Introduction to the Medicare Access and CHIP Reauthorization Act (MACRA)

What is the Medicare Access and CHIP Reauthorization Act? 

The Medicare Access and CHIP Reauthorization Act (MACRA) was a law passed by Congress in 2015 impacting how providers will be reimbursed; transitioning payments from a volume-based Fee for Service (FFS) model to value based incentives model aligned with lower costs and better patient outcomes.

Despite its broad usage, MACRA in and of itself is a very broad concept, with much of the legislation being unrelated to provider reimbursement. The component of MACRA directly impacting incentives is known as the Quality Payment Program (QPP), which in essence tasked the Department of Health and Human Services (HHS) with creating an alternative to the Sustainable Growh Rate (SGR).

The Quality Payment Program (QPP) provided two payment models for clinicians to participate: 

                                                                            

 

    Advanced Alternative Payment Models (APMs)             Merit-Based Incentive Payment System (MIPS)

What are Advanced Alternative Payment Models (APMs)?

APMs are payment partnerships between a community of clinicians and CMS, that provide incentives to provide high-quality and cost-efficient care. Models exist for specific conditions, care episodes, as well as entire populations. 

Examples of APMs are Next Generation ACOs (Population), Comprehensive Primary Care Plus (CPC+) (Population), Oncology Care Model (OCM) (Care Episodes), Comprehensive ESRD Care Model (Condition), and others.

For the performance year, CMS estimates that approximately 70,000-120,000 clinicians will participate in Advanced APMs. 

What is the Merit-Based Incentive Payment System (MIPS)?

All clinicians not participating in an Advanced APM, are automatically participating in MIPS (with the exceptions of a first year clinicians and clinicians treating a small Medicare patient population). 

MIPS replaces programs like Physician Quality Reporting System (PQRS) and Meaningful Use that were all previously reported separately with one composite reporting system. 

Clinicians will be requried to report on four (4) categories:

  • Quality (replaces PQRS)
  • Improvement Activities (New)
  • Advancing Care Information (replaces MU)
  • Cost (replaces Value-Based Modifier)
Who Reports Under What?

If you bill Medicare more than $30,000 and provide care to more than 100 Medicare patients per year, and you are a:

  • Physician
  • Physician Assistant
  • Nurse Practitioner
  • Clinical Nurse Specialist
  • Certified Registered Nurse Anesthetist

Then you are participating in the QPP beginning 2017.

 

If you are participating in (a):

  • Oncology Care Model
  • Comprehensive Primary Care Plus
  • Next Generation ACO Model
  • Comprehensive ESRD Care Model
  • Medicare Shared Savings Program ACO
    • Track 2
    • Track 3

Then you are reporting under the respective APM guidelines.

 

If you are not participating in any of the above programs, then you are reporting under MIPS.

Learn More About APMs

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Comprehensive Primary Care Plus

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Next Generation ACO Model

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Oncology Care Model

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Comprehensive ESRD Care Model

 

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