MACRA: Understanding healthcare reform and how reimbursement is changing
"Every dollar you're paid by CMS is going to change, and the measurement year is earlier than you think."
– Arien Malec, Vice President, McKesson RelayHealth1
Important changes for Medicare reimbursement
Compliance with the Medicare Access and the Children’s Health Insurance Program Reauthorization Act (MACRA) Quality Payment Program (QPP) can lead to positive or negative adjustments for Medicare reimbursement.To help avoid negative adjustments in 2019, most2 practitioners will need to start reporting data in 2017. You can select one of these options for the 2017 reporting year3:
Option 1: Test of data submission
If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), you can avoid a downward payment adjustment.
Option 2: Partial-year participation
If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small positive payment adjustment.
Option 3: Full-year participation
If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment.
Option 4: The Advanced Alternative Payment Model (APM)
Participate in an Advanced Alternative Payment Model, such as Medicare Shared Savings Track 2 or 3, in lieu of reporting quality data to the Quality Payment Program. For those required to report, doing nothing will result in penalties.
Not sure what to do about MACRA?
You’re not alone. A recent study4 found that only half of the physicians surveyed were familiar with MACRA. Under MACRA, the QPP introduces important changes for Medicare reimbursement, including MIPS and APMs.
The Merit-based Incentive Payment System (MIPS)
The proposed rule allows clinicians to choose measures and activities appropriate to the type of care they provide. MIPS allows Medicare clinicians to be paid for providing quality care demonstrated and measured in four performance categories:
Clinical Practice Improvement Areas (CPIA)
- Expanded practice access
- Beneficiary engagement
- Population management
- Care coordination
- Practice safety and assessmentClinicians can choose the activities best suited for their practice; the rule proposes more than 90 activities to choose from. Examples include:
Advancing Care Information (ACI)
Clinicians will report key measures of interoperability and information exchange. Clinicians are rewarded for
their performance on the key measures they select. Key measures include:
- Patient electronic access
- Coordination of care through patient engagement
- Health information exchange
The Quality performance category replaces the Physician Quality Reporting System (PQRS).
Examples of quality reporting requirements include:
- Effective clinical care
- Patient safety
- Communication and care coordination
- Efficiency and cost reductions
- Some examples of MIPS Quality Measures include:*
- Diabetes: Eye Exam
- Screening for osteoporosis for women aged 65-85 years of age
- Chronic Obstructive Pulmonary Disease (COPD): Spirometry evaluation
- Preventative care and screening:
- Influenza immunization
- Care planning
- CMS will calculate these measures based on claims and availability of sufficient volume. Clinicians do not need to report anything additional.The cost category will be calculated in 2017, but will not be used to determine your payment adjustment in 2019.
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*These are actual code descriptions from CMS.