Merit-based Incentive Payment System (MIPS)

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CMS is planning a new “Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration” that would allow clinicians who participate in certain Medicare Advantage (MA) plans that involve taking on risk to be treated as Advanced Alternative Payment Model (Advanced APM) participants under the Medicare physician fee schedule. By way of background, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established two tracks for Medicare physician fee schedule/Quality Payment Program updates:

  1. The Merit-based Incentive Payment System (MIPS), which adjusts Medicare payments based on performance on quality, cost, improvement activities, and advancing care information measures, or
  2. Advanced APMs, under which eligible clinicians may earn incentive payments for sufficient participation in certain payment arrangements that coordinate care, improve quality, and reduce costs.

Continue Reading CMS Considering New Medicare Advantage Payment Arrangement Incentive (MAQI) Demonstration

The Medicare Payment Advisory Commission (MedPAC) has issued its annual recommendations to Congress on updates to Medicare fee-for-service payment system rates, many of which overlap recommendations made in previous years. For instance, MedPAC continues to call for implementation of a unified prospective payment system (PPS) for post-acute care (PAC) providers, including skilled nursing facilities (SNFs), home health agencies (HHAs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs), to be implemented beginning in 2021.  In the latest report, MedPAC recommends that Congress direct the Secretary of Health and Human Services to begin blending the relative weights of the setting-specific payment systems and the unified PAC PPS in 2019.  At the same time, MedPAC recommends that Congress modify the updates for the individual PAC systems by:

  • Reducing home health payment rates by 5% in 2019, rebasing payments beginning in 2020, and eliminating the use of the number of HHA therapy visits as a factor in payment determinations.
  • Reducing Medicare IRF PPS rates by 5% for FY 2019.
  • Eliminating the LTCH PPS update for FY 2019.
  • Eliminating SNF PPS market basket increases for fiscal years (FYs) 2019 and 2020, and implementing previous recommendations to reform SNF PPS payments in a way that shifts payments to medically-complex stays. MedPAC notes that it has endorsed SNF PPS reforms since 2008, and it “has grown increasingly frustrated with the lack of statutory and regulatory actions to lower the level of payments and implement a revised payment system.”

MedPAC also includes detailed discussions of Medicare payment for physician and other health professional services. MedPAC recommends increasing physician fee schedule rates in 2019 by the amount specified in current law (0.25%). MedPAC also offers extensive recommendations for revising the framework for updating Medicare physician payments established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Most notably, MedPAC recommends eliminating the Merit-based Incentive Payment System (MIPS) and adopting a new voluntary value program under which: (1) clinicians can elect to be measured as part of a voluntary group; and (2) clinicians in voluntary groups can qualify for a value payment based on their group’s performance on a set of population-based measures. Additionally, MedPAC presents the findings of its Congressionally-mandated report on coverage of telehealth services.

With regard to other Medicare fee-for-service payment systems, MedPAC recommends:
Continue Reading MedPAC Calls for Medicare Post-Acute Care and Physician Payment Reforms, Recommends Medicare Payment Updates

A number of recent Congressional hearings focused on federal health policies, including the following:

  • House Energy and Commerce Committee hearings on the impact of health care consolidation, oversight of the Department of Health and Human Services (including the Trump Administration’s HHS budget request), and drug compounding.
  • Ways and Means Committee hearings on President Trump’s HHS

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CMS has issued a final rule with comment period making changes to the Quality Payment Program (QPP) for 2018, the second performance year for the reformed physician payment framework mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS is continuing its “slow ramp-up” of the QPP by building on the transition policies established for 2017. In the 2018 rule, CMS intends to encourage successful QPP participation under either the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (APM) track while reducing burdens on clinicians.

