streamlines Medicare’s existing qual- ity programs and offers physicians an upside for good performance. MACRA still has its shortcomings,
Ms. Kinney says, chief among them, the fact that the annual payment up- dates, which freeze from 2020 to 2025, fail to keep up with health care cost inflation. “But we have time to fix it, and the
$60 billion needed to get there, we can get in little bites,” Ms. Kinney said. The big hurdle was the $144 billion needed to eliminate the SGR, “and we never have to jump that hurdle again.”
TWO PATHWAYS In SGR’s place, MACRA created two payment tracks that get rid of at least some problems with the old system, Ms. Kinney adds. As of 2019, MIPS consolidates the multitude of existing Medicare qual- ity reporting programs: the Physician Quality Reporting System (PQRS), meaningful use of electronic health records (EHRs), and the value-based payment modifier. (See “Your Guide to Medicare Value-Based Care,” April
2015 Texas Medicine, pages 26–34, or
www.texmed.org/GuidetoMedicare ValueBasedCare.) Whereas the ACA shifted all of
the incentives in those programs into penalties for noncompliance — up to 11 percent — MIPS replaces those with both bonuses and penalties ranging from 4 percent in 2019 to a 9-percent cap in 2022 and beyond. Physicians will receive a single
MIPS score based on quality (30 percent); resource use, or cost (30 percent); and EHR use (15 percent) standards derived from the existing programs, but with some improve- ments: funding to develop new qual- ity measures with input from state and national medical organizations; potential adjustments for patients with more severe health conditions or those who don’t follow doctors’ or- ders; and quality scores based on pre- set targets versus peer rankings. A new fourth clinical practice im-
provement category (15 percent) gives credit for practice enhancements in several areas, including:
• Expanded access (e.g., providing after-hours care);
• Population management (e.g., mon- itoring patient health by using reg- istries);
• Patient engagement (e.g., self-man- agement training);
• Patient safety and practice assess- ment (e.g., use of checklists); and
• Transition to or participation in an APM.
Ms. Kinney says MACRA “was
written to give doctors options,” and CMS’ recent proposal asks for input to further define clinical practice im- provement activities. CMS also has yet to fully define
APMs per MACRA. But Dr. Lock- hart says bigger incentive payments strongly suggest Medicare favors participation in the models, in which practices assume some level of finan- cial risk for their patient population, in addition to following quality, cost, and EHR standards similar to MIPS. From 2019 to 2024, practices can
earn an annual lump-sum bonus of 5 percent of their total Medicare pay-
2019–22 & beyond
MIPS: ±4% to ±9% maximum bonuses or penalties, plus additional bonuses for exceptional performance, based on perfor- mance two years prior
2019–24
Alternative payment model (APM) program: lump sum bonus payment of 5% of Medicare fees for participat- ing in accountable care organizations, medical homes, bundled payments, or other initiatives
2020–25
0% FFS payment update
2026 & beyond
0.75% FFS update for APM participants
0.25% FFS update for MIPS participants
September 2015 TEXAS MEDICINE 59
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