MACRA Proposed Rule Released; Victories for PALTC Professionals

April 29, 2016
Policy Snapshot
Centers for Medicare and Medicaid (CMS), Alternative Payment Models (APM), Practice Management, Electronic Health Records (EHR), Health Information Technology (HIT), Meaningful Use, Physician Quality Reporting System (PQRS)

This week the Centers for Medicare & Medicaid Services (CMS) issued their proposed rule for implementing certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA ended more than a decade of last-minute fixes to the sustainable growth rate (SGR) formula and made improvements to various health care programs by streamlining quality based payments programs such as the Physician Quality Reporting System, the Value Modifier Program, and the Medicare Electronic Health Record (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 proposed rule would implement these changes through the unified framework called the Quality Payment Program, which includes two paths: The Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

This rule proposes policies to improve physician payments by changing the way Medicare incorporates quality measurement into payments and by developing new policies to address and incentivize participation in alternative payment models.

“It’s gratifying to know that our hard work in educating CMS about the nuances of our care setting has resulted in some movement to ensure that our members won’t be penalized for choosing to work with this ill, vulnerable, complex population,” said the Society’s Public Policy Committee Chair, Karl Steinberg, MD, CMD, of important provisions to members that are highlighted below.

The Society is still reviewing the details of the 962-page rule but of note for Society members include provisions that:

  • Exclude services billed under CPT codes 99304-99318 when the claim includes the POS 31 (SNF, meaning a resident receiving skilled post-acute services) modifier from the definition of primary care services for MIPS under the Resource Use Criteria category.
  • MIPS-eligible clinicians (no longer ‘eligible professionals’) who lack control over the EHR technology in their practice locations (e.g. surgeons using ambulatory surgery centers or a physician treating patients in a nursing home who does not have any other vested interest in the facility, and may have no influence or control over the health IT decisions of that facility) would need to submit an application demonstrating that a majority, 50 percent or more, of their outpatient encounters occur in locations where they have no control over the health IT decision of the facility, and request their advancing care information performance category score be reweighted to zero.

“This is a clear signal that CMS is listening to our society’s comments and is a positive step forward for PALTC professionals” said Alex Bardakh, Director of Public Policy and Advocacy.

"Our public policy leadership team continues to work on understanding the implications for our members," said Society President Susan Levy, MD, CMD. "Their efforts and hard work to date are evident in this proposed rule. These successes demonstrate the value of membership." The Society will continue to review the rule and inform members of other provisions of interest along with a summary. Comments on the proposed rule are due June 27.

More resources:

  • A press release about this rule
  • Two fact sheets about this proposed rule
  • A blog about the Advancing Care Information performance category (replacing the Meaningful Use program for Medicare physicians) under MIPS 
  • A blog from the Secretary of HHS 
  • CMS MACRA Listening Session