Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

On April 14, 2015, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). It was signed into law on April 16, 2015. The MACRA permanently repeals the flawed Sustainable Growth Rate formula for determining Medicare payments for clinicians’ services, provides consistent physician fee schedule increases of 0.5% per year from 2015 to 2019, establishes a new framework for rewarding clinicians for value over volume, and streamlines other existing quality reporting programs into one new system.

The MACRA will help accelerate paying for and rewarding value. Commencing in 2019, implementation of the MACRA is a major opportunity to put a broad range of health care providers on the path to value through the new Merit-Based Incentive Payment System (MIPS) and incentive payments for participation in certain Alternative Payment Models (APMs).

The Goal of MACRA is to help link fee-for-service payments to reimbursement based on quality and value.

Merit-Based Incentive Payment System (MIPS)

The MACRA legislation sunsets the payment adjustments associated with the Physician Quality Reporting System, the Value-based Payment Modifier, and the Medicare Electronic Health Record (EHR) incentive program for Eligible Professionals. The MIPS payment model combines those efforts into a single consolidated program with four weighted performance categories upon which eligible professionals (EPs) will be assessed: Quality; Resource Use; Clinical Practice Improvement Activities; and Meaningful Use of Certified EHR Technology. MIPS will provide providers with a Composite Performance Score that incorporates MIPS EP performance on each of these categories. Based on this Composite Performance Score, EPs may receive an upward, downward, or no payment adjustment. MIPS offers an opportunity for EPs to achieve significant financial incentives for providing health care that advances the goals of a better, smarter, and healthier system.

Alternative Payment Models (APMs)

MACRA also provides incentives for participation in certain APMs. “Qualifying APM participants” will not be subject to MIPS adjustments and will receive a lump sum incentive payment equal to 5 percent of the prior year’s estimated aggregate expenditures under the fee schedule. The 5 percent incentive payment is available from 2019 to 2024, however, starting in 2026, the fee schedule growth rate will be higher for qualifying APM participants than for other practitioners. MACRA also encourages expansion of the APM options available to physicians, especially specialists, through physician focused payment models (PFPMs). The law requires the establishment of a Technical Advisory Committee that will assess PFPM proposals submitted by stakeholders.  Bundled payments may be considered an advanced APM provided the entity bears a certain amount of financial risk as follows:

  • Total risk (maximum amount of losses possible under the Advanced APM) must be at least 4 percent of the APM spending target.
  • Marginal risk (the percent of spending above the APM benchmark (or target price for bundles) for which the Advanced APM Entity is responsible (i.e., sharing rate) must be at least 30 percent.
  • Minimum loss rate (the amount by which spending can exceed the APM benchmark (or bundle target price) before the Advanced APM Entity has responsibility for losses) must be no greater than 4 percent.

Value Based Reimbursement programs like MACRA are impacting virtually every healthcare organization.  Partnering with Global enables your organization to be ready, compliant and effective in using these programs to create value.

Contact Global today to learn more about how our experience with CMS programs like MACRA.

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