Background

Before we start discussing MACRA it is important to understand the reasons prompted this bill to develop and the reasons to repeal Sustainable Growth rate (SGR). Since Medicare inception (1965) a method to pay healthcare professionals for their services was not satisfactory and had some basic problems. SGR was not a flawless cost control program and it tied growth terribly in Medicare programs over many years. Therefore, such flaws in SGR program had affected the growth and investment of the practices thus proving to be a continuing distraction as well as hurdle to any meaningful payment reform. Several attempts had been made in order to control the genie of spending but unfortunately all proved largely unsuccessful. This led to the increase of provider payments resulting in public outcry thus mounting pressure on the policy makers. The medical community had no other choice but to pressuring and lobbying the Congress to keep postponing the payment reductions brought in by SGR. Each year Congress complied until it couldn’t. So, policy makers at the Congress realized that concrete steps needed to be taken and further stalling would only increase financial pressure. There is a need for the designing of a new framework which not only control healthcare payments but also have substantial amount of ground work for patient care and well-being.

MACRA

In 2015, Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law by the Congress. It met with the support in both House of Representatives and the Senate. It was introduced with the purpose to reduce the burden on healthcare professionals, enhance patient’s outcome and optimize the value and standard of the patient care experience. At its core, MACRA is conceptualized to enact a new and superior payment framework that should reward healthcare professionals for giving better care instead of more service. In a nutshell, quality treatment over the mere patient volume. That is how MACRA replaced the Medicare reimbursement schedule with a new development payment method program which focused more on quality, value and above all accountability. MACRA is designed to have one quality program which aims to combine and streamline various quality reporting programs under a single entity. MACRA has another quality tracking reform program called Medicare Incentive Payment System (MIPS).

Medicare Incentive Payment System

MIPS is a healthcare program intended for healthcare professionals in order to increase their reimbursements by complying with the rules and demands needed to get the proper compensation. MIPS is a combination of three already existing programs developed and introduced by CMS. These are Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM) and the Electronic Health record (EHR). It incorporates these three programs attributes into a single payment model with a goal of creating a more robust, efficient and comprehensive system with fewer redundancies.
In MIPS, healthcare providers payments will be adjusted either positively or negatively based solely on the performance in the four main categories.
1- Quality
2- Clinical Practice Improvement
3- Advancing Care Information
4- Resource Use
The evaluation of a healthcare professional in the four mentioned categories will be translated into a score maximizing 100. The healthcare professionals need to do their absolute best in order to be able to reap the full benefits of MIPS.

Quality

There are a total of six measures for both process and outcome metrics. However, these measures are different for different practices depending on the status and scale of the practice. For full participation the clinician or group has to report on the six measures, one of which should belong to an outcome measure. If less than six measures are applicable on a certain practice, then the practice needs to report only on the applicable measures. Similarly, specialists and subspecialists may fall under the separate set of applicable measures which suit their appropriate work. Moreover, clinicians has to report at least one outcome measure available within the set. Incase if unavailable then the clinicians must report another high priority measure.
High priority quality measures incorporate outcome, appropriate use, patient safety, efficiency, patient experience and care coordination. It is important to note that reporting additional high priority measures makes the healthcare provider eligible to earn bonus points up to 10 percent of the total points possible. Moreover, each Quality measure submitted via Certified Electronic Health Record Technology (CEHRT) will receive one additional bonus point.
These Quality measures will be evaluated against an available historical data, determined from baseline period. In case of non-existent baseline data Quality measures will be extracted by an actual performance.

Clinical Practice Improvement

Healthcare providers under this category will more likely to be rewarded for their efforts if HHS believes that such efforts and activities will have a positive impact in improved outcomes. These improved activities regarding healthcare include:
• Care Coordination
• Beneficiary Engagement
• Population management
• Health Equity
According to CMS, these activities are going to weigh either medium or high. In order to earn full credit in this category practices will have to participate either in four medium-weighted or two full-weighted activities during 2017. However, there are exceptions for small practices in rural areas or health care professional shortage areas, geographically speaking. In such situations and areas healthcare providers need to complete either two medium-weighted or one high-weighted activities.

Advancing Care Information

The purpose of the measures involving this category focuses on the advancement of patient engagement and healthcare quality using CEHRT along with secure exchange of health information electronically from one provider to another. Practices will be needed to report on the five specific measures under such category and are required to secure the option of reporting on additional measures in order to earn a high score. The total weight equals 25 percent in this category. The score is incorporated of two main components:
• Base Score
• Performance Score
Base score is dependent on both the participation and reporting and will be counted if the healthcare provider uses the component and report its use. In order to secure any meaningful score in this category providers need to report the measures actively. These measures are:
E-prescribing
Summary of care
Performing Security Risk Analysis
Provision of Patient Electronic Access
Performance score on the other hand depends on the following measures:
Patient electronic Access
Care Coordination through Patient Engagement
Health Information Exchange
Public Health Registry
Clinical Data Reporting
Healthcare providers completing at least one of the improvement activity from a specified list using CEHRT will make them eligible to receive 10 percent bonus.

Resource Use
This category as the name suggests is the analysis and measure of cost effectiveness which is the most crucial component in nay planning or design. The provider however is not required to report this because Medicare will already have an access to the data in its claim files for each of the practice.


MIPS Qualifying Criteria Practices will not be considered as a qualifier in MIPS program if they have 100 or fewer patient’s attendance during a performance period which is a 24 month long assessment period. Even before the start of performance period some may be excluded from MIPS simply because of the low-volume threshold which is $30,000 or less in Medicare billing charges. MACRA Timeline

2015: 0.5% annual adjustment for the practices till December 2019.
2016: A list of MIPS Quality measures for the 2017 performance period had been proposed. In November, CMS to set the criteria for provider payment models. MIPS Quality measures due each Nov 1 for the next performance period.
2017: Marked the beginning of the performance baseline period for MIPS reporting and scoring which would determine 2019 payment adjustments.
2018: Every eligible healthcare professional must be informed annually of the MIPS adjustment factor.
2019: MIPS bonuses and penalties began to apply to payments for provider services and phased in 5% bonuses from 2019-2024.
2020: Maximum penalties for MIPS were set to 5% and MIPS bonuses were between 5-15% with 10% bonuses on exceptional services.
2021: Maximum penalties for MIPS will be 7% with the highest MIPS bonuses between 7-21% and additional bonuses up to 10% for exceptional performance.
2022 & Beyond: Maximum penalties for MIPS will be 9% with MIPS bonuses between 9-27% with additional bonuses up to 10% for exceptional performance.