The Medicare Access and CHiP Reauthorization Act (MACRA) was signed into law by President Obama in April 2015 with overwhelming bi-partisan support. The bill includes many changes, and arguably the most critical impact is the introduction of a new payment model that will affect all providers starting with the 2019 payment year.

Unfortunately, many in the healthcare industry have a false sense of security: while 2019 is the official start date for the new payment models, 2017 will be the performance year that determines 2019 payment adjustments.

Be ready for MACRA by Jan. 1, 2017

By the end of 2016, organizations and providers must understand the impact of the MACRA changes, develop their strategies for success in the new model, and implement changes necessary to support their strategies.

Organizations must start taking action now. CMS will publish the proposed rule in the spring of 2016, and the final rule no later than November 1, 2016.

MACRA requires that all providers participate in one of two new payment tracks, known as “MIPS” and APMs.” The legislation provides the framework and high-level detail for each track:

Track One: Merit Based Incentive Payment System (MIPS)

This track decreases the control that participants have over their final reimbursement.

  • This is the default track; participants must qualify for and opt into the APM track
  • Participants include physicians and mid-levels, but not hospitals
  • This is a budget-neutral model: losers will pay the winners
  • Payment adjustments (positive and negative) increase from a maximum 4% in 2019 to a maximum of 9% from 2020 forward
  • Exceptional performers are eligible for bonus payments
  • The MIPS score will aggregate quality, resource use/cost, clinical practice improvement, and meaningful use measures

Track Two: Alternative Payment Models (APMs)

This track increases the control that participants have over their final reimbursement.

  • To participate, a threshold percentage of reimbursement must be placed at risk
  • The risk must be more than a nominal financial risk
  • CMS will determine which programs qualify as APMs on a yearly basis
  • Eligible Patient-Centered Medical Home (PCMH) models will be considered an APM and do not require financial risk
  • Qualifying providers that participate in special “eligible” APM tracks will receive a yearly 5% bonus payment

Allscripts Consulting is focused on understanding the legislation and how it will impact our clients. Each client’s path to success under MACRA will be unique, and Allscripts can help each step of the way. Contact Allscripts Consulting to schedule an introductory consultation.

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About the author

Matthew Fusan is a Strategic Sales Consultant at Allscripts. In this role he is focused on clients’ transition from fee-for-service to value-based care, develops solutions and provides strategic guidance to help clients succeed with alternative payment models and population health management. Prior to this role, Matthew was part of the Allscripts Regulatory Team providing guidance as Allscripts prepared products and services for new opportunities and challenges based on the transition to value-based care. Prior to Allscripts, Matthew held a variety of program management and delivery leadership positions at Blue Cross and Blue Shield of North Carolina and Highmark Blue Cross and Blue Shield. Matthew has more than 15 years of experience in the healthcare industry and holds a Bachelor of Science degree from Penn State University.

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