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

Policy & Regulation News

MACRA Quality Payment Program Promotes Alternative Payment Models

New MACRA legislation introduces the Quality Payment Program, which promotes alternative payment models. Providers will participate in this program through MIPS.

By Catherine Sampson

- The newly-proposed MACRA implementation rule establishes the Quality Payment Program and shines a spotlight on alternative payment models for Medicare. Alternative payment models (APMs) are a central feature of new proposed rule for implementation of the MACRA legislation, CMS Acting Administrator Andy Slavitt said yesterday when unveiling details of the proposals to bring the bi-partisan effort to life.

HHS announced new MACRA legislation known as the Quality Payment Program.

The proposed rule introduced the Quality Payment Program (QPP), a value-based reimbursement framework that will include two paths to systemic improvement: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APM) track.

“As a nation, we’ve made significant advances in transitioning the healthcare system to one that pays for quality, encourages coordinated care and smarter spending, and focuses on better outcomes for people. Accountable care organizations, comprehensive primary care models, and bundled payments are gaining significant traction. The Medicare FFS program now has over 30% of its payments in programs like these, and the number is rising,” said Acting CMS Administrator Andy Slavitt in a media call.

“These advances have created needs and uses for technology that simply didn’t exist when meaningful use was developed.  All of this, taken together, has given us the opportunity to step back and conduct a full review of the MU program so we can move to the next level of how technology can support us as we move to the world of the more mobile patient, and the need for connected and coordinated care,” Slavitt said.

The proposed rule is supposed to improve the “relevancy and depth” Medicare’s quality-based payments. Also, the program is going to be more flexible than a one-size-fits all approach, said Dr. Patrick Conway, CMS acting principal deputy administrator and chief medical officer. Under this program, clinician gain more flexibility because they get to choose measures and activities that are appropriate for the type of healthcare they provide. 

A majority of Medicare clinicians are likely to first participate in the QPP through MIPS, said CMS. Some of the most significant aspects of the APM framework include:

  • Alternative payment models (APM) that are eligible to become Advanced APMs would provide a path for healthcare providers to become Qualifying Alternative Payment Model professionals and earn incentive payments for participation in alternative payment models specified under MACRA.
  • HHS proposed two types of Advanced APMs: Advanced APMs and Other Payer Advanced APMs. To be an Advanced APM, an APM is required to use certified EHR technology, provide payment for covered professional services based on quality measures and be either a Medical Home Model or only have a small amount of financial risk.
  • Under the MACRA’s requirements, MIPS would distribute payment adjustments to between about 687,000 and 746,000 eligible providers in 2019. Payment adjustments would be based on performance on specified measures and activities within the four performance categories.
  • HHS projects that MIPS payment adjustments would be approximately equally distributed between negative adjustments ($833 million) and positive adjustments ($833 million) to MIPS eligible providers.
  • Additionally, MIPS would distribute about $500 million in exceptional performance payments to those whose performance exceeds a specified threshold. HHS believes that these payment adjustments will drive quality improvements in providers’ healthcare practices.
  • HHS expects between 30,658 and 90,000 providers to become Qualifying APM Participants in Advanced APMs, and are estimated to receive between $146 million and $429 million in Alternative Payment Model Incentive Payments in 2019.

Stakeholders have 60 days to comment on the proposed rule before CMS moves to finalize the framework. CMS officials have stated that they are committed to integrating industry feedback into the agency’s reform efforts, and hope to be more responsive to provider needs in the future.

“We have more work to do, but we are committed to implementing this important legislation and creating a healthcare system that works better for doctors, patients, and taxpayers alike,” said HHS Secretary Sylvia Burwell. “We look forward to listening and learning from the public on our proposal for how to advance that goal.”


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