opportunity to be paid more for better care and investments that support patients. It reduces existing requirements, while still emphasizing and rewarding quality care. In the first year, it also provides a flexible performance period, so that those who are ready can dive in immediately, but those who need more time can prepare for participation later in the year.
  • The second path helps clinicians go further by participating in organizations that get paid primarily for keeping people healthy. For example, they could be part of an Accountable Care Organization where clinicians come together to coordinate high-quality care for the patients they serve. When they get better health results and reduce costs for the care of their patients, the clinicians receive a portion of the savings.

While the AMA is in the process of fully analyzing the regulations, a first review revealed that CMS responded to many of the concerns expressed by physicians about the proposed rule issued last spring. For example:

  • Details are provided about the 2017 transition period announced in September. The only physicians who will experience payment penalties in 2019 are those who choose to report no performance data next year, and those who report for at least 90-days will be eligible for positive payment adjustments.
  • The low-volume threshold that exempts physicians from all performance reporting has been increased from $10,000 in annual Medicare revenue and less than 100 Medicare patients to $30,000 in revenue or 100 patients. CMS estimates that this change will exempt 32.5 percent of physicians and other clinicians from the program.
  • Performance reporting requirements have been further reduced, and the resource use component of the Merit-based Incentive Payment System (MIPS) has been reweighted to zero for 2017.

“We recognize, as described through many insightful comments, that many eligible clinicians face challenges in understanding the requirements and being prepared to participate in the Quality Payment Program in 2017,” Slavitt said in an executive summary of the rule. “As a result, we have decided to finalize transitional policies throughout this final rule with comment period, which will focus the program in its initial years on encouraging participation and educating clinicians, all with the primary goal of placing the patient at the center of the health care system. At the same time, we will also increase opportunities to join Advanced APMs, allowing eligible clinicians who chose to do so an opportunity to participate.”

Evolving Along with Payment Reform

CMS is building the Quality Payment Program to evolve along with the health care system. That’s why it facilitates participation in new payment models. The Affordable Care Act created the Center for Medicare and Medicaid Innovation (Innovation Center) to implement and scale the best ideas from the medical community to improve the quality of care for Medicare beneficiaries while lowering costs. Medicare has a plan for eligible beneficiaries to receive free diabetes prevention services, the quality of hip and knee replacements are being improved while lowering costs, and primary care clinicians are using flexibility to deliver the best outcomes with a payment system that rewards results. CMS intends to broaden opportunities for clinicians, including small practices and specialties, to participate in these kinds of initiatives. CMS is also reviewing reopening some existing Advanced Alternative Payment Models for application to allow more clinicians to join these types of initiatives. In 2018, CMS expects about 25 percent of eligible clinicians will be a part of the second path of Advanced Alternative Payment Models.

Providing Comprehensive Support to Physicians

To further support small practices, MACRA provides $20 million each year for five years to train and educate Medicare clinicians in small practices of 15 clinicians or fewer and those working in underserved areas. Beginning December 2016, local, experienced organizations will offer free, on-the-ground, specialized help to small practices using this funding.

Continuing to Listen

HHS is receiving feedback on the final rule with a comment period and will accept comments until 60 days after the final rule’s release date.

Quick Resource Links

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MACRA 911: Will MACRA Make Interoperability Better?

MACRA 911: Will MACRA Make Interoperability Better?

In September, CMS Acting Administrator Andy Slavitt in a bold and surprising move announced that physicians will have more options to comply and avoid a negative payment adjustment in 2019. Just a few months ago CMS was considering delaying the implementation of the Medicare Access and CHIP Reauthorization Act, which is set to start Jan. 1, 2017, but instead offered physicians more flexibility to the MACRA program with four options for participation. But, will this additional flexibility to entice more physicians to participate in the Medicare reimbursement program also make interoperability better in the long run?

Now that physicians will have a choice in how they participate in MACRA, the question becomes whether a technology upgrade will be necessary as well. Because MACRA is designed to overhaul how physicians are paid under Medicare, how they will use technology to achieve value-based care will take a valuable role in the coming year. The success of MACRA and a physician’s technology will be based on interoperability, or the ability of two or more systems or components to exchange information and to use the information exchanged. It may sound simple, but is it?

