The Centers for Medicare & Medicaid Services (CMS) announced on its blog earlier this month that it will allow physicians to select their level of participation for the first performance year of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program. The program starts January 1, 2017. Of note, during the first performance year (2017), “[c]hoosing one of these options would ensure [physicians] do not receive a negative payment adjustment” under MACRA in 2019.
Under the Quality Payment Program, physicians will fall under the Merit-Based Incentive Payment System (MIPS) if they do not qualify under the Advanced Alternative Payment Model (Advanced APM) option. In 2019, those physicians in the MIPS default option could face Medicare rate adjustments of up to five percent based on their performance under four weighted performance categories: (i) quality (50 percent); (ii) resource use (10 percent); (iii) advancing care information (25 percent); and (iv) Clinical practice improvement (15 percent). Advanced APMs include, for example, Track 2 and 3 MSSP Accountable Care Organizations (ACOs); next generation ACOs; and bundled payment models. Physicians who qualify under the Advanced APM option earn a five percent incentive, are excluded from MIPS adjustments, and receive higher fee-schedule updates after 2024.
Recognizing that many physicians could face negative payment adjustments under MIPS as a result of participating under the Quality Payment Program, CMS will allow eligible physicians to “pick their pace of participation” and ensure that they do not receive such negative payment adjustments in 2019 by choosing one of four options for the first performance year:
1. test the Quality Payment Program
2. participate for part of the calendar year
3. participate for the full calendar year
4. participate in an Advanced APM in 2017
The first three options fall under MIPS; the fourth option falls under the Advanced APM. In the first option, physicians could “submit some data to the Quality Payment Program,” avoid negative payment adjustments, and test the waters before broader participation in subsequent years. Under option two, the performance year could begin later than January 1, 2017, a physician practice “could qualify for a small positive payment adjustment,” and a physician would submit Quality Payment Program information for fewer days. The third option is ideal for those physician practices that are ready to participate beginning January 1, 2017, and who are able to submit a full year of quality data. Additionally, physicians “could qualify for a modest positive payment adjustment.” The fourth option would fit those physicians or physician groups who treat enough Medicare beneficiaries and who receive enough of their Medicare payments through an Advanced APM (e.g., MSSP ACOs). Through the Advanced APM option, physicians/physician groups would “qualify for a 5 percent payment in 2019.” CMS has not clarified what the difference is between a “small” and “modest” payment adjustment. However, CMS may address this in the final rule, along with how it will implement MIPS and the Advanced APM. CMS will release the final rule by November 1, 2016.
J. Nicole Martin is with Cozen O'Connor in Philadelphia, Pennsylvania.