Medicare Access & CHIP Reauthorization Act (MACRA)

On April 14, 2015, Congress passed the MACRA Act of 2015, which 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 Quality Payment Program that allows eligible clinicians to participate via one of two paths: 1) Merit-based Incentive Payment System (MIPS) or 2) Advanced Alternative Payment Models (APMs).

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 performance categories—will establish a MIPS composite performance score (0-100) used to determine physician payment:

1. Quality
2. Cost
3. Promoting Interoperability; and
4. Improvement Activities

Special Note: The Cost Performance Category was weighted at 15 percent of the final score for Year 3 for all eligible clinicians. This was the result of changes to the MACRA law through the Bipartisan Budget Act of 2018, which allows for the Cost category to be weighted between 10 percent and 30 percent.

*Since CRNAs are not eligible to report the Promoting Interoperability category, there is an automatic re-weight to the Quality category.

  
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




Source: CMS.GOV

The Bipartisan Budget Act of 2018 made changes to the MACRA law by extending the transition years for MIPS through 2021. The extension allows for a gradual increase in the performance threshold for avoiding MIPS payment penalty, and the weighting of Cost performance category in the MIPS final score.

The Act mandated that MIPS payment adjustments are only applied to Medicare Part B covered professional services rather than items, such as drugs. It set the 2019 performance threshold at 30 points, and increased the weight of the Cost performance category to 15%. The changes made by the law did not impact the maximum penalties for low performance or non-participation (without an exclusion), so they remain the same.

Another provision in the new law was the addition of a criterion for the low-volume threshold exclusion from MIPS reporting.  An eligible clinician (EC) who provides less than 200 covered professional services during a performance year will be exempt.

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 explained how the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VM), and the Medicare Electronic Health Records (EHR) Incentive/Meaningful Use (MU) Program would be sunset and replaced by the 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).

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.

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



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

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 CMS-defined threshold (e.g. Medicare billing charges less than or equal to $90,000 OR provides care for 200 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.

The AANA reviewed the Final Rule on MACRA, sought feedback from members, monitored CMS resources and submitted comments that specifically addresses 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. CMS publishes updates to the Quality Payment Program within MACRA annually, 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.

 

1) Check your MIPS eligibility status using the QPP Participation Status Tool.
2) Determine the look-back period for reporting year, which can be found within the QPP Participation Status tool. (Eligibility is based on volume of claims a year prior to the reporting year)

Submit quality measure data through the CMS Enterprise Portal or the Quality Payment Program Sign In page; penalties for not reporting may impact you for the next payment adjustment year. More information is available on our Quality Payment Program page. 
 
If you submitted quality data during a given Reporting Year, you will have access to your MIPS Performance Feedback Report. Beginning in late 2018, this report replaces the Quality and Resource Use Report (QRUR), and will help you understand your performance in terms of cost and quality so you can prioritize potential areas for improvement.
 
CMS also recommends taking these steps for participating in MIPS:

• 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 meets 2015 certification criteria by the Office of the National Coordinator for Health Information Technology. If it is, it should be ready to capture information for the MIPS Promoting Interoperability category and certain measures for the quality category.
• Use the CMS 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. 
• Consider the virtual group option for reporting MIPS data.

CMS has created a “Quality Payment Program” website with overviews, tutorials and tools to educate providers. The QPP Resource Library is also available with documents that explain each aspect of MIPS Reporting.