CMS proposed rule details Medicare’s new physician “Quality Payment Program”
Reporting under new measures slated to begin in 2017
The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for Medicare payment to physicians, released a proposed rule on April 27, 2016, setting forth key provisions of its Quality Payment Program for physicians, implementing key provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repealed the Sustainable Growth Rate (SGR) formula for annually adjusting Medicare payment to the nation’s physicians, replacing the SGR with a value-based payment system to be developed by CMS consistent with MACRA’s directives. The proposed rule has been published in the May 9, 2016 Federal Register. Comments are due by June 27, 2016.
The proposed Quality Payment Program has two payment incentive tracks: 1) a Merit-based Incentive Payment System (MIPS) focused on successfully achieving quality measures, and 2) a payment incentive based on significant participation in an Advanced Alternative Payment Model (APM). Most physicians will be impacted by MIPS. Under the Quality Payment Program, “eligible professionals” now will be “eligible clinicians,” including physicians, physician assistants, nurse practitioners, clinical nurse specialists, and CRNAs as well as practice groups that include these clinicians.
MIPS consolidates components of Medicare’s Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program while maintaining a strong incentive focus on integrated use of certified EHR technology (CEHRT). Through MIPS, CMS proposes to pay eligible clinicians for providing high quality, efficient care through identified success in four (4) performance categories –
- Cost (10% of total score in year 1). Replaces the cost component of the VM, also known as Resource Use. The cost score would be based on Medicare claims, requiring no clinician reporting. This category uses over 40 episode-specific measures to account for differences among specialties. Clinicians must see a sufficient number of patients (generally at least 20) for a cost measure to be scored. If a clinician does not have enough patient volume in any cost measure, then a cost score will not be calculated; CMS will reweight the cost category to zero and adjust other MIPS category scores to make up the difference.
- Quality (50% of total score in year 1). Replaces PQRS and the quality component of the VM. Clinicians would select six reporting measures rather than nine (9) as currently required under PQRS. The rule proposes more than 200 measures to select from; more than 80% of the quality measures proposed are tailored to specialists. Clinicians may opt to report a specialty measure set specifically designed around certain conditions and specialty types. Using claims data, CMS also will calculate population measures, two for individual clinicians and small groups of 2-9 clinicians and three for groups of 10 clinicians or more.
- Clinical Practice Improvement Activities (15% of total score in year 1). Activities falling within this CPIA category include care coordination, beneficiary engagement, and patient safety. Eligible clinicians select activities that match their practice’s goals from a list of more than 90 options. Clinicians also are eligible to receive credit in this category for participation in APMs and Patient-Centered Medical Homes (PCMHs).
- Advancing Care Information (25% of total score in year 1). Replaces the Medicare EHR Meaningful Use program for physicians. Eligible clinicians would choose to report customizable measures that reflect how they use EHR technology in their practices. A clinician’s overall score in this category would be made up of a base score and a performance score. A base score is derived from clinician response to identifiable measures within six objectives: (i) Protect Patient Health Information; (ii) Patient Electronic Access; (iii) Coordination of Care through Patient Engagement; (iv) Electronic Prescribing; (v) Health Information Exchange; and (vi) Public Health and Clinical Data Registry Reporting. A performance score is derived from measures clinicians select from three of these objectives: Patient Electronic Access. Coordination of Care through Patient Engagement, and Health Information Exchange. Clinicians must achieve the Protect Patient Health Information objective, which requires a security risk analysis, to receive a performance score and must engage in immunization registry reporting under the Public Health/Registry reporting objective. Clinical Decision Support and Computerized Provider Order Entry reporting no longer will be required.
Medicare will begin measuring clinician reporting under MIPS in calendar year (CY) 2017, with payments based on those measures beginning in CY 2019. MACRA requires MIPS to be budget neutral. As such, clinicians’ MIPS scores will be used to compute positive, negative, or neutral payment adjustments. In CY 2019, negative adjustments can be no greater than 4% and positive adjustments can be up to 4%. These percentages increase to 5% in CY 2020, 7% in CY 2021, and 9% in CY 2022. MACRA also provides $500 million annually for exceptional performance bonuses in CY 2019-CY 2023, an amount not subject to budget neutrality. Under MACRA, CY 2019 is the last year for a 0.5% physician fee schedule increase.
A second incentive payment option for clinicians is participation in an Advanced APM. Clinicians successfully meeting Advanced APM criteria receive a 5% Medicare payment boost, need not report under MIPS, and cannot receive MIPS payment incentives. An Advanced APM must accept risk, must be a CMS Innovation Center model or a statutorily-required demonstration, must base clinician payment on quality measures, and must require use of certified EHR technology by at least 50% of its clinicians. PCMHs expanded under Innovation Center authority can qualify as APMs without taking on financial risk. Only clinicians who participate “to a significant extent” by receiving enough of their payments or seeing enough of their patients through an Advanced APM are eligible for the 5% payment incentive.
A closing note. CMS has been working in collaboration with America’s Health Insurance Plans (AHIP), major commercial payers, the National Quality Forum (NQF), and other stakeholders to promote multi-payer alignment on core measures for physician quality programs. In February 2016, the collaboration announced seven (7) sets of clinical quality measures in the areas of 1) ACOs, PCMHs, and primary care; 2) cardiology; 3) gastroenterology; 4) HIV and Hepatitis C; 5) medical oncology; 6) obstetrics and gynecology; and 7) orthopedics. Additional information regarding this public/private payer alignment effort can be found at Core Quality Measure Collaborative.