Now that the Medicare Access and CHIP Reauthorization Act (MACRA) has replaced the sustainable growth-rate formula for determining physician pay, radiologists and other physicians are feeling the pressure to move from volume to value. The law is poised to fundamentally change how Medicare pays providers, and many are grappling with the choice between reimbursement paths that it presents. One thing is clear: Radiologists should actively engage their colleagues throughout the health care system if they want to thrive under these new models.
In particular, Alternate Payment Models (APMs) mandate that siloed participants in the health care system collaborate in providing exceptional patient care at a reduced cost. Some view this as a challenge. Others view MACRA as a great unknown and are struggling to get their arms around what it means for them.
Understanding the Implications of MACRA
What is the difference between the Merit-based Incentive Payment System (MIPS) and APMs? MIPS is a modified fee-for-service system in which physicians are paid for each service they provide for patients and are financially incentivized to report quality measures. APMs are an entirely new approach. Under a bundled payment APM, a practitioner or medical group contracts with a payer to receive one bundled payment for services provided for a patient or group of patients based on specific clinical episodes or conditions. This payment is then divided among the providers involved in the care. Under an accountable care organization (ACO) or shared-savings APM, participating providers who demonstrate improved quality and reduce costs share in the savings.
While both the MIPS and APM pathways are available to radiologists and other physicians, the Centers for Medicare & Medicaid Services (CMS) is directing providers toward APMs by offering a simpler reporting system and a higher annual incentive than MIPS.
Following is a closer look at the options and what they could mean for radiologists.
Under MIPS, physicians get a percentage adjustment to Medicare Part B payment based on a four-part score designed to measure quality, cost, and value of care. For 2017, the Quality category counts for 60% of the total, the Advancing Care Information (formerly Meaningful Use) category counts for 25%, the Clinical Practice Improvement Activities category accounts for 15%, and the Resource Use category counts for 0%. For 2018 and beyond, Resource Use will be weighted.
For the transition year of 2017, CMS lowered the cost performance category to 0% and gave clinicians the following four reporting options.
• Option one: Report under MIPS, but only one quality measure, one improvement activity, or the required advancing care information measures to avoid a payment reduction. Physicians who choose this option will not be eligible for a bonus in 2019.
• Option two: Report under MIPS for less than the full year but for at least a full 90-day period in 2017 on one quality measure, more than one improvement activity, or more than the required advancing care information measures to avoid penalties. This could lead to eligibility for a small bonus in 2019.
• Option three: Report under MIPS for the full year in 2017 on quality, improvement activities, and advancing care information to be eligible for the maximium 4% bonus, as well as a potential exceptional performer bonus in 2019.
• Option four: Successfully participate in an APM. Physicians who choose this option will earn a 5% bonus incentive in 2019 and be exempt from MIPS payment adjustments.
In short, if a physician reports at least some data in 2017, he or she will not receive a payment reduction. If a physician or group chooses not to participate, they are risking significant financial resources—and will be guaranteed a financial loss with a negative penalty payment.
The transition to MIPS may be fairly straightforward for groups that are already pursuing value-based payment methods and have reporting mechanisms in place. Further, the transition to APMs may be natural for physician groups who are already taking on substantial risk.
CAPG's Guide to Alternative Payment Models offers case studies that highlight CAPG member experiences with a range of APMs, from bundled payments to capitated, coordinated care.
In 2017, under MACRA's quality payment program, clinicians may earn a 5% incentive payment through sufficient participation in the following Advanced APMs:
• Comprehensive end-stage renal disease (ESRD) Care Model (Large Dialysis Organization [LDO] arrangement);
• Comprehensive ESRD Care Model (non-LDO arrangement);
• CPC+ (Comprehensive Primary Care Plus);
• Medicare Shared Savings Program ACOs—Track 2;
• Medicare Shared Savings Program ACOs—Track 3;
• Next Generation ACO Model; and
• Oncology Care Model (two-sided risk arrangement).
In 2018, it's expected that physicians may also earn the incentive payment through sufficient participation in the following models:
• ACO Track 1+;
• New voluntary bundled payment model;
• Comprehensive Care for Joint Replacement Payment Model (Certified Electronic Health Record Technology [CEHRT] track); and
• Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT track).
These lists will continue to change and grow as more models are proposed and developed in partnership with the clinician community and the Physician-Focused Payment Model Technical Advisory Committee.
To qualify as an Advanced APM participant, an eligible clinician must either receive at least 25% of the clinician's payments for Medicare Part B covered professional services through an Advanced APM or see at least 20% of the clinician's Medicare patients through an Advanced APM.
The final rule excludes small practices from reporting requirements in 2017 due to low-volume threshold, which has been set at less than or equal to $30,000 in Medicare Part B-allowed charges or less than 100 Medicare patients. It also provides $100 million in education and technical assistance to small and rural practices in 2017.
A few large groups are planning to accept payment adjustments based on their performance under existing APMs. They will receive a lump sum incentive payment and higher annual provider payment as benefits. They will also be exempt from the MIPS reporting measures.
Any radiologist who fails to engage in MIPS or APMs risks losing money in the Medicare program and generating a perception of not being a team player among hospitals and communities working in APMs. It's highly recommended that practices that aren't ready to participate in APMs now should nevertheless prepare for APMs in the future by participating in MIPS.
Why the Urgency Surrounding MACRA?
According to the Congressional Budget Office's most recent long-term projections, which include the estimated effects of MACRA, net Medicare spending will grow from 3% of gross domestic product (GDP) in 2015 to 4.2% of GDP in 2030, 5.1% in 2040, and 5.9% in 2050. Because of slower growth in Medicare spending in recent years, the solvency of the hospital trust fund has been extended. Medicare Trustees, however, have projected that the Part A trust fund will be depleted in 2030. To offset this, either taxes must increase substantially or hospital spending must decrease significantly.
Despite the mounting pressure as deadlines approach, several medical group leaders cite a lack of basic infrastructure to assess performance on reported measures or determine measures to report based on current performance. To meet MIPS' reporting and performance thresholds, medical groups must expedite efforts to build and refine their quality reporting and performance management infrastructure.
Both the APM and MIPS tracks require strong, consistent performance on quality and efficiency measures. Those working across mixed medical staffs must carefully consider which models will meet performance objectives. No matter what path they choose, radiologists, physicians, and other specialists—whether part of a hospital system or independent—face some weighty decisions.
In years ahead, CMS is likely to require all physicians to join APMs. As radiologists become involved in these payment systems, they must make sure their APM partners understand the value imaging brings to patient care. To do this and thrive in today's complex health care environment, they should continue to build relationships with referring physicians and patients throughout their health systems. Regardless of the payment structure and challenges that lie ahead in health care reform, the radiologist must remember that the key ingredient to overall success is the healthy outcome of their patients.
— Amy Nguyen Howell is a board-certified family practice physician. She is the CMO and oversees all clinical programs at CAPG and supports advocacy work in Sacramento, California, and Washington, D.C. Additionally, she contributes to the Steering Committee on the Core Quality Measurement Collaborative; Healthcare Payment and Learning Action Network Population-Based Payment Work Group; and Clinical Programs Committee at the National Committee for Quality Assurance. She is also a faculty member at the University of Southern California Sol Price School of Public Policy and continues to serve as a family physician at Playa Vista Medical Center.
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2. Muchmore S. Few docs ready for risk under MACRA. Modern Healthcare website. http://www.modernhealthcare.com/article/20160813/MAGAZINE/308139982. Published August 13, 2016. Accessed November 1, 2016.
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