In the MIPS, existing CMS quality programs—including the PQRS,
the VBM, and the EHR meaningful use program—are combined
and streamlined to reduce the administrative burden on providers.
MACRA was inclusion of an additional incentive payment. This provision calls for setting aside additional
funding so that even if 100 percent of physicians score
above the threshold and, therefore, nobody receives
a negative update, the top achievers will still receive
recognition through a positive update. A total of
$500 million per year is being allocated to this fund
and will be distributed to either the top 75 percent of
physicians who score above the threshold, or those
with scores that fall in the top three quartiles above the
threshold. The maximum additional update under this
section is 10 percent, but that amount could be lower if
large numbers of physicians score above the threshold.
MACRA also provides $100 million over five years
to be distributed to quality improvement organizations,
regional extension centers, and other entities that provide technical assistance to small and rural practices.
Preference for the technical assistance program goes
to those practices in health professional shortage areas
or to practices with low composite scores. The goal is
to help these practices improve performance in MIPS
or transition into APMs.
Although the new law preserves traditional fee-for-service Medicare physician reimbursement, it takes a
number of steps, including the provision of payment
incentives, to encourage development of and participation in alternative payment models.
The law states that to qualify for incentives and other
benefits, physicians must participate in APMs that base
payment on quality measures, such as those included
in MIPS; use certified EHR technology (although those
who meet certain criteria are exempt from meaningful
use requirements); and include an element of financial
risk with the potential for monetary loss.
Recognizing that APM options are nonexistent
in many areas of the country or are unavailable for
physicians in certain specialties, the law prioritizes
development of new specialty-focused models, models
for small practices of 15 or fewer physicians, models
developed in conjunction with private payors, statewide
payment models, or Medicaid-based options. The goal
is to encourage specialty societies and other stakehold-
ers to develop new and innovative payment models.
The law’s language is broad enough that it may leave
the door open for creation of a model based on the Col-
lege’s Clinical Affinity Group (CAG) concept from the
VBU, in which providers are grouped together based
on the patients or conditions they treat, not their spe-
cialty designation. 9
Physicians who receive a high enough proportion
of payments (either from Medicare alone or through
a combination of Medicare and other payors) through
qualified APMs will be exempted from the MIPS pro-
gram, including EHR meaningful use mandates and
many of its reporting requirements. Furthermore, they
will receive a 5 percent lump-sum incentive payment
to offset the risk and initial cost associated with transi-
tioning to such a system. This incentive will be in effect
from 2019 through 2024. Those physicians who strive
to meet this participation threshold but fall short may
be exempted from the MIPS program; however, they
will be ineligible for the 5 percent incentive.
In addition, physicians who participate in an APM at
any level and are in the MIPS program will automati-
cally receive at least 50 percent of the total possible score
on the CPIA portion of the composite score, allowing
them to earn higher updates.
Under the new system, increasing incentives will
be available to physicians to encourage movement to
APMs over time. Along with the 5 percent incentive
and exemption from the MIPS program requirements,
starting in 2026, the current conversion factor will
be split in two. The fee-for-service conversion factor
will grow at a modest rate of 0.25 percent annually,
whereas qualified APM participants will be paid for
items and services using a separate qualifying APM
conversion factor that will increase by 0.75 percent
annually. Although both of these growth factors are
small (and likely to be reconsidered before 2026), the
difference will inevitably lead to an increasing pressure
to participate in APMs.
JUL 2015 BULLETIN American College of Surgeons
POST-SGR MEDICARE PHYSICIAN PAYMENT