Under the Merit-Based Incentive Payment System (MIPS) portion of MACRA, an eligible physician must allow a single unique patient to view, download or transmit their patient record, within a performance period, or allow them to use an application programming interface (API) to access their record–or a combination of both. However, value-based care cannot be achieved without the interoperable exchange of data and the analysis of the data, to improve care and lower costs.

Although CMS backtracked a little by giving physicians more choices in how they participate in the program, the start date of Jan. 1, 2017, remains the same giving physicians mere months to get tech-ready yet again for another government mandate.

“We’ll be smart if we look at the Quality Payment Program as a framework we can work with that if implemented with care, can begin the process of turning things around towards a more sensible, simpler approach where physicians and other clinicians will feel supported by laws and regulations, the technology vendors, and the infrastructure that surrounds them,” Slavitt said at the 2016 Annual Meeting of the American Medical Association.

“This is why we need to be so committed to a collaborative implementation, increased transparency, and a continual improvement process so that over the next several years we allow feedback on the ground to inform the policies we implement.”

Nevertheless, John Squire, president and chief operating officer of Amazing Charts, a West Warwick, R.I.-based electronic health record software vendor, is less confident in small practices’ ability to succeed under MACRA. Squire, whose company’s provider clients are mainly in the 1 to 10 practice size range, says that most of them aren’t the least bit familiar with MACRA’s rules. He notes how many of them do not have an IT staff, so no one is perusing the latest CMS regulations, meaning they only hear about them over time from physician association groups. “We are focused on educating these practices since they’re simply not ready,” Squire said. “CMS has a long way to go in terms of educating small practices,” he added.

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MACRA 911: Getting Started

On April 16, 2015, President Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), significantly changing the health care financing system for the first time since 1965. The details of these sweeping changes are still being worked out, but all physicians should make plans for the new payment system.

MACRA repealed the Sustainable Growth Rate (SGR) payment system, which governed how physicians were paid under Part B of the Medicare program, and replaced its fee-for-service reimbursement model with a new two-track system requiring physicians to accept a certain amount of risk: Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

While MACRA only impacts Medicare payments, commercial payers typically follow Medicare’s payment models, and it is likely that risk will be more prominent in the commercial setting over the next several years. This is just the beginning of the official rulemaking process, but it is already clear that physicians will have a choice in whether to participate in MIPS or meet requirements for an APM.

The Medical Association is studying the proposed rule and may provide comments particularly on those provisions of the rule of most significance to smaller practices. The timeline of the implementation of MACRA is of the utmost importance in that physicians will begin reporting Jan. 1, 2017, which will affect Medicare payments in 2019. The Association will provide more information as it becomes available.

Here are the steps you can take to prepare your practice for one of the two new Medicare paths:

Review your quality measurement and reporting. Understanding current quality reporting requirements and how you are scoring across both the Medicare Physician Quality Reporting System (PQRS) and private payers will help your practice be better suited for the upcoming changes.

Access and review your Medicare Quality and Resource Use Reports (QRUR) to see where you can make improvements related to cost ahead of time. Two particularly important components to identify as you prepare for meeting the care coordination requirements are: (1) your most costly patient population conditions and diagnoses, and (2) targeted care delivery plans for these conditions.

Tip: You can access your 2014 annual PQRS feedback reports and QRURs on the CMS Enterprise Portal using your Enterprise Identify Data Management account. Learn more about how to access these reports. If you are part of a large practice, you may need to talk to your administrator about accessing your QRUR.

Understand your patient data and benchmarks. Data registries can streamline reporting and improve performance scores. You can view a list of 2016 CMS-approved qualified clinical data registries and contact information on the CMS website.

Check on your electronic health record (EHR). If you use an EHR, contact your vendor to discuss how its product supports adoption of new payment models.

Make sure your EHR is certified to the Office of the National Coordinator for Health IT’s (ONC) 2014 or 2015 certification requirements. Using a 2014 or 2015 edition EHR is essential for participation in either MIPS or APMs.

Ask your vendor when it will update your software to the 2015 certified edition and whether reporting quality measures through the EHR is a viable option based on the proposed MIPS quality requirements.

Tip: You can check your product’s certification in a listing by the ONC.

For more information on how to prepare for the new Medicare payment systems, review this MACRA checklist.

