The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provided for value-based payment of Medicare benefits based on  system designed to measure and promote quality in care.  In April, a proposed rule will allow Medicare payments to be based on a score from four categories:

  • Quality – 50% of the score replacing the old PQRS and CQM systems.  The new system will use 6 discipline-specific measures instead of the 9 required now.
  • Advancing Care Information – 25% using EHR in what was known as “Meaningful Use.”  The new proposal calls for more flexibility with reporting use of technology based on how it used by the physician rather than requirements that must be met or excluded from.
  • Clinical Practice Improvement – 15% which is a new thing.  “Clinicians would be rewarded for clinical practice improvement activities such as activities focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities that match their practices’ goals from a list of more than 90 options. In addition, clinicians would receive credit in this category for participating in Alternative Payment Models and in Patient-Centered Medical Homes.”
  • Cost or Resource Use -10% of the score based on claims data using scenarios that provide the most cost-effective methods.  There is no reporting of this – it is based on claims submission.

The scoring will start for physicians in 2017 and the new payment system (MIPS) goes  into effect in 2019.

Right now, government officials responsible for implementing the system are doing due diligence with listening sessions on the rule proposals.  Final comments are due by June 27th.  Findings on the effects of socio-economic factors on quality are due in October.  Changes to the system are very possible as the result of this investigative period.

Advanced Payment Models (APMs)

The proposed rule allows for an extra 5% bonus for physicians who choose to participate in a program ensuring use of quality, technology and cost-effectiveness.  Participants also run the risk of reduced payments if criteria is not met.

Download the Facts Sheet from CMS