Module one of our presentation will give a brief overview of the
Medicare Access and CHIP Reauthorization Act, or MACRA.
The Medicare Access and CHIP Reauthorization Act, or MACRA, was passed
by Congress on March 26, 2015, and signed into law by President Obama on
April 16, 2015. The MACRA makes three important changes to how Medicare
pays those who give care to Medicare beneficiaries. These changes
include: Ending the Sustainable Growth Rate (SGR) formula for
determining Medicare payments for health care providers' services.
Making a new framework for rewarding health care providers for giving
better care not just more care. Combining our existing quality reporting
programs into one new system.
To that end, the separate payment adjustments that are currently
assessed under PQRS, the value modifier and the electronic health record
meaningful use program will all sunset as of December 31, 2018. On
January 1, 2019, incentive payments for the newly created merit based
incentive payment system, or MIPS, as well as the alternative payment
models, or APMs, will begin. Medicare eligible professionals will be
able to elect to take the MIPS track or the APM track in order to
maximize these incentives. For those participating in the MIPS program,
your payment adjustment could be positive, neutral or negative, while an
EP electing to participate in an APM could receive an upward payment
adjustment of 5 percent for up to 6 years if the criteria for that APM
are met.
For those EPs who elect to participate in the MIPS program, the
incentives would apply to either individual EPs, groups of EPs, or
virtual groups. For the first two years of MIPS, 2019 and 2020, the
Medicare EPs that have been identified by the legislation as
MIPS eligible are physicians, physician assistants, nurse practitioners,
clinical nurse specialists and certified registered nurse anesthetists
as individuals, as well as groups that include these practitioners.
Starting in 2021, the law gives the Secretary discretion to add more
eligible provider types. Any EP who is participating in a qualifying
APM is excluded from MIPS, while those EPs who have been deemed as a
partial qualifying APM participant will have a choice of either being
exempt from MIPS or receiving the MIPS Adjustment. The MACRA also
allows for certain low volume thresholds as well. Beginning in 2019, EPs
participating in the MIPS will be eligible for positive or negative
Medicare payment adjustments that start at 4 percent and gradually
increase to 9 percent for 2022. EPs will receive a composite score that
will range from 0 to 100 and will measure performance in four different
categories: quality measures, resource use, clinical improvement
activities and meaningful use of certified electronic health record
technology. The weight of each category starting in 2019 and going
beyond 2022 is shown in the table on this slide. EPs who score at the
threshold will receive no payment adjustment; those whose composite
score is above the performance threshold will receive a positive payment
adjustment on each claim for the following year, while those whose
composite score is below the performance threshold will receive a
negative payment adjustment on each claim for the following year. And
per the MACRA legislation, these adjustments must be budget neutral.
Physicians with high composite scores will be eligible for a positive
payment adjustment that is up to three times the baseline positive
payment adjustment for a given year. For example, the baseline positive
payment adjustment for 2019 will be 4 percent, so high performers will
be eligible for a positive payment adjustment of up to 12 percent. For
2019 through 2024, an additional positive payment adjustment of up to 10
percent will be available to exceptional performers. Beginning in 2026,
all physicians participating in the MIPS will be eligible for a 0.25
percent increase in their payments each year.
If you are eligible and choose to participate in a qualifying APM, you
will receive a 5 percent lump sum bonus on your Medicare payments for
2019 through 2024. Beginning in 2026, you will qualify for a 0.75
percent increase in your payments each year.
MACRA defines any of the following as an alternative payment model: An
innovative payment model expanded under the Center for Medicare &
Medicaid Innovation (CMMI), including Comprehensive Primary Care (CPC)
initiative participants but not Health Care Innovation Award recipients
A Medicare Shared Savings Program accountable care organization (ACO)
Medicare Health Care Quality Demonstration Program or Medicare Acute
Care Episode Demonstration Program, or another demonstration program
required by federal law An APM must require participants to meet all of
the following criteria: Uses quality measures comparable to measures
under the MIPS Uses certified electronic health record (EHR) technology
Bears more than nominal financial risk OR is a medical home expanded
under the CMMI For more information on the Medicare Access and CHIP
Reauthorization Act, and on the Merit based Incentive Payment System and
Alternative Payment Models specifically, please go to the website listed
on this slide. The MACRA Path to Value presentation is also available
for viewing. That concludes Module one of the Medicare Quality Reporting
Programs presentation for 2016. Thank you for watching. To view the
remaining modules of this presentation, please see the links in the
"Descriptions" section of this video.
This MLN Connects video is part of the Medicare Learning Network. The
information presented in this presentation was correct as of the date it
was recorded. This presentation is not a legal document. Official
Medicare program legal guidance is contained in the relevant statutes,
regulations, and rulings.