Policy Advisory

Policy Advisory
Medicare Access and CHIP Reauthorization Act of 2015
(Public Law No: 114-10)
On April 16, 2015, the law to repeal and replace Medicare’s Sustainable Growth Rate Formula
became law. The law contained health IT provisions related to current incentive programs and the
need for interoperability. The Medicare Access and CHIP Reauthorization Act (H.R. 2) or MACRA
was passed by the House of Representative on March 26, 2015 by a wide margin of 392-37 and by
the Senate on April 14, 2015 by a vote of 92-8.
Background
The Sustainable Growth Rate (SGR) was created to control Medicare spending. Since 2003,
Congress has spent $170 billion on short term patches to the SGR formula to prevent massive cuts
in physician reimbursement, at times the imposing cut was more than 20 percent.
The Medicare Access and CHIP Reauthorization Act (H.R. 2) outlines ways to improve fee-forservice Medicare and focus on quality instead of volume. The current estimated cost for the repeal
of the SGR at $174.5 billion. With the addition of a two year extension of the Children's Health
Insurance Program (CHIP), the law's cost rose to an estimated $213 billion, but only $70 billion was
offset. The law also delays the implementation of the “two-midnight” rule through FY15 and
extends other Medicare Programs for two years.
Overall Reimbursement
The bill indicates that Medicare physician reimbursement will increase by 0.5 percent each year from
2015-2019. The rates in 2019 will be maintained through 2025, while providing professionals with
the opportunity to receive additional payment adjustments through the MIPS. In 2026 and
subsequent years, professionals participating in APMs that meet certain criteria would receive annual
updates of one percent, while all other professionals would receive annual updates of 0.5 percent.
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College of Healthcare Information Management Executives
20 F Street NW, Suite 700 · Washington, DC 20001
Phone: (202) 507-6158 · Fax: (734) 665-4922 · [email protected] · www.chimecentral.org
Health IT Proposals
Merit-Based Incentive Payment System (MIPS)
In 2019, the Meaningful Use, Physician Quality Reporting System (PQRS) and Value-Based
Modifier (VBM) programs will be combined into one incentive program called Merit-based
Incentive Payment System (MIPS). MIPS will apply to:
 doctors of medicine or osteopathy
 doctors of dental surgery or dental medicine
 doctors of podiatric medicine
 doctors of optometry
 chiropractors
 physician assistants
 nurse practitioners
 clinical nurse specialists
 certified registered nurse anesthetists
Other professionals paid under the physician fee schedule may be included in the MIPS beginning in
2021, provided there are viable performance metrics available. Professionals who treat few Medicare
patients, as well as professionals who receive a significant portion of their revenues from eligible
APM(s), will be excluded from the MIPS.
Summary of MIPS Incentives / Penalties
Program
2014-2017
Meaningful Use:
Penalties:
Meeting certain
1% in 2015
requirements in the use 2% in 2016
of certified EHR
3% in 2017
systems.
4% in 2018
5% in 2019 and beyond
PQRS:
2% penalty for failure to report
Incentivizes
PQRS quality measures in 2017
professionals to report and beyond
on quality of care
measures.
VBM:
No penalties
Adjusts payment
based on quality and
resource use in a
budget-neutral manner.
2018-2023
MIPS:
-Negative payment adjustments
(performance score falls between 0
and ¼ of threshold) capped at:
 4% in 2019
 5% in 2020
 7% in 2021
 9% in 2022
-Some physicians will receive no
adjustments if their performance
score is equal to the threshold;
-Positive payment adjustments:
proportionally larger incentive
payments up to a maximum of 3
times the annual cap for negative
payment adjustments – total
capped at $500 million/year each
year 2019-2024
2
College of Healthcare Information Management Executives
20 F Street NW, Suite 700 · Washington, DC 20001
Phone: (202) 507-6158 · Fax: (734) 665-4922 · [email protected] · www.chimecentral.org
In 2019-2025, physician reimbursement will be based on a composite score from 0-100 based on
performance in four categories: quality; resource use; EHR Meaningful Use; and clinical practice
improvement activities. The score will be compared to a set threshold to determine penalties or
bonuses. Eligible professionals (EPs) will only be scored on measures that apply to them and they
will also be incentivized on improved performance from one year to the next. EPs will know the
composite score they need to achieve to receive incentive payments or avoid penalties at the
beginning of each performance period – the threshold will be determined by the mean or median of
the composite performance scores for all MIPS EPs during a period prior to the performance
period. See table for summary on negative, zero or positive payment adjustments under MIPS.
Every year a list of quality measures for the forthcoming MIPS performance period will be
published after the comment rulemaking process. This list of quality measures may include updates
and modifications to previous quality measures. EPs will select which measures on the final list to
report and be assessed on.
Technical assistance will be provided for practices with less than 15 professionals to improve MIPS
performance or to aid in the transition to APMs (with priority given to practices with low MIPS
scores and those in low or underserved areas).
$15 million will be allocated for quality measure development from 2015-2019. The law also renews
funding for the National Quality Forum (NQF) for the review, endorsement and maintenance of
quality and resource use measures through FY 2017.
Alternative Payment Models (APM)
Physicians will receive up to a five percent increase each year from 2019-2024 if a majority of their
revenue comes from an APM (or APMs) or a patient centered medical home (PCMH). Participants
need to receive at least 25 percent of their Medicare revenue through an APM in 2018-2019. In
2025 and subsequent years, professionals participating in APMs that meet certain criteria would
receive annual updates of one percent, while all other professionals would receive annual updates of
0.5 percent. The policy also incentivizes participation in private-payer APMs.
Interoperability
By December 31, 2018, electronic health records must be interoperable. The law directs the
Secretary to establish metrics to determine interoperability by July 1, 2016. If the nation has not met
the Secretary’s metrics, HHS must submit a report to Congress before the end of 2019 with
recommended actions the federal government should take to create widespread interoperability.
The law prohibits providers from purposefully blocking information sharing with other EHR
products, applicable within one year after the date of the enactment (April 2016). Hospitals and
providers must also attest that they are not willfully blocking capability or interoperability of their
certified EHR technology.
3
College of Healthcare Information Management Executives
20 F Street NW, Suite 700 · Washington, DC 20001
Phone: (202) 507-6158 · Fax: (734) 665-4922 · [email protected] · www.chimecentral.org
The law also directs the Secretary to conduct a report of the feasibility of establishing a mechanism
for users to compare EHR vendor products, a website of surveyed user results and publicized
reporting from vendors on their certified products.
Questions & Comments should be directed to:
Leslie Krigstein
Interim Vice President of Public Policy
[email protected]
(202) 507-6158
(May 2015)
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College of Healthcare Information Management Executives
20 F Street NW, Suite 700 · Washington, DC 20001
Phone: (202) 507-6158 · Fax: (734) 665-4922 · [email protected] · www.chimecentral.org