Tuesday, 21 April 2015 18:51

Passage of Key Bill Heralds Changes to Come for Performance Evaluation in Healthcare

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r tallerIn the news this week was the bipartisan passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which permanently repealed the sustainable growth rate (SGR) formula for physician reimbursement in the Medicare program. Following Senate passage with a vote of 92-8 this week, President Obama signed the legislation, with members of both parties in the House of Representatives and the Senate attending.

Two provisions of the legislation that have attracted attention include the Merit-Based Incentive Payment System (MIPS) and support for transition to alternative payment methods (APMs). Beginning in 2019, bonuses will be available for eligible professionals who score well in MIPS, which will become the new pay-for-performance program under the Medicare system. The current penalty calculations under the Physician Quality Reporting System (PQRS), electronic health records/meaningful use (EHRs/MU) and the value-based payment modifier (VBM) would end at the close of 2018.

MIPS will gauge program performance based on four categories: quality, resource use, meaningful use, and clinical practice improvement activities. MIPS is intended to build upon and improve current quality measures and concepts in effect now for PQRS, MU and VBM. The next step will be publication of regulations on the details of how MIPS will be implemented.

MACRA also provides incentives for physicians to develop and participate in new models of healthcare delivery/payment. Professionals who receive a significant share of their revenues through an APM are slated to receive bonuses each year from 2019-2024. There are dual tracks for professionals to qualify for the bonus. The first option will be based on receiving significant percent of APM revenue through Medicare and the second option will be based on receiving significant percent of APM revenue from Medicare and other payors combined.

Meeting the quality reporting requirements for the APMs is still required, although these providers would be exempt from the MIPS quality program. Also, physicians participating in patient-centered medical homes would not be required to assume downside financial risk, although other models would incorporate some degree of this risk – in addition to opportunities for increased revenues and savings that many APMs provide. As with MIPS, the next step will be publication of regulations on how the APM components of MACRA will be implemented.

About the Author

Rhonda Taller has over 30 years of experience with health information technology working within the vendor environment, with roles in product management, management, government affairs, and strategic consulting. Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use, and health reform. Rhonda has held volunteer positions with HIMSS and WEDI, including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing the HIMSS ICD-10 Task Force (2013-2014), and serving as co-chair of WEDI ICD-10 Transition Workgroup.

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Last modified on Tuesday, 21 April 2015 21:55

Rhonda Taller has over 30 years of experience with health information technology working within the vendor environment with roles in product management, management, government affairs and strategic consulting.  Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use and health reform.  Rhonda have held volunteer positions with HIMSS and WEDI including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing HIMSS ICD-10 Task Force (2013-2014) and co-chair of WEDI ICD-10 Transition Workgroup.