HealthInsight understands that the payment environment for health care providers is more complex than ever as the Centers for Medicare & Medicaid (CMS) continues to implement new payment policies transitioning the system to value-based approaches. The adoption of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will impact the payment structure for the health care community in many ways. MACRA eliminates the Sustainable Growth Rate (SGR) formula and creates a new reimbursement model focused on paying providers for value and better care. CMS has created the Quality Payment Program (QPP) to execute MACRA. Most clinicians in outpatient practices will participate in the Merit-Based Incentive Payment System (MIPS) initially, and eventually more will move into the qualifying Advanced Alternative Payment Models (APMs) arm, although most current APMs will not be qualifying. Implementation rules are still being finalized, but the initial payment adjustments scheduled to be made in 2019 would be based on clinicians' performance beginning in January 2017.
The MIPS combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-Based Payment Modifier) and the Medicare Electronic Health Record (EHR) meaningful use incentive program into a single program. Eligible practitioners will be measured on quality, resource use, clinical practice improvement activities and meaningful use of certified EHR technology, now called Advancing Care Information. Most clinicians in accountable care organizations (ACOs) and the Medicare Shared Savings Program (MSSP) will not be considered Advanced APMs. Only a few existing APMs will qualify, such as the higher tracks of the MSSP that have significant shared risk, some bundled payment arrangements and enhanced versions of patient-centered medical homes. The law also created programs to offer support to physician offices so they can prepare and adapt successfully, with a focus on quality.