On April 27, CMS released a notice of proposed rulemaking (NPRM) for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Supported by a bipartisan majority and stakeholders, such as patient and medical associations, the MACRA legislation ended more than a decade of last-minute fixes and potential payment cliffs for Medicare doctors and clinicians. It also made numerous improvements to America’s health care system.
Proposed MACRA Requirements
Currently, Medicare measures the value and quality that physicians and other clinicians provide through a patchwork of programs. In the MACRA legislation, Congress streamlined these programs into a single framework to help clinicians transition to payments based on value from payments based on volume. The proposed rule would implement changes through this unified framework known as the Quality Payment Program, which includes two paths:
1. The Merit-based Incentive Payment System (MIPS): Most Medicare clinicians will initially participate in the Quality Payment Program through MIPS. MIPS allows Medicare clinicians to be paid for providing high value care through success in four performance categories:
- Quality (50 percent of total score in year 1)
- Advancing Care Information (25 percent of total score in year 1)
- Clinical Practice Improvement Activities (15 percent of total score in year 1)
- Resource Use (10 percent of total score in year 1)
2. Advanced Alternative Payment Models (APMs): Clinicians who take a further step toward care transformation would be exempt from MIPS reporting requirements and qualify for financial bonuses. These models include:
- Comprehensive ESRD Care Model (Large Dialysis Organization arrangement)
- Comprehensive Primary Care Plus (CPC+)
- Medicare Shared Savings Program – Track 2
- Medicare Shared Savings Program – Track 3
- Next Generation ACO Model
- Oncology Care Model Two-Sided Risk Arrangement (available in 2018)
How to Submit Comments
The public can submit comments in several ways, including via electronic submission or mail:
1. Electronically: Once the NPRM is published in the Federal Register, you may submit electronic comments to http://www.regulations.gov.
2. By regular mail
3. By express or overnight mail
4. By hand or courier
Medicare Eligible Professionals: Take Action by July 1 to Avoid a 2017 Medicare Payment Adjustment
Compared to previous years, the streamlined hardship applications reduce the amount of information that eligible professionals (EPs), eligible hospitals, and CAHs must submit to apply for an exception. The new applications and instructions for a hardship exception from the Medicare Electronic Health Records Incentive Program 2017 payment adjustment are available below.
This new, streamlined application process is the result of PAMPA, which established that the Secretary may consider hardship exceptions for “categories” of EPs, eligible hospitals, and CAHs that were identified on CMS’ website as of December 15, 2015. Prior to this law, CMS was required to review all applications on a “case-by-case” basis.
Importantly, EPs, eligible hospitals, and CAHs that wish to use the streamlined application must submit their application according to the timeline established in PAMPA:
- Eligible Professionals: July 1, 2016
- Eligible Hospitals & CAHs: July 1, 2016
Please note: CAHs should use the form specific for the CAH hardship exceptions related to an EHR reporting period in 2015. CAHs that have already submitted a form for 2015 are not required to resubmit.
In the American Recovery and Reinvestment Act of 2009 (ARRA), Congress mandated that payment adjustments should be applied to Medicare eligible professionals, eligible hospitals, and critical access hospitals (CAH) that are not meaningful users of Certified Electronic Health Record (EHR) Technology under the Medicare EHR Incentive Program.
If a provider is eligible to participate in the Medicare EHR Incentive Program, they must demonstrate meaningful use in either the Medicare EHR Incentive Program or in the Medicaid EHR Incentive Program, to avoid a payment adjustment. Medicaid providers who are only eligible to participate in the Medicaid EHR Incentive Program are not subject to these payment adjustments.
Eligible Professional Reconsideration Form
The deadline for Eligible Professionals to submit Reconsideration forms for the 2016 payment adjustment, based on the 2014 EHR reporting period, was February 29th, 2016. No applications will be accepted after the deadline. For inquiries about the Reconsideration Application, please email firstname.lastname@example.org.
2016 PQRS GPRO: Register by June 30 Deadline
Groups can register to participate in the 2016 Physician Quality Reporting System (PQRS) Group Reporting Option (GPRO) via the Physician Value - Physician Quality Reporting System (PV-PQRS) Registration System. PQRS GPRO is an option available to groups with 2 or more eligible professionals (EPs). Groups must meet the satisfactory reporting criteria through the PQRS GPRO in order to avoid the -2.0% CY 2018 PQRS payment adjustment.
Physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists in groups of all sizes and those who are solo practitioners are subject to the Value Modifier in 2018, based on performance in 2016. Avoiding the 2018 PQRS payment adjustment by satisfactorily reporting via a PQRS GPRO is one of the ways groups can avoid the automatic downward payment adjustment (-2.0% or -4.0% depending on the size and composition of the group) and qualify for adjustments based on performance under the Value Modifier in 2018.
More information is available on the PQRS Payment Adjustment Information web page.
Groups can participate in the PQRS program for the 2016 performance period by selecting one of the GPRO reporting mechanisms between April 1, 2016 and June 30, 2016 (11:59 pm EDT):
- Qualified PQRS Registry.
- Electronic Health Record (EHR) via Direct EHR using certified EHR technology (CEHRT) or CEHRT via Data Submission Vendor.
- Web Interface (for groups with 25 or more EPs only).
- Qualified Clinical Data Registry (QCDR)
- Consumer Assessment of Health Providers and Systems (CAHPS) for PQRS Survey via a CMS-certified Survey Vendor (as a supplement to another GPRO reporting mechanism). See CAHPS for PQRS Made Simple for complete details.
Groups with 2 or more EPs that choose not to report via the PQRS GPRO in 2016 must ensure that the EPs in the group participate in the PQRS as individuals in 2016 and at least 50 percent of the EPs meet the criteria to avoid the 2018 PQRS payment adjustment in order for the group to avoid the automatic downward payment adjustment and qualify for adjustments based on performance under the Value Modifier in 2018.
The Registration System can be accessed using a valid Enterprise Identify Management (EIDM) account. Instructions for obtaining an EIDM account with the correct role are provided on the PQRS GPRO Registration web page. Instructions for registering to participate in the 2016 PQRS GPRO are provided in the 2016 PQRS GPRO Registration Guide.