Admittedly, we love our acronyms in health care, from the ACA to CMS. Today, I want
to add two more to the mix: MACRA and MIPS. These acronyms are key to understanding
how Medicare will now pay physicians, and other providers, through its physician fee
schedule (PFS).
The first, MACRA, refers to the Medicare Access and CHIP (Children’s Health Insurance
Program) Reauthorization Act. See what I mean about acronyms? MACRA has an acronym
inside an acronym. MACRA was passed by Congress last year to replace the sustainable
growth rate (SGR) mechanism to the PFS. Don’t waste time trying to remember SGR,
which was designed to counter health care’s spending growth by automatically reducing
Medicare physician fees if spending exceeded a target, because it is gone (and never
worked very well). Few, if any, bemoan its demise. MACRA is supposed to reward what
it considers “high-performing providers” while supporting alternative payment models
such as accountable care organizations and patient-centered medical homes.
The cuts to fees under SGR will be replaced with modest annual updates instead. Fees
increased by 0.5 percent in June 2015 and will increase by 0.5 percent each year from
2016 through 2019, and then remain at that rate through 2025. However, high-performing
providers and providers participating in alternative payment models can earn bonus
payments. But, how does a provider become a high-performing provider?
That brings me to the second new acronym, MIPS, which stands for the merit-based incentive
payment system that will be established in 2019. A high-performing provider is one
who has a high MIPS score, which is an assessment of multiple performance metrics,
including quality, resource use, clinical practice improvement activities and meaningful
use of certified electronic health record technology.The MIPS score combines elements
of what we formerly called the physician quality reporting system (PQRS), value based
modifier (VBM) and meaningful use (MU).
Why is this happening? In my opinion, it has to do with the fact that the SGR was
very unpopular, as well as the Centers for Medicare and Medicaid Services (CMS) trying
to control rising costs and improve quality. You have undoubtedly heard of the movement
from volume-based to value-based payment, which relates to CMS going away from fee-for-service,
which many experts view as the root of all evil, for a payment program that assesses
the performance of each eligible provider based on the performance aspects mentioned
above.
If all of this is quite boring and gives you a headache, I understand. I chuckled
when I read that the drafters of the new MACRA legislation recognized that this new
payment system may not appeal to some physicians and wrote into the law a requirement
that CMS report on the number of doctors dropping out of Medicare. This is probably
a good idea.
