Medicare Access & CHIP Reauthorization Act (MACRA)

Updated! MACRA Quick FAQs  

In April 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA). This legislation repeals the flawed Sustainable Growth Rate (SGR) formula and creates a new value-based physician payment system through the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs), which will have a significant impact on quality reporting for CRNAs beginning with the 2017 performance year.

NOTE: The MACRA Final rule was released on October 14, 2016, and this FAQ page has since been updated to reflect the changes from the proposed rule.

What is the Medicare Access and CHIP Reauthorization Act (MACRA)?

On April 14, 2015, Congress passed the MACRA Act of 2015 and was subsequently signed into law by President Obama on April 16, 2015. This legislation repeals the Sustainable Growth Rate (SGR) formula, which linked Medicare annual payment updates for physicians and other professionals to prior year spending and gross domestic product (GDP) growth. MACRA contains scheduled Physician Fee Schedule (PFS) updates and a new Quality Payment Program that allows eligible clinicians to participate streamlines via one of two paths: 1) Merit-based Incentive Payment System (MIPS) or 2) Advanced Alternative Payment Models (APMs).

How does MACRA affect CRNAs?

On October 14, 2016, CMS released the MACRA Final Rule, which describes the plans for the Quality Payment Program in more detail. The Final Rule also explains how the current Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VM), and the Medicare Electronic Health Records (EHR) Incentive/Meaningful Use (MU) Program will sunset and be consolidated and replaced by Merit-based Incentive Payment System (MIPS)  beginning with the 2017 performance year.
 
Beginning in 2019, CRNAs will receive a positive, downward, or neutral payment adjustment based on MIPS participation and performance. The payment adjustments will start at +/- 4% in 2019 (for the 2017 performance year) and grow to +/- 9% in 2022 and later. MIPS payment adjustments and incentive payments, which will be based on a composite scoring system, will begin in 2019 (see FAQ#3 for more information on MIPS).
 
Special Note: CMS is offering eligible clinicians 3 "pick your own pace" options to report to MIPS for the 2017 transitional year of MIPS:
MIPS Pick Your Pace


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In addition, the MACRA Final Rule promotes the development of Alternative Payment Models (APMs) by providing incentive payments for certain eligible clinicians who participate in advanced APMs; however, it is unclear how many CRNAs will fall under an advanced APM. APM incentive payments will also begin in 2019 based on 2017 participation. Eligible clinicians who are determined to be qualifying advanced APM participants (QPs) for a given year will be excluded from MIPS and receive a 5% lump sum incentive payment for that year (2019-2024). In other words, if you receive 25% of Medicare payments or see 20% of your Medicare patients through an advanced APM in 2017, then you earn a 5% incentive payment in 2019.

What is the Merit-Based Incentive Payment System (MIPS)?

The MIPS consolidates three existing quality reporting programs: the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VBPM), and the EHR Incentive/Meaningful Use (MU) Program.
 
Under MIPS, the following four new programs—or performance categories—will establish a MIPS composite performance score (0-100) used to determine physician payment:

  1. Quality (replaces PQRS);
  2. Cost (based on VBPM)--counting to begin in 2018;
  3. Advancing Care Information (replaces EHR/MU program)*; and
  4. Clinical practice improvement activities (new program)

Special Note: The Cost Performance category has been weighted at zero percent of the final score for the transition year of 2017 for all eligible clinicians. Since CRNAs were never eligible for the EHR/MU program in the past, participation in Advancing Care Information (ACI) will be optional for CRNAs in 2017; however, this will likely change in the years to come.
 
Figure 1 illustrates the weight distribution for the 2017 performance score. Most CRNAs will receive a weighted score of zero for the ACI performance category since it is not generally applicable to this specialty. According to the Final MACRA rule, the Quality performance category will be reweighted to 85% for clinicians not reporting on the ACI performance category).
 
Figure 1. 2017 Performance Category Weights for MIPS*

MIPS Performance Category Weights
The MIPS composite performance score will be compared against a MIPS performance threshold to determine whether a MIPS eligible clinician receives an upward payment adjustment, no payment adjustment, or a downward payment adjustment. Eligible clinicians participating in MIPS will be eligible for positive or negative Medicare payment adjustments that start at 4% in 2019 and gradually increase to 9% by 2022 (see Figure 2). 

As a budget-neutral program, MIPS – participating clinicians with higher composite scores will be eligible for a positive payment adjustment up to three times the baseline positive payment adjustment for a given year. For example, the baseline positive payment adjustment for 2019 will be 4%, so the higher performers will be eligible for a positive payment adjustment of up to 12%. This scaling process will only apply to positive adjustments, not negative ones. An additional positive payment adjustment up to 10% will be available to “exceptional” performers.

Figure 2. MIPS Payment Adjustments

MIPS Payment Adjustments


Source: CMS. Quality Payment Program [slide deck]. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MACRA-NPRM-Slides.pdf. Accessed September 21,2016.

