Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

Value-Based Care Final Rule to Implement MACRA Sent to OMB

CMS has submitted its final rule for implementing MACRA and its value-based care provisions to OMB.

- The final rule for implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) — and its provisions for value-based care and reimbursement — is now in the hands of the Office of Management and Budget (OMB) according to its website.

OMB is reviewing value-based care and reimbursement provisions

Last April, the Senate pass the legislation to permanently repeal Medicare’s Sustainable Growth Rate. MACRA replaces the sustainable growth rate formula with a payment model that links value-based care to reimbursement structures.

MACRA contains two provisions with ramifications for healthcare providers focusing on value-based reimbursement.

The first program is the Merit-Based Incentive Payment System (MIPS), which consolidates the Physician Quality Reporting System (PQRS), the Value Modifier, and the EHR Incentive Programs.

Starting in 2017, healthcare providers will be evaluated on a number of measures related to quality, resource use, clinical practice improvement, and meaningful use of certified EHR technology. MIPS will annually assess healthcare providers for their performance in the four categories and give them a MIPS score.

The MIPS scores will determine a healthcare provider’s Medicare reimbursement adjustment.

The Alternative Payment Models (APMs) are another way for healthcare providers to take part in value-based reimbursement for Medicare. Some APMs are accountable care organizations, patient-centered medical homes, and bundle payment models.

Under an APM, healthcare providers will receive a 0.5 percent lump-sum incentive payment for their Medicare payments from 2019 to 2024. By 2026, healthcare providers will qualify for higher annual payments.

Healthcare organizations will still be subject to quality measures comparable to those under MIPS.

The proposed rule contains substantial changes to quality reporting.

Last July, CMS proposed a physician fee schedule update to MACRA that stated new payment legislation will concentrate on person-centered care and better patient outcomes.

CMS later released a Measure Development Plan that initiated changes to quality measures for MIPS and APMs that supported person-centered care.

The report identified gaps in quality measure sets for PQRS, the Value Modifier, and the EHR Incentive Program. CMS planned to collaborate with federal and state partners and private payer to build an improved set of measures that reduce provider burden.

CMS stated that future quality measures will prioritize clinical care, safety, care coordination, patient and caregiver experience, population health and prevention.

In addition to quality measurement provisions, MACRA will foster EHR adoption and adjust financial incentives for certified EHR use. The proposed rule aims to reward providers for the outcomes of EHR use, provide more access to health IT, and promote interoperability.

Certified EHR adoption is a key part of quality scoring under MIPS and APMs.

Many industry groups have commended MACRA for repealing the sustained growth rate formula and promoting value-based care.

“We can shift to working with all levels of government toward policies that allow access to affordable quality care, lower health costs,” said James L. Madera, MD, Chief Executive Officer and Executive Vice President of the American Medical Association. “With the SGR behind us, we can now work toward those other elements with Congress, CMS, and others, putting the patients first and ensuring access to care, looking to reduce overall costs, and improving healthcare quality.”

Some healthcare organizations support MACRA, but emphasize that quality reporting requirements need to be convenient and effective. Healthcare providers will not benefit from financial incentives with unsatisfactory reports.

“It is important that CMS implement the new payment system in a way that measures providers fairly, minimizes unnecessary data collection and reporting burden, focuses on important quality issues, promotes collaboration across the health care delivery system, and provides the broadest opportunity for participation in APMs,” the American Hospital Association stated in an Issue Brief.

Other healthcare organizations, such as CHIME, called for the elimination of the “all-or-nothing” structure under the meaningful use program. MACRA will carry on the legacy of meaningful use, but some industry groups urge CMA to include more comprehensive evaluations for certified EHR use through MACRA.

The OMB typically has 90 days to review legislation, but some industry groups claim that a decision will be given in a month.

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