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While the ink is barely dry on the 962 pages of proposed regulations issued in April by CMS, the ripples of the Medicare Access and CHIP Reauthorization Act (MACRA) is already being felt throughout the health care industry. Keeping in mind this is still a proposed rule with comments to CMS due at the end of June, the final rule could very well look much different from what has been proposed. One thing is very clear – MACRA, in whatever form it finally takes, formally replaced the Sustainable Growth Rate (SGR), which would have continued to cut physicians’ reimbursement by 21 percent each year had it not been eliminated last year.

The Medical Association is studying the proposed rule and may provide comments particularly on those provisions of the rule of most significance to smaller practices. The timeline of the implementation of MACRA is of the utmost importance in that physicians will begin reporting Jan. 1, 2017, which will affect Medicare payments in 2019. The Association will provide more information as it becomes available.

MACRA repealed the SGR payment system, which governed how physicians were paid under Part B of the Medicare program, and replaced its fee-for-service reimbursement model with a new two-track system requiring physicians to accept a certain amount of risk: Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

It’s estimated that in 2017, about 90 percent of practices will fall into the MIPS category, and it will serve as a stepping stone for some of those practices to join APMs in subsequent years. The data collected during the 2017 calendar year reporting period will be reflected in 2019 payment adjustments.

While MACRA only impacts Medicare payments, commercial payers typically follow Medicare’s payment models, and it is likely that risk will be more prominent in the commercial setting over the next several years. Initially, physicians can choose MIPS or join an APM such as an accountable care organization or patient-centered medical home. If they make no choice or are deemed to be ineligible for an APM incentive payment, they will be assigned to MIPS.

Merit-based Incentive Payment System (MIPS)

The majority of physicians today participate in one or more of three existing payment incentive and quality improvement initiatives – Physicians Quality Reporting System, Meaningful Use and the Physicians Value-Based Payment Modifier – which will be dissolved as separate programs and melded into MIPS.

Under MACRA, physicians under MIPS will have to report their performance measures to CMS to be graded on four factors:

  1. Quality of Care – 30 percent
  2. Use of Resources – 30 percent
  3. Meaningful Use of EHRs – 25 percent
  4. Clinical Practice Improvement Activities – 15 percent

High-scoring physicians will get a bonus while low-scoring physicians will see a reduction in their fees. Physicians will be allowed to choose the quality measures upon which they will be evaluated. For the calculation of payment bonuses and penalties (and for ease of eventual consumer use through public reporting on Physician Compare), the Department of Health and Human Services (HHS) will be tasked with developing a composite score for each physician based on these factors. Maximum bonuses and penalties will be 4 percent in 2019, 5 percent in 2020, 7 percent in 2021, and 9 percent in 2022 and beyond. Additional funding of up to $500 million a year will be provided for separate bonuses for “exceptional performance,” from 2019 through 2024.

Alternative Payment Models (APMs)

Physicians choosing an APM will have to join an accountable care organization or an approved patient-centered medical home, or otherwise be in an alternative payment model entity where payment is at least partly based on quality performance and on total spending. Payment tied to performance must be 25 percent of a doctor’s or group practice’s Medicare revenue in 2019, increasing to 75 percent in 2022.

Physicians who join a CMS-approved alternative payment model will get an annual 5 percent bonus in their fees from 2019 to 2024. And, starting in 2026, physicians in alternative payment models will receive an annual across-the-board fee increase of 0.75 percent. Physicians participating in MIPS will get a 0.25 percent annual increase.

CMS proposes an approach to implementing the MACRA APM pathway through which eligible clinicians can become “qualifying participants” and earn statutorily specified incentives for participation. Advanced APMs must meet three proposed requirements deriving from the MACRA statute:

  1. Required use of certified EHRs;
  2. Payment for covered professional services based on comparable quality measures; and,
  3. Either being an enhanced medical home or bearing more than “nominal risk” for losses.

Joining an APM requires physicians to accept a certain degree of risk. Unfortunately, CMS has not yet adequately defined what degree of risk participants must accept to qualify. However, CMS proposed a “generally applicable financial risk standard” requiring APMs to include provisions that, if actual expenditures exceed expected expenditures, CMS can withhold payment, reduce payment rates, or require the APM to incur a debt to CMS. The risk must be more than nominal, which CMS accepts as “meaningful for the entity but not excessive.”

For more information about how MACRA can affect your payments, check out Health Affairs’ Health Policy Brief on Medicare’s New Physician Payment System from April 21, 2016.

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