The Centers of Medicare & Medicaid Services (CMS) released its proposed CY2016 Medicare Physician Fee Schedule on July 8. While this proposed rule always covers a wide range of significant payment issues, it has special weight this year, signaling the beginning of extensive rulemaking to implement the Medicare Access and CHIP Reauthorization Act (MACRA) passed by Congress earlier this year.
If MACRA lives up to its promise, health care could finally begin to look very different in just a few years. By repealing the reviled Medicare sustainable growth rate (SGR) and replacing it with a value-based system that encourages providers to take risk on their patient populations, MACRA will introduce unprecedented provider accountability into the system, forever (hopefully!) changing the incentives around patient care for the better.
Now that the dust has settled, it’s time for CMS and stakeholders to begin working out the details of implementation – details which are likely to be numerous and complicated, but which also potentially offer many opportunities for a broad cross-section of health care stakeholders, including providers, patients, service providers, vendors, and more.
In its proposed rule, CMS is broadly seeking feedback on how it should implement the two “tracks” in MACRA – the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) track. Under MIPS, provider payment will be tied to performance in four key areas: 1) quality; 2) resource use; 3) clinical practice improvement activities; and 4) meaningful use of certified electronic health record technology. Under the APM track, providers who derive a significant and increasing portion of their revenue over time from a “qualified” APM may receive a bonus payment.
Merit-Based Incentive Payment System
In the proposed rule, CMS seeks feedback on two specific areas: 1) how to structure a “low volume threshold” for excluding certain professionals from the definition of MIPS-eligible professionals; and 2) which activities should be classified as “clinical practice improvement activities.”
Specific questions posed by CMS on the low volume threshold include:
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
- What is an appropriate threshold?
- Should CMS consider one or a combination of factors when setting the threshold (e.g., # of patients treated, # of items/services provided, # of charges billed, etc.)?
- Are there other existing low volume thresholds in CMS programs that would be a good model for MIPS? Would the Medicare EHR Incentive Program low volume threshold be a good model?
The “ask” with respect to clinical practice improvement is more general, with CMS seeking feedback on activities that fall within the minimum list of subcategories established by Congress, including expanded practice access, population management, care coordination, beneficiary engagement, patient safety and practice assessment, and participation in APMs. This open-ended request is a real opportunity for stakeholders to help shape the types of activities that contribute to improved patient outcomes and to which provider payment should be linked.
Alternative Payment Models
Although CMS indicates that it welcomes feedback on any topic related to APMs, the proposed rule also states that a separate Request for Information (RFI) will be issued in the near future to gather more targeted stakeholder input. Per CMS, topics to be covered in its RFI include questions on the following topics:
- Criteria for assessing physician-focused payment models;
- Criteria and process for the submission of physician-focused payment models eligible for APM;
- Qualifying APM participants;
- The Medicare payment threshold option and the combination all-payer and Medicare payment threshold option for qualifying and partial qualifying APM participants;
- The time period to use to calculate eligibility for qualifying and partial qualifying APM participants;
- Eligible APM entities;
- Quality measures and EHR use requirements; and
- The definition of nominal financial risk for eligible APM entities.
Act Now If You Want to Weigh In!
Comments on the Medicare Physician Fee Schedule are due by September 8. All stakeholders with an interest in the Medicare program should consider submitting comments to CMS. This is your opportunity to get in on the ground floor in re-shaping the Medicare program.
