Signed into law in April, 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) repealed the Sustainable Growth Rate formula and combined various quality and reporting programs into one: the Quality Payment Program (QPP).
Beginning in 2017, Eligible Clinicians (ECs), which include PAs, follow one of two reporting tracks under the Quality Payment Program. The first is the Merit-based Incentive Payments System (MIPS). The second track is Advanced Alternative Payment Models (Advanced APMs). The 2017 reported data will affect reimbursement in 2019.
Please note that in the recently released MACRA Final Rule, CMS has codified its intention to allow flexibility in reporting in 2017, what it calls the ‘transition year.’ Consequently, in 2017, participants will have four reporting options:
If you provide care to Medicare beneficiaries, the details of the QPP, MIPS and Advanced APMs will be important to know as it will affect both your reporting activities, as well as your reimbursement.
As a PA, you are one of the types of health professionals that will immediately qualify as an Eligible Clinician (EC) and will be required to participate in one of two reporting and reimbursement tracks: MIPS, or Advanced APMs. Health professionals are excluded from MIPS if they either are in their first year of enrollment, or if they participate in an APM, or if they fail to meet an eligibility low-volume threshold. Most health professionals will begin in MIPS and eventually transition to Advanced APMs. PAs working in certified Rural Health Clinics or federally-qualified health centers will not be required to participate in MIPS or Advanced APMs.
In 2017, two new reporting tracks, MIPS and Advanced APMs, will replace reporting programs such as the Physician Quality Reporting System (PQRS), the Value-based Modifier, and Meaningful Use with a new set of reporting requirements.
Under MIPS, health professionals will be evaluated based on four different categories: quality (replacing PQRS), cost (replacing the value-based modifier), advancing care information (replacing Meaningful Use), and clinical practice improvement activities (new). CMS will provide options regarding measures to be assessed by. Health professionals have the choice to report and be assessed either as an individual or as part of a group. No reporting will be necessary for the cost category, as scores will be based on submitted claims. For PAs, reporting on the advancing care information category will be optional for year one (2017), but if you do not report, the weights of the other three categories will increase.
For Advanced APMs, payment models will report to indicate they meet the Advanced APM status and that the combined work of the ECs in the entity exceeds the Qualified Practitioner (QP) thresholds.
Participation under MIPS and Advanced APMs will affect your reimbursement beginning in 2019.
MIPS will provide zero-sum reimbursement adjustments based on data from 2017, with some health professionals receiving a pay increase, and some receiving a pay decrease. The base pay adjustment for 2019 is ±4 percent. This grows to ±5 percent in 2020, ±7 percent in 2021, and ±9 percent for 2022 onward. While the maximum decrease you can receive will not exceed this base pay adjustment, a participating practitioner can receive a higher positive reimbursement than this base. Due to the nature of the zero-sum reimbursement, top performers may see their base pay increase by as much as threefold, and, in addition, exceptional performers can receive an additional 10 percent increase as a bonus.
As a QP in an Advanced APM, you will be excluded from MIPS reimbursement adjustments and will receive a 5 percent lump sum bonus for the years 2019-2024. Starting in 2026, QPs will receive a higher fee schedule update.
AAPA is concerned with the effects of “incident to” on MIPS. When services delivered by PAs are legally billed under the name of the PA’s collaborating physician as an “incident to” service, the PA’s name and NPI typically do not appear on the claim form. This means that the actual provider of care is not identified and data sources are populated with information that is either incorrect or incomplete. Many aspects of the new Quality Payment Program are dependent on accurate data, especially regarding determination of health professional eligibility for participation in MIPS. To not be made ineligible, every health professional must meet a “low-volume threshold.” This low-volume threshold for MIPS, which would exclude one from the program, is having either less than $30,000 in Medicare charges, or less than 100 Medicare patients. PAs might be in a situation in which they treat a sufficient volume of eligible patients, but because a substantial number of those patient visits are billed under the physician, they may show up in the system as providing a low volume of care and be ineligible for MIPS participation.
The inability to accurately capture which health professional is providing what service causes additional problems for hidden providers beyond prohibitive eligibility determinations. Health professionals, based on data captured through MIPS and APM reporting, will have participation and performance information posted on CMS’ Physician Compare website, a publicly facing resource through which patients may seek and compare health professionals. As a result of inaccurate information as to who provided what care, this site will now be, at best, a misrepresentative communication of PA care provision and quality, and at worst mask the services performed by some PAs completely, leading to a practitioner’s omission from the site and the patient aware of one less care option.
In CMS’ recent MACRA Final Rule, the agency acknowledged AAPA’s concerns regarding hidden providers, but disagreed and declined to act. AAPA will continue to emphasize the negative repercussions of this policy and advocate for a policy that allows PA services to be recognized.
Under MIPS, Eligible Clinicians (ECs) will be reimbursed according to their composite score compared to the composite scores of other health professionals. An EC’s composite score is made up of scores in four different categories:
For an Alternative Payment Model (APM) to be an Advanced APM, three requirements must be met. The payment model must:
If the entity you work for meets these Advanced APM standards, you may be eligible to be a Qualified Practitioner (QP) under it if your entity then meets certain payment or patient thresholds. Participating as a QP under an Advanced APM is the second of two possible tracks under the QPP.
An Eligible Clinician can be considered a QP under an Advanced APM if the combined threshold score (money for or number of beneficiaries for Part B professional services for whose cost and quality of care the APM is responsible, divided by the money for or number of beneficiaries for Part B professional services that are eligible) of the entire entity for which they work meets or exceeds certain thresholds for payments or patients seen. In 2019 and 2020, that threshold is 25 percent of payments or 20 percent of patients. These numbers increase to 50 percent of payments/35 percent of patients for 2021 and 2022, and again to 75 percent of payments/50 percent of patients for 2023 and beyond. If the APM entity’s threshold score exceeds these QP thresholds, all ECs in the entity will be considered QPs.
If an APM entity is unable to meet these thresholds, its ECs may still be considered ‘partial QPs’ if the entity meets a lower threshold (for 2019, the partial QP thresholds are 20 percent of payments or 10 percent of patients). As a partial QP you will have the option of whether or not to participate in MIPS. If you choose not to participate you will not receive the bonus payment received for being a QP under an Advanced APM. If you choose to participate in MIPS, you will receive favorable weights in the scoring. In 2021 there will be an additional option for reaching these thresholds as CMS will begin to take into account patients covered by non-Medicare payers (such as Medicare Advantage plans).
As allowed by the QPP, CMS plans to provide technical assistance to MIPS Eligible Clinicians (ECs) in practices of 15 or fewer professionals. Priority is given to small practices in rural areas, HPSAs, medically underserved areas and practices with low composite scores. CMS will enter into contracts and agreements with appropriate entities such as Regional Extension Centers and Quality Improvement Organizations to offer guidance and assistance.
Submit your MACRA questions to us at MACRA@aapa.org.
Fact sheets, press releases, timelines, slide decks and more
Official Proposed Rule. Comments due June 27. Expected finalization in Fall 2016
Final Rule. Filed on Oct. 19, 2016
AAPA’s Comments to the Proposed Rule, submitted June 27, 2016, and comments to the RFI, submitted Nov 17, 2015