Are CRNAs exempt from MIPS?

In general, no—CRNAs are not exempt from MIPS unless they meet any one of the following exclusion criteria:

  • CRNAs are in their first year billing for Medicare
  • CRNAs whose volume of Medicare payments or patients falls below the threshold (ie, Medicare billing charges less than or equal to $30,000 OR provides care for 100 or fewer Medicare patients)
  • CRNAs who qualify for payment under advanced Alternative Payment Models (APMs)

Note that MIPS does not apply to hospitals or facilities. Additionally, providers practicing in rural health clinics or Federally Qualified Health Clinics will be give additional flexibility under MIPS.

What is an Alternative Payment Model (APM)?

As described in the Final Rule, Medicare clinicians who participate to a sufficient extent in an advanced APM would be exempt from MIPS reporting requirements and qualify for financial bonuses. The individuals who qualify for such bonuses are referred to as “advanced APM qualifying participants” or QPs in advanced APMs.
   
In order for a provider to receive enhanced payment through a qualified advanced APM, the APM must also meet the following eligibility requirements:

  • Use of quality measures comparable to measures under MIPS;
  • Use of a certified electronic health record (EHR) technology; and
  • Assumes more than a “nominal financial risk” (which is undefined), OR is a medical home expanded under the Center for Medicare and Medicaid Innovation (CMMI).

Examples of current advanced APMs under the Medicare Program or CMMI:

  • Medicare Shared Savings Program (MSSP) ACO (Tracks 2 and 3-two sided financial risk)
  • Medicare Next Generation ACO Model
  • Comprehensive ESRD Care (CEC) (large dialysis organization arrangements)
  • Comprehensive Primary Care Plus (CPC+)
  • Oncology Care Model (OCM) (two-sided risk track available in 2018)

If you are an advanced APM qualifying participant, you will receive a 5% lump-sum bonus on your Medicare payments for 2019 through 2024. This bonus will be in addition to the incentive paid through existing contracts with the qualified APM (eg, MSSP), demonstration program, etc. 
 
Figure 3. MIPS adjustments and APM Incentive Payment to begin in 2019

MIPS adjustments and APM Incentive Payment

Source: CMS. Quality Payment Program [slide deck]. Accessed September 21, 2016.

What can I do now to prepare for MACRA implementation?

According to the Final Rule, performance in 2017 will determine the threshold and consequent payment adjustment for the first year of MIPS in 2019. If you have not reported data on quality measures through the Physician Quality Reporting System (PQRS), start as soon as possible; penalties for not reporting may impact you for the 2018 PQRS payment adjustment year. More information is available on our 2016 PQRS FAQ page. 
 
If you submitted quality data during the last calendar year, you should have access to your individual PQRS Feedback Report or your group’s Quality and Resource Use Report (QRUR). This report will help you understand your performance in terms of cost and quality so you can prioritize potential areas for improvement.
 
Special Note: CMS is offering eligible clinicians 3 "pick your own pace" options to report to MIPS for the 2017 transitional year of MIPS:

MIPS Pick Your Pace


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CMS also recommends taking these steps to get ready for 2017:

  • Consider using a qualified clinical data registry or a registry to extract and submit your quality data.
  • If you have access to an Electronic Health Record (EHR) system, check that it is certified by the Office of the National Coordinator for Health Information Technology. If it is, it should be ready to capture information for the MIPS advancing care information category and certain measures for the quality category.
  • Use the Quality Payment Program website to explore the MIPS data your practice can choose to send in. Check to see which measures and activities best fit your practice. 

What is the AANA doing to help CRNAs prepare for MACRA?

The AANA reviewed the Proposed Rule and submitted comments that specifically addressed the needs of CRNAs and vigorously advocated the following:

  • Equal consideration for CRNAs and anesthesiologists
  • Improved payment for CRNAs and increased opportunities for incentives
  • Reasonable reporting requirements
  • Administrative simplification 

As always, the AANA Research and Quality Division is committed to keeping you informed and developing resources to support your quality improvement efforts. The Final Rule on MACRA became available on October 14, 2016, and we will continue to update the aana.com website with information and reporting tools in addition to pertinent “Viewpoint” articles through the AANA News Bulletin.

 

Where can I find more information on MACRA?

CMS has created a “Quality Payment Program” website with information, tools, and resources including fact sheets and webinars.

MIPS-Quality Payment Program

An Introductory Guide for CRNAs

The AANA Research and Quality Division has prepared a short video below to introduce CRNAs to the new Quality Payment Program that will begin in 2017. For more detailed information, you can also view the presentation titled "Merit-based Incentive Payment System (MIPS) Overview" that was created by the Centers for Medicare and Medicaid Services (CMS) and was presented on November 29, 2016.

Download slide of the presentation below.