The next milestone in provider payments: Shaping the substance of MACRA
Healthcare providers have long heard about the shift from fee-for-service to value-based reimbursements, but the transition hasn’t been immediate or clearly defined. But the Centers for Medicare & Medicaid Services (CMS) took the next step toward payment reform on Sept. 28, by releasing a long-term framework for how value-based medicine will take shape and how providers will be paid by Medicare in the coming decades.
The CMS Request for Information (RFI) seeks recommendations on how the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) — passed into law in April — should be implemented on a programmatic level. Essentially, this opportunity to provide feedback gives providers and healthcare IT (HIT) vendors the chance to direct their own destinies.
Healthcare stakeholders can make recommendations (due by Oct. 31, 2015) on payment methodologies, quality-reporting alignment and technology requirements, and which types of clinical quality measures should be used and updated annually.
Payment elements of MACRA
The major payment elements are divided into two main structures. One is the Merit-based Incentive Payment System (MIPS). Providers will be scored on this structure beginning in 2017, then affecting payments in 2019.
Four elements make up the MIPS 100-point scoring system:
- Meaningful use attestation — 25 percent
- Quality performance — 30 percent
- Resource use performance — 30 percent
- Clinical practice improvement — 15 percent
The other major payment element is provider participation in alternative payment models (APMs). The Center for Medicare and Medicaid Innovation (CMMI) has foreshadowed that participation in established patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) will count as APMs.
Providers participating in an APM will be eligible to receive an annual five-percent bonus in 2019, continuing through 2024. If providers meet income percentage thresholds through APM participation, they may be exempt from the MIPS scoring process.
This is positive news for qualifying providers; however, providers who will face MIPS judgment may question the ambiguity of the scoring system. For example, what are “resource use” and “clinical practice improvement”, and how will those factors be measured?
Those areas are where the HIT and provider sectors need to collaborate during this comment phase.
Key issues of MACRA
A key concern regarding MACRA is how far quality-reporting programs alignment can proceed. Currently, meaningful use, the Physician Quality Reporting System (PQRS) and the value-based modifier (VBM) are merging as part of the MIPS structure, which will end penalties specific to each of these individual programs.
Major concerns for the HIT sector include clarity of certification language, technology standards and reporting functions, including interoperability. Current ONC certification for meaningful use is expanding to cover other programs, but will not necessarily create separate certification measures for the advent of APM reporting or functionality within MACRA.
Current system certification requirements will remain consistent for existing APMs, such as the CMS chronic care management incentive, which utilizes existing EHR capabilities and certification within meaningful use.
Providers should also consider making recommendations concerning the scope of APMs, including how existing technology, standards and certification will align. To bring a wide variety of providers into the APM incentive pool — including behavioral medicine, for example, which was excluded from meaningful use — should programs such as bundled payments, Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstrations, Medicaid’s Strong Start Initiative and the CMS Comprehensive Primary Care Initiative (CPCI) also be included?
Regulatory timelines pose another issue: just as meaningful use timelines have historically been a burden for healthcare stakeholders, elements of MACRA and MIPS will likely also be subject to annual review. However, if CMS intends to continually roll out MACRA regulatory language within annual physician fee schedules (as it did in the 2016 fee schedule proposed rule), the practice of finalizing annual fee schedules late in a given calendar year needs to be re-evaluated.
By now, it’s clear that the puzzle of combining MACRA and MIPS has not yet been fully solved.
As part of Greenway Health’s continued service to customers through membership in the Electronic Health Record Association (EHRA), the Health Information and Management Systems Society (HIMSS) and other organizations, we will advocate for a regulatory structure that is attainable by our customers, aligned with clinically relevant processes and outcomes, and heavily reliant on existing health IT capabilities and certification.