In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act, known as MACRA. Since then, regulators have been working on releasing guidelines and programs governing MACRA, and many of these impact anesthesiologists.
Parts of the proposed rule (it hasn’t gone into effect yet) were announced on April 27 and discussed on this blog previously, including MIPS (Merit-based Incentive Payment System), APM (Alternative Payment Model), and Criteria for Physician-Focused Payment models. These regulations are contained in the 962 pages that comprise the MACRA ruling and are currently in a public comment session that ends June 27.
The final rule will be published later in 2016, but it is prudent that anesthesiologists understand the impact MACRA could make on their practices, if everything currently being proposed is enacted by January 1, 2017.
Here, we’ll briefly cover two of the most important pathways for physician payment: MIPS and APM.
MIPS is a variant of the standard fee-for-service model that most practices have used for decades. The goal of MIPS is to help calculate all adjustments for providers that are linked to value and quality. As of 2019, the max bonus is 4%; the max penalty is -4%. These will be assessed based on four categories of performance (consolidated from the labyrinth of criteria that existed prior to MIPS): quality, cost, advancing care information, and clinical practice improvement activities (CIPA).
Each of these, except for CIPA, replaces a current program. Quality replaces PQRS; Cost replaces the Value-based Modifier (VBM); and advancing care information replaces the EHR Incentive-Meaningful Use program.
In the first year, percentages of a practice’s MIPS score will be allocated as follows:
- Quality: 50%
- Cost: 10%
- Advancing care information: 25%
- CPIA: 15%
Those percentages will shift over time. Quality, for example, will be reduced to just 30% of the total score by 2022.
CMS estimates that negative payment adjustments under MIPS will approximate $833 million, while positive payment adjustments will total $1.3 billion. All anesthesia practices naturally want to be in the latter category.
The other payment model is the Alternative Payment Model, or APM.
APM is actually a system of models, including Medicare Advanced APMs and Other Payer Advanced APMs. There are stringent requirements for participating in APM over MIPS, to the point where most anesthesiology practices will be under MIPs. But in the future, MIPS will eventually transition into APM, so it’s important to understand where the field is headed.
The goal of APM is to encourage a value-based payment system in which providers strive for efficient care of a high quality. Payment for participation under APM is a 5% lump sum payment of the aggregate payment amounts under Medicare Part B for the prior year; this is in effect from 2019 to 2024. Starting in 2026, payment rates will see a 0.75 percent bump.
What qualifies a provider for APM? They must have a significant portion of their practice’s payments coming from payment models that include, at a minimum, a risk of financial losses and use of EMRs as quality measures. There may be other qualifications as the role of an APM is solidified throughout 2016.
As mentioned, most providers will not qualify for APM; they will instead be placed under MIPS until MIPS is gradually phased out in favor of APM.
The best course of action today for anesthesiologists is to familiarize the practice with both models, MIPS and APM, and keep abreast of changes as MACRA becomes ratified later this year. Until then, they should focus on increasing quality scores as much as possible and streamlining practices so adoption of new quality measures is easier down the road.