The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) promotes the transition to quality-based payment by implementing two payment pathways for clinicians. Starting in 2019, clinicians will choose from one of two pathways: the Merit-based Incentive Payment System (MIPS) or participation in eligible Alternative Payment Models (APM).
MACRA incentivizes participation in Medicare and private payer APMs. Clinical professionals who opt to participate in an APM and receive at least 25 percent of their Medicare revenue through an APM beginning in 2019 will receive a 5 percent lump-sum payment bonus on Medicare Part B services. This bonus will be available through 2024. In order to continue incentivizing movement toward APMs, the threshold for receiving the 5 percent APM bonus will increase to 50 percent of Medicare revenue, or combined Medicare and all-payer revenue received through an APM in year 2021. The threshold will continue to increase over time, reflecting the commitments made by the Centers for Medicare and Medicaid Services (CMS) and private payers to move toward value-based payment models.
Starting in 2026, eligible APM participants meeting the required revenue thresholds will receive a 0.75 percent annual increase on Medicare payment rates. All other professionals will receive a 0.25 percent annual increase.
Currently, the Medicare Pioneer ACO Model is the only APM that is confirmed as an eligible APM for participation under this pathway under MACRA. Other eligible APMS that may be recognized must include a requirement to utilize certified EHR technology, payment based on quality measures, and involve the assumption of financial risk or a patient-centered medical home model. Eligible models must be approved by CMS, but may be developed through the Center for Medicare and Medicaid Innovation (CMMI), other payers, or other stakeholders.
MACRA recognizes that the administrative and financial responsibilities of participating in an APM have been a barrier to small practices. To address this issue, $20 million annually has been allocated to assist practices of 15 or fewer eligible professionals, and practices serving rural and underserved areas in participating in an APM or clinical quality improvement activities under MIPS. The Government Accountability Office (GAO) has also convened the Physician-Focused Payment Models Technical Advisory Committee (PTAC) to assist the Secretary in identifying new models. Board of Trustees member Paul Casale, MD, FACC, has been appointed as a clinician representative to the PTAC.