What is MACRA?
The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) has been enacted and replaces the previous Medicare reimbursement schedule with a new pay-for-performance program focused on quality and accountability in patient care. Starting January 1, 2017, eligible Medicare Part B providers will enter a new payment framework called the Quality Payment Program (QPP), which replaces the Sustainable Growth Rate formula. The Quality Payment Program has two paths for participation:
Advanced Alternative Payment Models (Advanced APMs)
What are Advanced APMs?
Advanced Alternative Payment Models (Advanced APMs) are one of the two new payment paths that will be used by the Centers for Medicare and Medicaid Services (CMS) to determine Medicare payment adjustments for eligible clinicians under the QPP. The Advanced APMs path is most relevant for clinicians who continue to focus on and innovate in delivering coordinated, efficient and transformative care for patients. CMS will post a list of care models that will qualify as Advanced APMs before each year. Additionally, CMS will update this Advanced APM list on a regular basis during a given year. Clinicians who meet the criteria for participation in an Advanced APM will not be subject to payment adjustments under MIPS, but will instead be eligible to receive the APM Incentive Payment, equal to 5% of a clinician’s Medicare Part B billed services from the previous year. The APM Incentive Payment would be paid to qualifying clinicians beginning in the 2019 payment year under the QPP.
Further, only clinicians who are participating in Alternative Payment Models (APMs) that qualify as Advanced APMs during a given payment year are eligible to receive APM Incentive Payments. As a result, it is important to note that clinicians who are participating in any other APM (such as an Accountable Care Organization) are not necessarily eligible for receipt of APM Incentive Payments unless their care model specifically qualifies as an Advanced APM, as determined by CMS. For more complete details on the standards provided by CMS for qualifying care models that will qualify as Advanced APMs, please visit Practice Fusion’s Quality Payment Program resource center here.
The 2017 list of care models that are expected to qualify as Advanced APMs includes the following:
Comprehensive ERSD Care Model (Non-LDO Arrangement)
Oncology Care Model Two-Sided Risk Arrangement
What is CPC+?
CPC+ is a partnership among CMS, commercial insurance plans, and state Medicaid agencies that will: 1) provide financial incentives for practices to make fundamental changes in their care delivery through participation in one of two primary care practice tracks; and 2) allow practices to participate in either Round 1 or Round 2 of CPC+, which is being determined based on geographic region. Round 1 of CPC+ will run for 5 years beginning in 2017 in selected regions, while Round 2 of CPC+ will run for 5 years beginning in 2018 in regions that will be determined by CMS based on payer interest and alignment. While the application deadline for participation in Round 1 of CPC+ has closed, CMS is expected to begin accepting applications for participation in Round 2 of CPC+ in mid-2017.
When participating in Track 1 of the CPC+ model, clinicians will be expected to effectively utilize certified health IT tools, including Certified EHR technology, in working to achieve the performance objectives provided by CMS. Practice Fusion will be available for use to support practices that would like to participate in Track 1 of the CPC+ model.
CPC+ includes three payment elements for participating clinicians:
Care Management Fee (CMF): a flat fee paid per Medicare-covered patient for each quarter, which will be separate from any reimbursement paid for billed patient charges.
Performance-based incentive payment.
Payment under the Medicare Physician Fee Schedule (PFS).
Eligible clinicians are not required to participate in CPC+. However, under the QPP, if you are an eligible clinician who sees Medicare patients, then you must participate in either the MIPS program or an Advanced APM in 2017 to avoid being subject to a negative Medicare payment adjustment in 2019. It is also important to note that even if you participate in CPC+, if you are unable to meet the model’s performance requirements, you will instead need to report under the MIPS program in 2017 in order to avoid potentially being subject to a negative Medicare payment adjustment in 2019.
How do I know if I’m eligible?
Eligible applicants are primary care practices that are located in a state or region where the CPC+ model is supported. The following regions have been selected for Round 1 of the CPC+ initiative:
Kansas and Missouri: Greater Kansas City Region
New Jersey: Statewide
New York: North Hudson-Capital Region
Ohio: Statewide and Northern Kentucky: Ohio and Northern Kentucky Region
Pennsylvania: Greater Philadelphia Region
Rhode Island: Statewide
Additional information about each CPC+ Round 1 region and participating payers is available here. Additionally, further details about the CPC+ program eligibility can be found in the Request for Applications.
What do I need to do to get started?
You can review the reporting requirements listed in the Request for Applications on CMS’s CPC+ website. Although the application deadline for Round 1 of CPC+ closed on September 15, 2016, if your practice is interested and able to meet the eligibility requirements for Round 2 of CPC+, then you may submit a completed Request for Application to the Centers for Medicare & Medicaid Innovations (CMMI) when CMS begins accepting CPC+ Round 2 applications later in 2017.
Any questions about the application for CPC+ should be directed to CMS at CPCPlus@cms.hhs.gov.
You can visit Practice Fusion’s Quality Payment Program resource center here.
Read our blog post for further information that you can use to help determine if CPC+ may be the right care model for your practice.
CMS also provides further resources about the Quality Payment Program here.