ASCO Releases Analysis of MACRA Final Rule and Quality Payment Program

November 15, 2016

On Oct. 14, the Centers for Medicare & Medicaid Services (CMS) released a nearly 2,400 page final rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA). The final rule lays out the standards for participation in the Quality Payment Program (QPP)—the program instituted by MACRA which creates two value-based payment programs for physician reimbursement. Given the length of the final rule, ASCO created a summary of its provisions.   

The default QPP program is the Merit-Based Incentive Payment System (MIPS), which assesses clinicians on their performance across four categories and provides a neutral, positive, or negative overall payment adjustment that is based on that performance. Alternatively, physicians may elect to participate in an Advanced Alternative Payment Model (APM). 

QPP begins in 2017, which will serve as a transition year during which providers can avoid a negative payment adjustment by reporting minimal data in any MIPS performance category to CMS or by participating in an advanced APM (which makes them eligible for an incentive payment in 2019).

More About MIPS:

The first MIPS-based payment adjustments will occur in 2019 (based on data collected in 2018 from services performed in 2017). MIPS maintains the current fee-for-service physician payment model, but will also assess physician performance by calculating a provider's Composite Performance Score (CPS) by weighing their score in four performance categories. A positive or negative payment adjustment will be based on performance relative to other providers. CMS proposed the following values for 2019 and beyond (subject to change):

Performance Category

2019 Payment Year (based on 2017 data)

2020 Payment Year (based on 2018 data)

2021 Payment Year and Beyond (based on 2019+ data)

Quality

60%

 

50%

30%

Resource Use

0%

 

10%

30%

Improvement Activities

15%

 

15%

15%

Advancing Care Information

25%

25%

25%

Most performance categories are based on existing CMS quality and value improvement programs: 

New Performance Category

Existing Precursor Program

Quality

Physician Quality Reporting System (PQRS)

Cost

Value-Based Payment Modifier Program

Improvement Activities

Not applicable

Advancing Care Information

Meaningful Use Program, which is also called the EHR Incentive Program

2017 MIPS Reporting Options - Pick Your Pace

CMS is allowing practices to pick the pace at which they implement QPP reporting in 2017. Options (including doing nothing and being penalized) include:   

Level of Participation

Reporting Requirements in 2017

Payment Adjustments in 2019

None

No MIPS data reported

Automatic negative 4% adjustment

Minimal

Submit one measure or one activity under the quality or improvement activity categories, or report the required measures of the ACI performance category 

Neutral or Slightly Positive Adjustment

Medium

Submit data on all performance categories for at least 90 days

Positive adjustment

High

Submit data on all performance categories for more than 90 days, and up to a full year

Positive adjustment, and if warranted an additional positive adjustment for high performance

Negative payment adjustments in 2019 would not exceed 4 percent, however, positive adjustments could be higher or lower than 4 percent depending on refinements CMS may have to make to achieve budget neutrality.

MIPS exempt providers include:

  • Low-volume threshold providers (providers with less than $30,000 in Medicare Part B allowed charges or treat fewer than 100 Medicare beneficiaries annually).
  • Providers in their first year of Medicare participation.
  • Qualifying APM participants or Partial Qualifying APM Participants.

More About APMs:

APMs are value-driven payment models that focus on lowering the cost of care while attempting to increase the quality of care through the use of financial incentives and quality reporting. The final rule identifies several types of APMs, but incentive payments will be available only to clinicians that meet the standards for qualifying participation in an Advanced APM from 2017-2022 or qualifying participation in a combination of Advanced APM and Other Payer Advanced APM from 2019 to 2022.

Three requirements differentiate an Advanced APM from an APM (see the full summary for details):

  • Requiring at least 50 percent of eligible clinicians in each participating APM Entity group, or, for APMs in which hospitals are the APM Entities, each hospital, to use Certified Electronic Health Records Technology (CEHRT) to document and communicate clinical care to their patients or other health care providers;
  • An Advanced APM must include quality measure performance results as a factor when determining payment to participants under the terms of the APM and include at least one outcome measure; and
  • An Advanced APM must meet the applicable general financial risk and nominal financial risk standards.

Qualifying APM participants will receive a 5 percent incentive payment from CMS in 2019-2024 (based on services performed in 2017-2022), while partially qualifying APM participants will be exempted from MIPS but will not receive an APM incentive payment.  

CMS plans to publish a final list of Advanced APMs before Jan. 1, but programs already identified as Advanced APMs for 2017 are:

  • The Oncology Care Model – Two sided risk
  • Comprehensive ESRD Care – Two sided risk
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Shared Savings Track 2
  • Shared Savings Track 3

Please see the full summary for a more detailed analysis and answers to frequently asked questions about QPP. ASCO remains engaged with policymakers to improve QPP and will submit comments on the final rule during the open comment period. Stay tuned to ASCO in Action for all the latest cancer policy news.

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