The proposed rule would implement these changes through a unified framework called the “Quality Payment Program.” It includes two paths:
- The Merit-based Incentive Payment System (MIPS) or
- Advanced Alternative Payment Models (APMs)
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Under the MIPS payment system, physicians are required to report measures under 4 performance categories, each of which is assigned a certain number of earned points that can be earned to determine to composite performance score determining the adjustment. CMS also will provide each physician or group with a weighted score. The four categories are:
- Quality Measures (50 points) – Six measures are required and less in specific areas with partial credit for small and rural practices.
- Advancing Care Information (ACI) (25 points) – Formerly known as meaningful use. CMS wants practices to report on the use of electronic health records.
- Clinical Practice Improvement Activities (CPIA) (15 points) – Awards for improvement of practice activities that improve care. There is a list of 90 activities. Radiology may qualify to report about 15 percent of them.
- Cost (10 points) – This is not a category where measures are reported on the claim. Rather, CMS applies its own claims data which is linked to how many patients can be attributed to the physician or group.
Alternatively, physicians or groups may qualify to gain a 5 percent bonus for participating in alternative payment models. CMS redefines APMs as Advanced Alternative Payment Models and proposes that they include the following existing models as of Jan. 1, 2017:
- Medicare Shared Savings Program – Tier 2 and 3
- Comprehensive Primary Care Plus
- The Next Generation Accountable Care Organization Model
- Comprehensive End Stage Renal Disease Care Model
- The Oncology Care Model (two-sided risk arrangement)
On May 13, CMS issued a Flexibilities and Support for Small Practices fact sheet in response to many stakeholders’ concerns about the proposed rule that shows that 87 percent of solo practitioners and 69.9 percent of small groups (2-9 doctors) will see penalties under MIPS. This is in comparison to the projected 49.2 percent penalty and 50.4 percent positive scores for larger practices.
CMS acknowledges that the NPRM will have a negative impact on small practices, but it believes that the impacts based on 2014 data are artificially inflated. CMS’ rationale for this misperception is that it is based on 2014 data, which does not take into consideration special accommodations for small and rural practices in the rule. CMS also notes that few small practices were reporting measures in 2014. When these aspects of the data are taken into account, CMS predicts that actual impacts in 2019 will be much smaller.
In the proposed rule, CMS makes special accommodations for small and rural practices by:
- Excluding practices from MIPS that generate a low volume of care from Medicare patients and bill less than $10,000 worth of claims annually.
- Acknowledging the unique needs and challenges of being in compliance with the use of electronic health records (formerly known as meaningful use). CMS is promoting the use of technology that is meaningful and easy to use.
- Allowing for flexibility in MIPS scoring so that fewer measures are required and partial credit is given to small and rural practice to qualify for bonuses in the quality measure and clinical practice and improvement categories.
- Allowing for group reporting where the reporting of the group covers all individual physicians in the practice regardless of their level of individual participation or possible participation in a multispecialty virtual group.
- Promoting the use of a single reporting mechanism, such as registries.
CMS also developed the Transforming Clinical Practice Initiative and has awarded $685 million to 39 national and regional health care networks and supporting organizations to provide technical assistance to help equip more than an estimated 140,000 clinicians with tools and support. The ACR’s R-SCAN project was one of the 10 support and alignment networks that was awarded funding to help physicians transition into new clinical practice.
The ACR will comment extensively on the MACRA proposed rule and its effects on small and rural practice. Comments are due on June 27, 2016.