MACRA is Medicare Access and CHIP Reauthorization Act designed by CMS to reward Healthcare providers for giving better care instead of more service. CMS is required by law to implement a quality payment incentive program, referred to as the Quality Payment Program, which rewards value and outcomes in one of two ways: Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). The first two transition years of the MIPS were implemented gradually to reduce burden and provide flexible participation options, to allow clinicians to spend less time on regulatory requirements and more time with patients.
The Quality Payment Program has two tracks you can choose based on their practice size, specialty, location, or patient population:
If you decide to participate in an APM, you may earn an incentive payment for providing high-quality, high value care and cost-efficient care. APMs can focus on specific clinical conditions, care episodes, or populations. If you decide to participate in MIPS, you will earn a performance-based payment adjustment for the services you provide to Medicare patients.
To be successful under either, groups are required not only to track measures and activities but to perform well in those areas—and even to outperform their peers.
Medicare Access and CHIP Reauthorization Act (MACRA) significantly changes how Medicare will reimburse physicians in the future.
With greater emphasis on quality, value and physicians taking more financial risks, MACRA makes three important changes to how Medicare pays those who give care to Medicare beneficiaries.
These changes create a Quality Payment Program (QPP) and aims at making a new framework for rewarding health care providers for giving better care not more just more care.
MACRA does away with the Sustainable Growth Rate (SGR) formula, and adopts two new QPP paths – The Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs).
The MACRA abolishes the SGR and from 2015 through 2025 provides physicians with a stable, sometimes flat, update to the Medicare physician fee schedule payment rates. Beginning 2026, physicians and other health care professionals will receive different annual updates.
So depending on the data you submit for the performance year, in the payment year, your Medicare payments will be adjusted up, down, or not at all.
Without the passage of MACRA, physicians could have been subject to negative payment adjustments of 11% or more in 2019 because of the MU, PQRS and VBM programs, with even greater penalties in future years. In contrast, under MACRA, Payment adjustment for the performance year 2017 will be in the payment year 2019 ranges from - 4% to + (4% x scaling factor) as required by law. Payment adjustment for the performance year 2018 will be in the payment year 2020 ranges from - 5% to + (5% x scaling factor) as required by law.
Payment adjustment for the performance year 2019 will be in the payment year 2021 ranges from - 7% to + (7% x scaling factor) as required by law. (The scaling factor is determined in a way so that budget neutrality is achieved). So, if you don’t send in any 2019 data, then you will be subject to a negative 7% payment adjustment.
You’re a part of the Quality Payment Program if you bill more than $90,000 a year in allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and furnish covered professional services to more than 200 Medicare beneficiaries a year and provide more than 200 covered professional services under the Physician Fee Schedule (PFS).
For MIPS, you must be one of the following:
You can also participate as a group if the group includes at least one of the clinician types listed above.