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Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

On April 16, 2015, President Barack Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  This legislation is meant to reform the way that Medicare reimburses physicians and other healthcare providers that bill the Medicare Physician Fee Schedule.  As part of the proposed rule to implement MACRA, the Centers for Medicare and Medicaid Services (CMS) renamed the programmatic features as the “Quality Payment Program.”

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

On April 16, 2015, President Barack Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  This legislation is meant to reform the way that Medicare reimburses physicians and other healthcare providers that bill the Medicare Physician Fee Schedule.  As part of the proposed rule to implement MACRA, the Centers for Medicare and Medicaid Services (CMS) renamed the programmatic features as the “Quality Payment Program.”

How does the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) reform Medicare payment for healthcare providers – i.e. physicians, nurse practitioners, physician assistants, and clinical nurse specialists?

The MACRA Law makes three important changes to how Medicare pays those who give care to Medicare beneficiaries. These new payment polices are now known as the “Quality Payment Program (QPP)”:

  • Ends the Sustainable Growth Rate (SGR) formula for determining Medicare payments.
  • Creates a new framework for rewarding health care providers for giving better care not more care.
  • Combines existing quality reporting programs – i.e. Physician Quality Reporting System (PQRS), Valued-based Payment Modifier (VBM) and the Meaningful Use of Electronic Health Records –  into one new system.

This Quality Payment Program replaces a patchwork system of Medicare reporting programs with a flexible system that allows health care providers to choose from two paths that link quality to payments:

  1. Merit-Based Incentive Payment System (MIPS)
  2. Advanced Alternative Payment Models (APMs)

When do the new payment programs go into effect?

MIPS and APMs will go into effect over a timeline from 2017 through 2021 and beyond.

The new Merit Incentive Payment System (MIPS) and the option of participating in an approved Advanced Alternative Payment Model (APM) will begin on January 1, 2017 for the first reporting period under the Quality Payment Program. Activities reported in 2017 will be used by CMS to adjust payments to eligible providers under the Quality Payment Program in 2019.

Understanding the Merit-Based Incentive Payment System (MIPS)

The MIPS combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one single program. MIPS most closely approximates the current fee-for service system.  A notable exception is that payment adjustments will be tied to a Composite Performance Score based on measures in a number of categories including; quality, resource use, clinical practice improvement activities, and meaningful use of certified EHR technology. Providers may be reimbursed more (for meeting quality outcomes) or less (if they fall below an averaged national metric).

You may be able to report through claims, registries, Qualified Clinical Data Registries, health information technology developers, and certified survey vendors.

MIPS Reporting

  • First MIPS reporting period begins on January 1, 2017 and runs through December 31, 2017.
  • MIPS Eligible Clinicians: Physicians, PAs, NPs, CMS, CRNA
  • For applicable clinicians, 2017 MIPS performance will determine payment increases/penalties for the 2019 Payment Year.
  • Maximum MIPS negative payment adjustment will be -4% for 2019, if an eligible clinician chooses to do nothing.
  • As proposed, then three major categories of exempted physicians:

Options for MIPS Reporting

Eligible Clinicians have two options for reporting:

  • Report as an “Individual,” – combination of TIN/NPI
  • Report as a “Group,” – Group’s billing TIN as identifier

A “Group” is defined as two or more Eligible Clinicians (EC) that have assigned billing rights to the same TIN. There will be no “virtual groups,” until the 2018 reporting year.

How do I report my information to CMS for the MIPS?

Quality of Care
  • Qualified Clinical Data Registry (QCDR)
  • Electronic Health Record
  • Claims Data
  • GPRO
Resource Use
  • Claims Data
EHR Meaningful Use
  • Attestations
  • QCDR
  • EHR
Clinical Improvement Activities
  • Attestation
  • QCDR
  • “Qualified Registry”
  • EHR
  • Claims Data


MIPS Incentive Payments/Adjustments

The MIPS is a system where each eligible clinician will receive a composite score or “index,” that will determine whether they receive a positive or negative payment adjustment for a given year starting in 2019 based on data and activities reported in 2017.  This composite score is based on an eligible clinicians performance in four different categories:  Quality, Cost, Clinical Performance Improvement Activities, and Advancing Care Information, previously known as Meaningful use of Electronic Health Records.  Below is a chart summarizing the various categories and their scores.  Please download the CMS information regarding this four program elements of MIPS.

MIPS Potential Payment Adjustments

What are Alternative Payment Models (APMs)?

APMs use bundles to link the payment of unconnected services for an episode of care or condition. Bundling services that were previously billed separately is meant to reduce unnecessary spending and improve quality. Physicians who provide a certain percent of their patient care in the APMs will be exempt from many MIPS requirements and will be offered additional incentives. For example:

  • From 2019-2024, pay some participating health care providers a lump-sum incentive payment.
  • Increased transparency of physician-focused payment models.
  • Starting in 2026, offers some participating health care providers higher annual payments.

Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs.

CMS currently has a number of APMs that are being evaluated through demonstration projects, but the first MACRA changes to physician payment are operational now. CMS now has as a goal, in general, having 30% of traditional Medicare payments tied to performance by the end of 2016, and 50% of these payments tied to APMs or some type of performance/value-based reimbursement by the end of 2018. Reimbursements under the new MACRA policy depend heavily on system-based and patient-based outcome measures. As the only physicians trained to provide both complex surgical and medical treatment for women with gynecologic cancers, gynecologic oncologists should be leaders in the development of best practice models and outcome measures for women with gynecologic cancers.

Which path should I take?

Want to learn more before you make your decision regarding which pathway is right for you? Please continue to visit this special MACRA page of the SGO website for various updates, toolkits, etc. And, take a few minutes to watch this video produced by the Centers for Medicare and Medicaid Services:

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The SGO is working on the development of Advanced Alternative Payment Models so that there will be opportunities for gynecologic oncologists to participate in this Quality Payment Program pathway. The soonest that could be available would be for 2018 reporting.

What is SGO doing regarding the implementation of MACRA and the Quality Payment Program?

The SGO continues to work with CMS and Congress to ensure that the agency implements the new payment systems in a way that makes sense for how SGO members deliver quality care and that minimizes administrative burdens. On April 27th, 2016, a proposed rule was issued by CMS signifying the most extensive change in physician payment policies in the last two decades. SGO Health Policy and Socioeconomic Committee worked diligently to analyze the information to determine how it will impact gynecologic oncology practices. The SGO submitted comments on this proposed rule.

The final rule is due to be released in the fall, most likely late October. SGO will be sharing information with its members regarding the specific requirements for 2017 reporting.

What is SGO doing to facilitate the participation in APMs?

The SGO Taskforce on the Future of Physician Payment Reform has been developing an APM for uterine cancer with the goal to improve the quality of care while reducing overall expenditures. The Taskforce first sought input from multiple stakeholders and developed an in-depth pathway for the care of patients with endometrial cancer from the time of diagnosis. This pathway detailed all services, reimbursed and uncompensated, provided to a woman with endometrial cancer. Next, the Taskforce used this pathway to create the framework for an APM specifically focused on the surgical management of women with endometrial cancer at the time of initial diagnosis. Over the next year, the Taskforce will continue to develop the endometrial cancer care APM and will validate the APM using retrospective data obtained from a variety of settings and practices. Though the initial endometrial cancer APM focuses on operative care, additional bundles incorporating other care pathways and other gynecologic cancers will soon be developed.

Additional resources for learning about MACRA and the Quality Payment Program

Final Rule and Executive Summary


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