Original article
Health services research and policy
MACRA, MIPS, and the New Medicare Quality Payment Program: An Update for Radiologists

https://doi.org/10.1016/j.jacr.2016.10.012Get rights and content

Abstract

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 advances the goal of tying Medicare payments to quality and value. In April 2016, CMS published an initial proposed rule for MACRA, renaming it the Quality Payment Program (QPP). Under QPP, clinicians receive payments through either advanced alternative payment models or the Merit-Based Incentive Payment System (MIPS), a consolidation of existing federal performance programs that applies positive or negative adjustments to fee-for-service payments. Most physicians will participate in MIPS. This review highlights implications of the QPP and MIPS for radiologists. Although MIPS incorporates radiology-specific quality measures, radiologists will also be required to participate in other practice improvement activities, including patient engagement. Recognizing physicians’ unique practice patterns, MIPS will provide special considerations in performance evaluation for physicians with limited face-to-face patient interaction. Although such considerations will affect radiologists’ likelihood of success under QPP, many practitioners will be ineligible for the considerations under currently proposed criteria. Reporting using qualified clinical data registries will benefit radiologists’ performance by allowing expanded arrays of MIPS and non-MIPS specialty-specific measures. A group practice reporting option will substantially reduce administrative burden but introduce new challenges by requiring uniform determination of patient-facing status and performance measurement for all of the group’s physicians (diagnostic radiologists, interventional radiologists, and nonradiologists) under the same taxpayer identification number. Given that the initial MIPS performance period begins in 2017, radiologists must begin preparing for QPP and taking actions to ensure their future success under this new quality-based payment system.

Introduction

The historic fee-for-service approach for determining physician payments has been criticized for engendering greater health care costs without associated improvements in quality [1]. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 [2] accelerates a transformation in physician payment models by calling for new approaches that will substantially increase the fraction of physicians’ payments that are tied to quality and value 3, 4, 5. In April 2016, CMS released a 962-page proposed rule [6] that provides a detailed regulatory framework for implementing the MACRA legislation through the new Quality Payment Program (QPP). The QPP implements the legislative requirement set forth in MACRA, requiring distribution of Medicare Part B payments through either advanced alternative payment models (APMs) or the Merit-Based Incentive Payment System (MIPS). The MIPS is a modified fee-for-service payment program that is tied to quality essentially by consolidating into a single program current federal performance programs including the Physician Quality Reporting System (PQRS), the value-based payment modifier, and meaningful use of certified health record technology, as well as adding a new performance category, clinical practice improvement activities (CPIAs). The ACR [7], the Society of Interventional Radiology [8], and the American Society of Neuroradiology [9] have provided detailed feedback to CMS regarding this initial proposal. Although the framework is certain to continue to evolve through iterative rule making over the coming years, the proposed rule provides substantial insights into how MACRA is likely to affect future physician practice and payment models. Our intent in this article is to provide an overview of the proposed MACRA implementation via the QPP, with specific attention to implications and imperatives for radiologists in MIPS.

Section snippets

Performance Measurement Under MIPS

Although MACRA introduces two paths for physician participation (advanced APMs and the MIPS), under the proposed QPP structure, a large majority of MIPS eligible clinicians (ECs), including radiologists, will initially fall into the MIPS path. Thus, provisions set forth in the MIPS component of the QPP will determine their payment adjustments. MIPS ECs will receive a composite performance score (CPS; 0-100 scale) reflecting a weighted combination across four categories:

  • 1.

    Quality (the successor of

Differential Considerations for Patient-Facing and Non-Patient-Facing Physicians

Even with the specialty-specific measures for the quality performance category, other types of measures within MIPS (eg, cross-cutting measures and measures within the ACI category) that require frequent face-to-face patient interaction for successful reporting may still be problematic for radiologists. Although radiologists are patient centered and greatly influence patient care, across the specialty, radiologists have variable exposure to actual face-to-face encounters with patients. Thus,

The Role of Registries

Given the central role of measure reporting throughout the MIPS in ultimately determining positive or negative payment adjustments, the method used by CMS to obtain performance data represents a key consideration. Mechanisms for EC in MIPS to submit measures to CMS are generally similar to existing measures for reporting into the current law PQRS, although several differences exist. Under MIPS, an individual EC can still use Medicare Part B claims, qualified registry, direct electronic health

The Impact of Group Reporting

Before MACRA, physicians within a given practice could elect to register for PQRS and report performance data using the group performance reporting option (GPRO), rather than reporting as separate individuals. Using the GPRO, a single Medicare-billing taxpayer identification number (TIN) can be used to define the entire physician group. The GPRO can substantially reduce the administrative burden and cost of performance reporting. Under the QPP, CMS has proposed QCDR, electronic health record,

How Radiologists Can Prepare for Success Under MACRA and MIPS

In exploring the anticipated impact of the MIPS proposed rule on various specialties, CMS estimates that 49.2% of radiologists will receive negative payment adjustments and 50.8% positive adjustments. Given that the first performance period will begin in 2017, it is imperative that radiologists begin taking action now to be well positioned for success under the new program. Indeed, action is warranted at the individual radiologist, group practice, and national specialty levels (Table 3).

Take-Home Points

  • The recently passed MACRA legislation will consolidate existing performance programs into the single Merit-Based Incentive Payment System that will link an increasing, and eventually large, fraction of physicians’ Medicare payments to the quality and value of care.

  • Under MACRA, most physicians will receive positive or negative payment adjustments based on the MIPS framework; whereas MIPS incorporates a set of radiology-specific quality measures, radiologists will also be required to participate

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    The Medicare Access and Chip Reauthorization Act (MACRA) of 2015 has replaced the sustainable growth rate payment methodology by Medicare.33,34 A new payment incentive program was implemented and called the Merit–Based Incentive Payment System (MIPS), which incorporated features of the Physician Quality Reporting System (PQRS), Electronic Health Record Meaningful Use (MU) and Value-Based Payment Modifier (VBPM).33–36 MACRA also incorporated potential financial penalties, such as failure to implement an electronic medical record (EMR).37

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Dr Rosenkrantz is supported by a research grant from the Harvey L. Neiman Health Policy Institute. Dr Hirsch has received fees unrelated to the present work from Medtronic, Carefusion, and Codman Neurovascular. The authors have no conflicts of interest related to the material discussed in this article.

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