With regard to MIPS participation, the final rule:

  • Reweighted the performance category scoring for 2018 as follows: Quality 50%, Cost 10%, Improvement Activities 15%, and Advancing Care Information 25%.
  • Increased the performance threshold to 15 points in year two (up from 3 points in 2017).
  • Established a Virtual Groups participation option under which solo practitioners and groups of 10 or fewer eligible clinicians that exceed the low-volume threshold may come together “virtually” to participate in MIPS for a one-year performance period.
  • Increased the low-volume threshold to less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries (up from $30,000 charges/200 beneficiaries) in order to exclude more practices.
  • Provided bonus points for: the treatment of complex patients; use of only the 2015 Edition Certified Electronic Health Record Technology; and clinicians and small practices that submit data on at least one performance category in an applicable performance period.
  • Implemented an optional facility-based scoring mechanism for facility-based clinicians, beginning with the 2019 performance year.
  • Created hardship exemptions in the Advancing Care Information performance category.
  • Added a new improvement activity for clinicians who attest to consulting specified applicable appropriate use criteria (AUC) through a qualified clinical decision support mechanism for outpatient advanced diagnostic imaging services ordered (applicable to clinicians who are early adopters of the Medicare AUC program in the 2018 performance year and for clinicians who begin the Medicare AUC program in future years as specified in separate regulations).
  • Promulgated an interim final rule with comment period to address extreme and uncontrollable circumstances MIPS eligible clinicians may face as a result of widespread catastrophic events affecting a region or locale in CY 2017, such as Hurricanes Irma, Harvey and Maria.

CMS also adopted a number of policies affecting APM participants.  For instance, the final rule:
Continue Reading CMS Modifies Medicare Physician Quality Payment Program Rules for 2018

CMS has proposed new regulations to continue implementing the “Quality Payment Program” (QPP) — the new Medicare physician fee schedule (MPFS) update framework mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). As previously reported, starting in 2017, physicians will be paid under the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (APM).

For the second year of the QPP, CMS is proposing to continue a number of transition policies established for 2017 while “ramping up to full implementation.” Notably, with regard to the MIPS track, CMS proposes to:
Continue Reading CMS Proposes Changes for Second Year of Medicare Physician Quality Payment Program

On January 24, 2017, CMS is hosting a call to discuss how to complete the final reporting period for the “legacy” Medicare physician quality reporting programs (Physician Quality Reporting System, Medicare Electronic Health Record Incentive Program, and Value-Based Payment Modifier) and transition to the new Merit-based Incentive Payment System (MIPS).  Registration is required to participate.

Temporary Transition Policies Reduce Threat of Negative Adjustments in 2019, But Adds to Complexity

On November 4, 2016, the Centers for Medicare & Medicaid Services (CMS) is publishing a sweeping final rule reforming the Medicare physician fee schedule (MPFS) update framework, as mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). …

In a recent blog post, CMS Acting Administrator Andy Slavitt announced CMS’s plans to give physicians more options for complying with significant upcoming changes to Medicare physician fee schedule (MPFS) rules – which will help physicians avoid triggering a negative payment adjustment in the first year of the program.

As previously reported, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the longstanding sustainable growth rate methodology for updating the MPFS.  Instead, MACRA established a period of stable MPFS annual updates, after which MPFS updates will be made pursuant to either a new Merit-based Incentive Payment System (MIPS) or based on participation in qualified Alternative Payment Models (APMs).  CMS published a proposed rule in May 2016 to implement the MIPS and APM reforms, which together CMS calls the “Quality Payment Program.”  The first reporting period for the Quality Payment Program begins on January 1, 2017, and it will impact physician payment in 2019.
Continue Reading CMS Announces Flexibility for Physician First-Year Participation in MACRA Quality Payment Program

The Centers for Medicare & Medicaid Services (CMS) has proposed regulations to implement major reforms of the Medicare physician fee schedule (MPFS) update framework that were mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  As discussed in our client alert, MACRA repealed the longstanding sustainable growth rate (SGR) methodology for updating the MPFS. Instead, MACRA established a period of stable MPFS annual updates, after which MPFS updates will be made pursuant to either a new Merit-based Incentive Payment System (MIPS) or based on participation in qualified Alternative Payment Models (APMs). CMS’s proposed rule to implement the MIPS and APM reforms, which together CMS calls the “Quality Payment Program,” is lengthy (the advance version is almost 1000 pages) and very complex. The following is an overview of the major provisions of the rule.
Continue Reading CMS Proposes Implementation of MACRA Physician Payment Reforms

