Beginning in 2019, Medicare payments through MACRA are to begin the phasing out of traditional fee-for-service payments.
The law repealed the annual Sustainable Growth Rate (SGR) formula, linking Medicare annual payment updates to prior year spending and gross domestic product (GDP) growth.
The law mandates that Medicare payment increases remain stable at 0.5 percent through 2019, and then remain flat through 2025. The first performance assessment year toward MACRA scoring is 2017, based on existing models providers are utilizing to determine payment in 2019, after which the new reporting structures begin.
The new Medicare payment models begin offering eligible clinicians (ECs) two payment tracks within the transition to value-based care and population health management; the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Models (APM) tracks.
Overall, MIPS has four scoring pillars from which providers will be assessed a 100-point scoring scale. The pillars are comprised of:
- Quality – Replaces PQRS and the value-based modifier quality, requires reporting of six measures
- Advancing Care Information – Formerly MU with similar but decreased measures focusing on data exchange
- Cost – Originally referred to as Resource Use, this scoring is based on Medicare claims and requires no reporting
- Improvement Activities – Expanded list of 90 options from nine categories. Basic APM and PCMH participation included in scoring options
Based on total scores, EPs will either be assessed an up or down payment adjustment ranging from four to nine percent annually from 2019 to 2022 and beyond, capping at nine percent.
Medicare Part B providers subject to MIPS include:
- Physician Assistants
- Nurse Practitioners
- Certified RN Anesthetists
- Clinical Nurse Specialists
From 2021 onward, the law allows for additional EP types to be added.
The APM track offers extra incentive rewards for providers in a variety of ACO, medical home and related value-based care payment models.
This model rewards two tiers of APM participation. Advanced APM participation – based on risk, include a 5 percent lump-sum bonus from 2019 to 2024 and higher fee schedule updates are offered. Providers in the Advanced APM track are also excluded from the MIPS track requirements.
Other more basic APM model participation – such as bundled payment programs – offers scoring preference in the MIPS Clinical Practice Improvement pillar.
Advanced APM participation, though, is based on qualifying within certain revenue and patient volume, as well as risk, factors:
- In 2019 and 2020, qualifying providers are to have 25% of payments or patients in an APM to qualify for the track and its incentives
- In 2021 and 2022, 50% of payments or patients within an APM, or through a combination of APMs and other payment arrangements
- Beginning in 2023, 75% APM or the combination of an APM and other payments