The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and NCQA
What is MACRA?
The Medicare Access and CHIP Reauthorization Act (MACRA) is a new payment program from Centers
for Medicare and Medicaid Services (CMS) that makes patient-centered care the key to success for physicians and other clinicians. MACRA became law in 2014 with broad support from medical societies, consumer advocates, insurance companies, Democrats and Republicans alike and the White House.
It replaces the Sustainable Growth Rate (SGR) formula for how CMS pays clinicians that care for Medicare beneficiaries in the traditional Medicare fee-for-service program. Under MACRA, Medicare will pay physicians and other clinicians for how well they meet patients’ care needs, not just how many services they provide.
But the concepts in MACRA aren’t unique just to those treating Medicare patients. Most other public and private insurers are moving from a fee-for-service model where they pay for volume, to value-based payment models, which takes into account the quality of care and the resources/costs. MACRA supports this nation-wide change by working toward harmony alignment among all insurers in how they reward value.
How does MACRA impact clinician payment?
Beginning in 2019, clinicians will receive payments through either the new Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APMs) (the majority of clinicians will receive payments through MIPS). The 2019 payment will be based on what clinicians are doing and reporting on in 2017.
Clinicians in MIPS will get bonuses or penalties to their fee-for-service payments based on measures in four areas. The proportions of the four areas that make up MIPS scores scale up until 2021, when they become permanent:
MACRA and NCQA
MACRA builds on work the National Committee for Quality Assurance (NCQA) has pioneered for more than 25 years. MACRA rates clinicians based on quality metrics, including many of NCQA’s HEDIS® measures, and directly rewards clinicians who earn NCQA Patient-Centered Medical Homes (PCMHs) and Patient-Centered Specialty Practices (PCSPs) recognition. The law also rewards clinicians in many other ways for results they can achieve by being patient-centered.
MIPS and NCQA Recognition
Becoming an NCQA-Recognized PCMH or PCSP directly increases clinicians’ payments through MIPS.
- Clinicians in NCQA-Recognized PCMHs or PCSPs automatically get full credit in the MIPS CPIA category.
- Clinicians in NCQA-Recognized PCMH and PCSP practices will likely do well in other MIPS categories.
- Quality Measures: NCQA’s PCMH and PCSP programs increase the use of high-value care, including prevention and good chronic care management and actively promotes quality improvement that will be reflected in MIPS quality measures.
- Advancing Care Information: Recognition emphasizes coordination of care and the use of HIT to share care information.
- Resource Use Measures: A growing body of scientific evidence shows that the PCMH model is saving money by reducing hospital and emergency department visits, mitigating health disparities and improving patient outcomes.
Alternative Payment Models
Alternative Payment Models move clinicians farther away from fee-for-service toward more quality and population-based payments. Clinicians in APMs meeting specific dollar and patient volume thresholds qualify as “Advanced APMs” that are exempt from MIPS and eligible for automatic 5 percent bonuses on their Medicare payments. However, for clinicians in APMs that do not meet the thresholds, the proposed MACRA rule rewards clinicians in APMs with NCQA Recognized PCMHs and PCSPs. Here’s how that works:
- CMS will first score each clinician in an APM individually. It will average scores for all clinicians in the APM and apply that average score to each clinician.
- Clinicians in NCQA PCMHs and PCSPs get automatic full CPIA credit. Clinicians who have not earned recognition only get half CPIA credit for being in the APM. Then, they have to earn additional CPIA points for individual CPIA activities.
- Having more PCMH and PCSP clinicians in an APM automatically gives all of that APMs’ clinicians higher MIPS scores.
CMS approved just five of its demonstration projects as Advanced APMs for 2017. These are: