On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule detailing, for the first time, the physician reimbursement framework required by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. MACRA, which replaced the flawed Sustainable Growth Rate (SGR) formula, created a new program for physician reimbursement that streamlines quality programs and addresses reporting burdens.
The new program—as detailed in the proposed rule—is called the Quality Payment Program (QPP) and includes two pathways: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). The MIPS program allows eligible clinicians to be paid via a composite score based on four performance categories. Payment adjustments under MIPS will begin in 2019, for performance data reported from Jan. 1–Dec. 31, 2017 (year 1). Clinicians who see enough of their patients through Advanced APMs would be exempt from MIPS payment adjustments and qualify for a 5 percent Medicare Part B incentive payment.
"The importance of this proposed rule cannot be overstated," said American Association of Orthopaedic Surgeons (AAOS) President Gerald R. Williams Jr, MD. "This is a significant and complex regulation that alters physician reimbursement and implements a number of new initiatives to decrease cost and improve quality of care for Medicare beneficiaries.
"As specialty physicians," he continued, "orthopaedic surgeons face unique challenges and require specialty-specific tools, measures, and other considerations in order to successfully participate in quality performance programs and APMs. We look forward to working closely with CMS to refine MACRA provisions and ensure physician payment reform ultimately improves the care of musculoskeletal patients."
According to CMS, most Medicare clinicians will initially participate in the QPP through MIPS rather than Advanced APMs. The agency stressed that in this track, the proposed rule "seeks to streamline and reduce reporting burden across all four categories, while adding flexibility for physician practices." The four performance categories under MIPS include Quality, Advancing Care Information, Clinical Practice Improvement Activities, and Cost.
- Quality (50 percent of total score in year 1): This category replaces the Physician Quality Reporting System (PQRS) and the quality component of the Value Modifier Program. For this category, clinicians would choose to report six measures (down from the nine currently required under PQRS) from a number of options.
- Advancing Care Information (25 percent of total score in year 1): This category replaces the Medicare Electronic Health Records (EHR) Incentive Program for physicians, also known as Meaningful Use. For this category, clinicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting.
- Clinical Practice Improvement Activities (15 percent of total score in year 1): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities that match their practices' goals from a list of more than 90 options.
- Cost (10 percent of total score in year 1): For this category, the score would be based on Medicare claims, meaning no reporting requirements for clinicians. This category would use 40 episode-specific measures to account for differences among specialties.
"We are working with the medical community to advance our collective vision for Medicare payment reform," said Patrick Conway, MD, CMS acting principal deputy administrator and chief medical officer. "By proposing a flexible, rather than a one-size-fits-all program, we are attempting to reflect how doctors and other clinicians deliver care, and give them the opportunity to participate in a way that is best for them, their practice, and their patients. Reducing burden and improving how we measure performance supports clinicians in doing what they do best—caring for their patients."
AAOS has previously communicated with CMS on the implementation of select provisions of MACRA, including episode groups, aspects of the MIPS program, developing alternative payment models, and encouraging creation of physician-focused payment models. Although CMS has recognized some of the AAOS concerns, including adding flexibility to quality reporting and responding to specialty-specific needs, serious issues still need to be addressed. Dr. Williams stressed that orthopaedic "involvement in the development and implementation of MACRA will be critical."
"AAOS recognizes CMS' efforts to provide additional flexibility and respond to specialty-specific concerns, especially in areas of quality reporting," said Thomas C. Barber, MD, chair of the AAOS Council on Advocacy. "The removal of an ‘all-or-nothing' approach and the decreased number of measures are significant positive changes from current policy. However, there are a number of issues that still need to be addressed. Specifically, AAOS has concerns about the timing of implementation and infrastructure readiness, the restrictive requirements for Advanced APMs, and access to Medicare claims data."
AAOS leadership and staff are closely reviewing the proposed rule and will be coordinating formal written comments with state and specialty societies.
Elizabeth Fassbender is the communications manager in the AAOS office of government relations. She can be reached at firstname.lastname@example.org
MACRA proposed rule
CMS fact sheet
U.S. Department of Health & Human Services press release