Medicare Access and CHIP Reauthorization Act (MACRA)

Learn about MACRA. Visit our MACRA FAQs, glossary, and resources pages to find the most up-to-date information on this important and developing topic. And watch your inbox for MACRAlerts.  Each MACRAlert will provide vital MACRA news.

MACRAlert

What is MACRA?

On April 16, 2015, President Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). As the policies passed in this new legislation are rolled out over the coming years, comprehensive changes in how Medicare pays physicians for services will be introduced. Reimbursement for rheumatologists and their practices will change significantly. The law:

  • Repeals the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care services
  • Changes the way that Medicare rewards clinicians moving away from fee-for-service and toward payment based on value

Under MACRA, nearly all physicians will have to choose between one of two paths: Merit-Based Incentive Payment System (MIPS), which consolidates existing Medicare fee-for-service physician incentive programs such as PQRS and meaningful use or participation in an Alternate Payment Model (APM)

“MACRA is a reality that directly effects rheumatology practices and their ongoing viability for providing care to patients. Understanding this new payment system and the options available to physicians is critical. The ACR is working proactively to support the rheumatology community in this transition through provision of relevant up to date information for providers, through development and support of a patient registry that will provide MIPS credit for participating practices, and by funding development of a rheumatology specific alternate payment model.” More >

– David Daikh, MD, PhD, ACR President

Two Payment Tracks

The Quality Payment Program (QPP) has two tracks to choose from which allow you to participate based on your practice size, specialty, location, or patient population: MIPS and APMs.

Merit-Based Incentive Payment System (MIPS)

  • MIPS changes how Medicare links performance to payment.
  • MIPS consolidates three current programs: the EHR Incentive Programs/Meaningful Use (MU), Physician Quality Reporting System (PQRS) and Value Based Modifier (VBM) into one quality program.
  • MIPS will evaluate four performance categories: Quality, Resource Use, Clinical Practice-Improvement Categories and Advancing Care Information (MU) . An eligible professional’s (EP) performance score will be used to determine if an EP receives a positive, negative or zero payment adjustment.
  • For physicians who select the MIPS track, a methodology will be used to assess their total performance for Medicare beneficiaries and each MIPS eligible physician will receive a composite quality score for each performance period.

Note: Details on MIPS will be the subject of policymaking for several years, but it is important to understand that some of the assessments made at the effective date of 2019 will be based upon 2017 data.

MIPS composite score

MIPS adjustment to provider base rate

Alternate Payment Models (APMs)

  • MACRA promotes the development of an eligible professional’s participation in Alternate Payment Models (APMs), which create a payment incentive program for qualifying participants.
  • From 2019 through 2024, qualifying APM participants will receive a lump sum incentive payment equal to five percent of the prior year’s estimated aggregate expenditures under the fee schedule. Qualifying APM participants will not be subject to MIPS adjustments
  • Eligible APMs are the most advanced APMs that meet the following criteria according to the MACRA law: Accountable Care Organizations, Patient Centered Medical Homes and bundled payment models.
  • Base payment on quality measures will be comparable to those in MIPS.

 

ACR Support and Involvement

ACR leadership from a number of highly engaged committees have joined forces to develop an action plan for the organization’s involvement in the implementation of the new law. This ACR MACRA Working Group is developing an education, communication, and advocacy strategy and is committed to helping our members navigate through the complexity of MACRA as it rolls out. We are currently working on an Alternative Payment Model (APM).

ACR Alternative Payment Model Development

The ACR’s Alternative Payment Model (APM) addresses the treatment of rheumatoid arthritis (RA), a life-long condition whose appropriate care varies depending on the stage of the disease. The APM reflects the varied involvement of the rheumatologist during these distinct stages, splitting payment into an initial stage for diagnosis (including, for example, communication with primary care physicians), followed by ongoing care stratified by disease severity and recognizing other illnesses that complicate treatment. This model aligns payment with physician work and reimburses for services that have traditionally been undervalued. Quality measures are built into the APM to ensure that treatment adheres to best practices. We believe the services provided by cognitive specialists such as rheumatologists are undervalued in the current system, and the additional training and expertise of rheumatologists are not recognized. Additionally, non-face-to-face care and chronic disease care coordination reimbursement as currently configured is inadequate for the time and effort required to comply with current codes. In the ACR’s RA-APM, these valuable services which may prevent costly or unnecessary procedures are appropriately reimbursed, while the model is designed to lower overall costs.

Status of ACR APM Development: The ACR Board approved the next phase and continued funding in November 2017. Small-scale data collection is in progress. The RA-APM is in development and its design is intentionally flexible and scalable. Many details, including dollar amounts, are not final. Overview of the ACR’s APM

Actions You Should Take

  • There is a great deal to learn. Get informed and stay up-to-date with the rapidly changing landscape. January 1, 2017 was a significant date. That’s the day data about your practice started counting for reimbursement in 2019.
  • Choose a payment pathway. Almost without exception, everyone in the United States will be forced into one of two tracks: MIPS or APM. The ACR is highly engaged in working to influence the rules that define APMs and MIPS so that they make the most sense for rheumatologists and the medicine you practice and we will keep you informed as the details unfold.
  • Join RISE. Rheumatology Informatics System for Effectiveness (RISE) is a Qualified Clinical Data Registry (QCDR), created and administered by the ACR. RISE represents a vital tool for survival in the pathway called MIPS.

Updated February 2018