The Medicare Access and CHIP Reauthorization Act of 2015

Passed with bipartisan support in 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is healthcare legislation primarily aimed to replace the fee-for-service (FFS) model with a physician payment framework that promotes quality-over-quantity care. The law does so by repealing the Sustainable Growth Rate reimbursement formula for updates to the Physician Fee Schedule and replacing it with new models for determining yearly payment rate updates for physicians’ services. Among an array of changes to Medicare and Medicaid, MACRA also temporarily extended the Children’s Health Insurance Program (CHIP) and increased premiums for Part B and Part D of Medicare for beneficiaries with income above certain thresholds ^[1].

Under MACRA, the Quality Payment Program (QPP) was established to help move the healthcare industry towards the goal of value-based care. The QPP utilizes new quality reporting mechanisms in conjunction with streamlined quality measuring schemes previously implemented by the Centers for Medicare and Medicaid Services (CMS). The program is composed of two payment models, the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). To facilitate a transition from FFS to quality-based payment, a period of positive pay increases for clinicians was established from July 1, 2015 to December 31, 2018, in the amount of 0.5% annually. The fiscal start of MIPS (based on the 2017 performance year), as well as incentives for participating in APMs and Advanced APMs, formally began on January 1, 2019 ^[2].

MIPS administers either positive or negative payment adjustments for clinicians whose practices are reliant on the FFS reimbursement model. Qualifying professionals (physicians, nurse practitioners, physician assistants, and clinical nurse specialists) who chose to participate in this program see annual payment increases or decreases depending on performance metrics. The law consolidates and streamlines three previously implemented quality reporting schemes within MIPS: Physician Quality Reporting System (PQRS), Meaningful Use (MU), and the Value-Based Payment Modifier (VM). Under MIPS, CMS will calculate a score from 0 – 100 for participating professionals based on four categories:

1) Clinical Quality

2) Advancing Care Information

3) Cost

4) Improvement Activities

The Clinical Quality category employs metrics previously reported under PQRS, the Advancing Care Information category utilizes measures formerly under the Electronic Health Record (EHR) Incentive program, and the Cost category uses metrics previously under the VM scheme. The Improvement Activities category recognizes providers for efforts that contribute to advancing patient care, safety, and care coordination. The maximum negative or positive payment adjustment is 4 percent in 2019 and will gradually increase to 9 percent in 2022 and beyond ^[3].

MACRA promotes participation in private payer and Medicare APMs. Beginning in 2018, eligible providers who chose to participate in an APM and receive at least 25 percent of their Medicare revenue through an APM earn a 5 percent bonus. To incentivize participation in APMs, the threshold for receiving the 5 percent APM bonus will increase to 50 percent of Medicare revenue in 2021. The threshold will continue to rise over time, reflecting CMS’s commitment to move toward quality-based payment schemes.

In order for providers to qualify for a payment track entirely separate from MIPS, an APM must be considered an Advanced APM by meeting the following criteria: 1) employ certified EHR 2) utilize quality-based metrics commensurate to those of MIPS 3) require clinical providers to bear more than nominal monetary risk for financial losses or operate as part of a medical home ^[4]. Finally, to address the unique payment integration challenges faced by small and rural practices, MACRA allocates $20 million annually to provide technical assistance to practices with 15 or fewer MIPS-eligible clinicians ^[5].

^[1] “2015-HR2.” CMS.gov Centers for Medicare & Medicaid Services, April 17, 2018. https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/2015-HR2.html

^[2] “Medicare Access and CHIP Reauthorization Act of 2015.” American College of Cardiology, April 28, 2015. https://www.acc.org/latest-in-cardiology/articles/2015/04/28/15/59/medicare-access-and-chip-reauthorization-act-of-2015-what-you-need-to-know.

^[3] “2018 MIPS Strategic Scoring Guide.” American Medical Association. AMA, 2018. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/physicians/macra/2018-mips-scoring-guide.pdf.

^[4] “Innovation Models.” Innovation Models | Center for Medicare & Medicaid Innovation, n.d. https://innovation.cms.gov/initiatives/#views=models.

^[5] “Quality Payment Program: Small Practice, Underserved, and Rural Support.” Physician Payment, March 14, 2019. https://www.aafp.org/practice-management/payment/medicare-payment/macra-101/qpp-surs.html.