The White House Office of Management and Budget (OMB) is now reviewing a highly-anticipated Centers for Medicare & Medicaid Services’ (CMS) proposed rule to implement major Medicare physician payment reform provisions included in the Medicare Access and CHIP Reauthorization Act (MACRA).  As previously reported, MACRA repealed the Medicare sustainable growth rate (SGR) formula and…

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS to develop quality measures that will apply to Medicare payments to physicians when new Merit-based Incentive Payment System (MIPS) and Medicare alternative payment model (APM) provisions go into effect (MIPS and APM payment adjustments begin in 2019).  Pursuant to this mandate, CMS has…

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS to establish care episode groups and patient condition groups, which will be used to measure resource use under the new Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs). Care episode groups describe the patient’s clinical problems at the time items and …

The Centers for Medicare & Medicaid Services (CMS) has published a sweeping final rule with comment period that specifies the requirements that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and Medicaid electronic health record (EHR) incentive payments and avoid downward payment adjustments under the Medicare EHR Incentive Program. Notably, the rule establishes the requirements for Stage 3 of the program as optional in 2017 and required for all participants beginning in 2018.
Continue Reading CMS Adopts Changes to Medicare & Medicaid EHR Policies

CMS has extended the comment period on its October 1, 2015 request for information (RFI) regarding implementation of the Merit-based Incentive Payment System and promotion of alternative payment models in accordance with MACRA. The comment period, which originally was scheduled to end on November 2, 2015, has been extended until November 17, 2015. CMS…

The next Medicare Payment Advisory Commission (MedPAC) meeting is scheduled for October 8 -9, 2015. Topics on the agenda include: Medicare drug spending; Alternative Payment Models and the Merit-based Incentive Payment System; Medicare Advantage coding intensity, health risk assessments, benchmarks, and star ratings; and access to emergency care in rural areas.

On October 1, 2015, CMS published a request for information (RFI) regarding implementation of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provisions that mandate significant reforms of the Medicare physician payment system. As previously reported, MACRA repealed the sustainable growth rate methodology (SGR) for updating the Medicare physician fee schedule, and after…

On July 15, 2015, the Centers for Medicare & Medicaid Services (CMS) published its proposed rule to update the Medicare physician fee schedule (MPFS) for CY 2016 – the first rulemaking since the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the sustainable growth rate (SGR) formula.  Under the proposed rule, the 2016 MPFS conversion factor (CF) would be $36.1096, compared with the 2015 CF of $35.9335, reflecting a 0.5% update factor specified under MACRA and a budget neutrality adjustment of 0.9999.  Note that the CF is subject to change in the final rule, however, if CMS does not meet a statutory target for expenditure reductions related to its review of misvalued procedures (discussed below). The proposed rule addresses numerous aspects of Medicare Part B and other CMS program policies.  Highlights include the following: 
Continue Reading Proposed CY 2016 MPFS Rule Takes First Steps in Implementing MACRA Reforms

Today President Obama signed into law H.R. 2, the “Medicare Access and CHIP Reauthorization Act of 2015” (MACRA), which reforms Medicare payment policy for physician services and adopts a series of policy changes affecting a wide range of providers and suppliers. Most notably, MACRA permanently repeals the statutory Sustainable Growth Rate (SGR) formula, achieving a goal that has eluded Congress for years. Now, after a period of stable payment updates, MACRA will link physician payment updates to quality, value measurements, and participation in alternative payment models.
Continue Reading President Obama Signs MACRA: Permanently Reforms Medicare Physician Reimbursement Framework, Includes Other Health Policy Provisions