April 29, 2016




In This Issue
This Week in Congress
CMS Releases Proposed Rule on MACRA
Final Rules Released on Medicaid Managed Care
HSA Limits Released for 2017
Compliance Cornered: Will a HIPAA Audit be in Your Future?
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Two Weeks Remaining for Legislative Council Applications
The ShiftShapers Podcast with David Saltzman
HUPAC Roundup
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CMS Releases Proposed Rule on MACRA
On Wednesday, the Centers for Medicare and Medicaid Services (CMS) released a 962-page proposed rule on the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA), which replaced the Sustainable Growth Rate (SGR) formula that was formally repealed last year. These are the first major regulations proposed in years relating to Medicare physician payments and are designed to direct physicians to value-based care while increasing flexibility. Major changes include phasing-out the meaningful use program for physicians and replacing it with the Advancing Care Information program, as well as changes to accountable care organizations (ACOs) and quality and value measures. The rule is scheduled for publication on May 9 and will be available for public comment for 60 days.
MACRA replaces the much-maligned SGR with a 0.5% annual increase in the physician fee schedule and links payments to a newly-established Merit-based Incentive Payment System (MIPS). This would consolidate the Physician-Quality Reporting System, the Physician Value-based Payment Modifier, and the Medicare EHR Incentive Program for eligible professionals, and would measure physicians in quality, cost, technology use, and practice improvement. Providers would have the option to be paid under the MIPS or an alternative payment model (APM), with physicians in APMs eligible for bonuses. The rule proposes using 2017 as the performance period to determine payments and scores for 2019.
Physicians operating under the MIPS system would be measured in four categories: quality, advancing care information, clinical practice improvement activities, and cost. Quality would comprise half of the total score in the first year and clinicians would choose to report six measures from among a range of options that accommodate differences among specialties and practices. Under advancing care information (25% of total score in year 1), clinicians would report how they use technology in their day-to-day practice, with an emphasis on interoperability and information exchange. Clinical practice improvement activities makes up 15% of the first year score and rewards clinical practice improvements, such as care coordination, beneficiary engagement, and patient safety. Finally, cost comprises 10% of the first-year score and is based on Medicare claims. Providers using MIPS will be required to use 2015-edition certified health information technology by 2018.
The APMs include the Next Generation ACO, the Comprehensive Primary Care Plus model, the two-sided risk arrangement in the Oncology Care Model, and the Comprehensive ESRD care model. Additionally, Track 2 and 3 ACOs in the Medicare Shared Savings Program (MSSP) may be eligible as Advanced APMs as they include some financial risk for participating physicians. ACOs in Track 1 of MSSP will not qualify for the APM designation. There will be three standards to determine whether providers will qualify for the advanced APM: the maximum amount of losses under an Advanced APM must be at least 4% of the spending target; marginal risk levels must be at least 30%; and the minimum loss rate cannot exceed 4%. Additionally, half of clinicians must use certified electronic health records in the first year, jumping to 75% by 2018. However, the number of EHR measures will decrease from 18 to 11 and clinical decision support reporting and CPOE will cease to be required.
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