As part of the effort to fix what had become a yearly exercise to delay cuts in Medicare reimbursements to doctors, Congress passed MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – which repealed the Sustainable Growth Rate (SGR) formula. The replacement is the Quality Payment Program (QPP), a new value-based reimbursement system with two tracks: The Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models, or Advanced APMs. According to the Centers for Medicare and Medicaid (CMS), the QPP replaces a patchwork of Medicare reporting programs with a “flexible system that allows you to choose two paths that link quality to payments – MIPS and Advanced APMs.”
Now, each Medicare Part B clinician is either in MIPS, an Advanced APM, both or neither (which means their model is regular fee-for-service). CMS predicts that eventually most Part B providers will be subject to MIPS because they can only be exempt under certain conditions. MIPS fee schedule updates took effect in 2015, based on quality, resource use, clinical practice improvement activities and Advancing Care Information (ACI – what CMS now calls meaningful use). These are portrayed in a Clinical Practice Improvement Score (CPS) of up to 100 points.
Beginning January 1, 2017, MACRA combines meaningful use, the Physician Quality Reporting Systems (PQRS) and the Value-Based Modifier (VBM) programs into MIPS. What a clinician receives in MIPS payment adjustments in 2018 will be based on a small annual adjustment for inflation and on the CPS for 2017. After that, a given year’s CPS will help determine the next year’s payment adjustments.
Qualifying APM participants who are excluded from MIPS can begin receiving 5% incentive payments in 2019. That same year, MIPS will begin making payment adjustments of 4% that could rise as high as 9% starting in 2022.
While Medicare still limits reimbursements for telemedicine services to clinicians who see patients in rural and medically underserved areas, the Affordable Care Act created Accountable Care Organizations (ACOs). These are groups of doctors, hospitals and other health care providers who give patients coordinated health care to their Medicare patients. Last year, CMS created a new category of ACOs, called Next Gen ACOs. Along with Medicare Advantage plans and facilities using bundled payments, Next Gen ACOs can apply for a waiver, allowing them to receive reimbursements for telemedicine services involving urban patients at any location – even in the patient’s home.