The Medicare Access and CHIP Reauthorization ACT (MACRA), signed into law in April 2015, repealed the Sustainable Growth Rate (SGR) and instituted significant reforms to the Medicare physician payment system. Starting with performance in 2017 that affects payments in 2019, providers must choose one of two payment pathways.
The MIPS and APMs both require provider payments to be associated with performance metrics or value-based assessments. MIPS uses an array of metrics to adjust payments, whereas financial risk and performance assessment under APMs depends on the model chosen. MIPS payments and the APM incentive are based on performance two years prior to the payment year; that is, performance in 2017 will determine payments in 2019.
The Society of Hospital Medicine (SHM) estimates that the vast majority of hospitalists will be in the MIPS pathway for the first year and should prepare accordingly.
The Merit-based Incentive Payment System (MIPS) adjusts payments, either up or down, based on a score of 1-100 assigned to a provider based on performance. Providers must report measures and activities across four categories: Quality, Advancing Care Information, Improvement Activities, and Cost. These categories build off existing programs, such as PQRS, the physician value-based payment modifier, and Meaningful Use. Although the proportional weights of the domains can change, MIPS scoring will be based on a combination of performance across these areas.
Hospitalists can expect variation in category weightings due to a hospital-based exemption from the Advancing Care Information category.
Alternative Payment Models (APMs) is the other payment pathway providers can pursue. Participation in an approved Advanced APM and meeting the threshold exempts providers from participating in the MIPS and makes them eligible for a 5% increase in Medicare payments. Most hospitalists will be unable to meet the requirements for this pathway and will therefore remain in the MIPS.