MACRA: What Providers Can Expect in 2019

Updated: Nov 5, 2018

E&A attended the eHealth Initiative annual conference in Washington, DC attended by HHS Administrators. Rob Anthony, Health Insurance Specialist for the Centers for Medicare and Medicaid Services (CMS) delivered a presentation overview of MACRA, MIPS and Alternative Payment Models (APMs). Here are a few highlights on what providers can expect in the coming years:

Background: On April 16, 2015, President Obama signed the Medicare Access and CHIP Reauthroization Act of 2015 (MACRA) into law. A once in a decade legislation, MACRA is expected to advance and reform our healthcare industry.

The main goal of MACRA is to push our healthcare industry towards value and quality.

  • Four major elements of MACRA:

  • It repeals the out-dated Sustainable Growth Rate (SGR), used in calcluating Medicare reimbursement payments.

  • It will changes the way Medicare rewards clinicans for value over volume

  • It will streamline quality programs under a consolidated program known as the Merit-Based Incentive Payment System (MIPS).

  • It will provide bonus payments for providers pariticipating in eligible Alternative Payemnt Models (APMs)

MACRA is a step forward in HHS' historic announcement on January 2015 announcing a timeline to shift Medicare reimbursements from volume to value. By the end of 2016, HHS wants 30% of fee-for-service Medicare payments will be tied to quality or value through APMs. HHS wants to see this grow to 50% by the end of 2018.

To achieve these payment reform goals, eligible providers can jump on one of two tracks: MIPS or APMs begining on January 1, 2019:

Track 1 - MIPS:

  • MIPS will consolidate the Physician Quality Reporting System (PQRS), Value-based Payment Modifier modifier, and EHR incentive program for Eligible Providers (EPs) into a single payment system. MIPS will factor in data from these programs in addition the following four weighted measures to produce a composite score for particpants. Using the information from these programs to create a consolidated program with four weighted measures.

  • Weighted measurements:

  • Quality Measures: 30%

  • EHR use: 25%

  • Clinical Practice Improvement Activities: 15%

  • Resource Use Measures: 30%

  • Participants in MIPS will be on an adjusted payment timeline. For example, in 2019, providers can see adjustments ranging from +4% to -4%. This adjustment can gow to +6% or -6% in the following year and continue to grow until stabilizing at 9%.

  • MIPS applies to Individual EPs, groups of EPs, or virtual groups.

Track 2 - APMs:

  • This provides incentives for participation in Alternative Payment Models (APMs). APMs include participants involved in models presented by the CMS Innovation Center and participants in the Medicare Shared Savings Program (MSSP):

  • The APM track will functions as an additional bonus payments on top of the financial incentives already in play by specified in the APM models.

  • HHS looks to increase the number of EPs using APMs. This will be done by scaling current APM models to fit numerous participants and by taking industry input on alternative APM approaches.

  • These participants will receive a lump sum bonus of 5% of their prior year's estimated aggregate expenditures under the fee schedule, plus their eligible APM-specific rewards. The 5% lump sum bonus is available from 2019-202

Through MACRA, HHS wants to see providers:

  • given multiple pathways with varying levels of risk and reward to tie payments to value-based models

  • expand the opportunities to participate in APMs

  • have less reporting burdens

Lastly, CMS officials stated that MACRA is meant to be a very iterative program with space to evolve with public and private sector innovations and APMs.

Upcoming legislative time table:

  1. A new proposed rule for MACRA can be expected in late spring 2016, after the HIMSS 2016 conference

  2. A final rule can be expected by early fall 2016.

Legislative Text of MACRA [H.R. 2]: