Proposed rule aims to modernize provider payment for quality care

The Department of Health and Human Services' (HHS) latest proposed rule would implement a unified framework called the Quality Payment Program, which essentially replaces the Meaningful Use program.

The Notice of Proposed Rulemaking is a first step in implementing certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This legislation ended more than a decade of last-minute fixes and potential payment cliffs for Medicare doctors and clinicians, while making numerous improvements to America’s healthcare system, according to the announcement from the federal agency.

“The legislation Congress passed a little over a year ago was a milestone in our efforts to advance a healthcare system that rewards better care, smarter spending and healthier people,” said HHS Secretary Sylvia M. Burwell. “We have more work to do, but we are committed to implementing this important legislation and creating a healthcare system that works better for doctors, patients and taxpayers alike. We look forward to listening and learning from the public on our proposal for how to advance that goal.”

Currently, Medicare measures the value and quality of care provided by doctors and other clinicians through a patchwork of programs. Some clinicians are part of Alternative Payment Models such as accountable care organizations, the Comprehensive Primary Care Initiative and the Medicare Shared Savings Program—and most participate in programs such as the Physician Quality Reporting System, the Value Modifier Program and the Medicare EHR Incentive Program.

Congress streamlined these various programs into a single framework to help clinicians transition from payments based on volume to payments based on value. The two paths of the Quality Payment Program are the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

“We are working with the medical community to advance our collective vision for Medicare payment reform,” said Patrick Conway, MD, Centers for Medicare & Medicaid Services (CMS) acting principal deputy administrator and chief medical officer. “By proposing a flexible, rather than a one-size-fits-all program, we are attempting to reflect how doctors and other clinicians deliver care and give them the opportunity to participate in a way that is best for them, their practice, and their patients. Reducing burden and improving how we measure performance supports clinicians in doing what they do best – caring for their patients.”

Most Medicare clinicians will initially participate in the Quality Payment Program through MIPS. Consistent with the goals of the law, the proposed rule would improve the relevancy and depth of Medicare’s quality-based payments and increase clinician flexibility by allowing clinicians to choose measures and activities appropriate to the type of care they provide. MIPS allows Medicare clinicians to be paid for providing high-value care through success in four performance categories: Quality, Advancing Care Information, Clinical Practice Improvement Activities, and Cost.

The proposed rule seeks to streamline and reduce reporting burden across all four categories, while adding flexibility for physician practices. CMS would begin measuring performance for doctors and other clinicians through MIPS in 2017, with payments based on those measures beginning in 2019.

Medicare clinicians who participate to a sufficient extent in Advanced Alternative Payment Models would be exempt from MIPS reporting requirements and qualify for financial bonuses. These models include the new Comprehensive Primary Care Plus (CPC+) model, the Next Generation ACO model and other Alternative Payment Models under which clinicians accept both risk and reward for providing coordinated, high-quality care.

Many clinicians who participate to some extent in Alternative Payment Models may not meet the law’s requirements for sufficient participation in the most advanced models, according to HHS, but "expect that the number of clinicians who qualify as participating in Advanced Alternative Payment Models will grow as the program matures."

HHS is accepting comments on its proposal until June 26.