HHS unveils proposed rule for new Quality Payment Program

May 12, 2016
New CMS payment system combines aspects of meaningful use, PQRS and Value-Based Modifier programs. Changes could start as early as 2017.

Representing an outright paradigm shift in quality reporting and payment programs, the highly anticipated proposed rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA) emphasizes a streamlined approach to measures reporting.

The Department of Health and Human Services (HHS) issued a notice of proposed rulemaking on April 27 that outlined agency plans to "align and modernize" Medicare payments after MACRA ousted the Medicare sustainable growth rate (SGR) formula. Collectively, these changes created the Quality Payment Program (QPP), which is divided into two paths that link to quality payments:

  • Merit-based Incentive Payment System (MIPS)
  • Alternative Payment Models (APMs)

MIPS is the QPP path that most doctors of optometry will utilize. It consolidates components of the Physician Quality Reporting System (PQRS), the Value-based Modifier (VBM) and Medicare EHR Incentive Program (meaningful use) into one program focused on quality, resource use, and continued certified EHR technology (CEHRT) use. Medicare physician payments will continue to be based on the fee schedule, but larger bonuses and penalties will be possible under the new approach.

"This is the new system. This is the way of the future, and it started already with some of these programs," said Jeff Michaels, O.D., AOA Quality Improvement and Registries Committee chair, during a MIPS continuing education (CE) course at AOA's Congressional Advocacy Conference.

MACRA was created to push the needle toward high-quality, high-value care. Depending on how well physicians perform under MACRA, the Centers for Medicare & Medicaid Services (CMS) will start increasing or decreasing Medicare payments up to 4% in January 2020. The potential maximum incentive or penalty will increase each year from 2019 to 2022 and will cap at 9% in 2022 and on. Top performers may be rewarded with incentives above the maximum set rate.

The actual amount a doctors' Medicare payments will be adjusted to will be based on performance across four categories: Quality, Advancing Care Information, Clinical Practice Improvement Activities and Cost, Dr. Michaels explained. These categories will be factored as such:

  • Quality - 50% of total score in first year. CMS has proposed that doctors choose to report six quality measures. The available measures for doctors of optometry to report will be similar to those found in PQRS.
  • Advancing Care Information/Meaningful Use of CEHRT - 25% of total score in first year. CMS has proposed that doctors report on many of the same measures and objectives that currently exist under the EHR Incentive Program, but CMS would move away from the all-or-nothing method of evaluating successful participation. Therefore, partial credit is available for those who do not fully meet these measures.
  • Clinical Practice Improvement - 15% of total score in first year. CMS has proposed that doctors would select activities that match their practices' goals from a list of more than 90 options, rewarding activities focused on care coordination, beneficiary engagement, and patient safety.
  • Cost/Resource Use - 10% of total score in first year. CMS has proposed for this measure to be based on Medicare claims, meaning no additional reporting requirements for clinicians, but physicians would be evaluated on how they compare to their peers related to health care costs.

These factors change over time to the point that Quality accounts for only 30% of the total score, while Cost/Resource Use increases to 30% by 2022, Dr. Michaels said. In the meantime, CMS intends to begin measuring doctors' performance through MIPS in 2017, and payments would begin in 2019.

AOA will be offering substantive comments on the proposed rule before the June 27, 2016, deadline to help ensure there are pathways to success for doctors of optometry under this new payment system.

Importance of registry use

AOA MORE (Measures and Outcomes Registry for Eyecare) by Prometheus Research has already proven to be a valuable resource for meeting meaningful use and PQRS measures. The registry recently received CMS' Qualified Clinical Data Registry (QCDR) designation for the 2016 PQRS year. However, AOA MORE will become absolutely critical to doctors of optometry under MIPS. MACRA and the new proposed rule give special consideration to QCDRs and encourage their use as a way to increase reimbursement and reduce burden under MIPS.

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