October 24, 2021

Volume XI, Number 297

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October 22, 2021

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Understanding the Implications of MACRA, MIPS and APMs

On May 9, 2016, the Centers for Medicare & Medicaid Services (CMS) published a notice of proposed rulemaking to implement the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Although the provisions of MACRA and its proposed rule that are related to the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) involve a dizzying array of acronyms, calculations and other complexities, the underlying policy objectives and future direction are clear – Congress (through a bipartisan piece of legislation) and CMS (through its power to implement MACRA) seeks to both build upon and solidify new payment and delivery models that move from volume to value, combine with and build upon private sector initiatives, and migrate to financial risk.

The law and proposed rule provide a timeline for this migration and provide for clear advantages (and benefits) to "early adopters" of the new APM payment and delivery models. For individual Medicare providers and groups, the ability merely to sit on the sideline and to refrain from participation, while not eliminated, now has a better-defined financial cost.  

The proposed rule establishes an architecture that will dramatically change the Medicare payment model for physicians and other health care practitioners. Building on the legislative framework established by MACRA and prior efforts by CMS' Innovation Center, the proposal would implement a payment system in which all eligible clinicians would either receive payment rate increases or cuts based on their ability to meet standards under a new "Merit-Based Incentive Payment System," at their election. The proposed rule would make extra bonuses potentially available for those who participate in certain risk-based models.

This article provides information about the law and proposed rule. In future articles, we will drill deeper into the implications of the proposed rule for physicians and other providers; hospitals and health systems; and Accountable Care Organizations (ACOs), clinically integrated networks and other organizations. 

MACRA Background – Policy Focus and Objectives

In January 2015, the U.S. Department of Health and Human Services (HHS) announced that CMS was setting benchmark goals for value-based payments and alternative payment models in the Medicare program. By the end of 2016, CMS declared, 30 percent of Medicare payments would be tied to quality or value through APMs, with an increase to 50 percent by the end of 2018. In addition, by the end of 2016, 85 percent of Medicare fee-for-service payments would be tied to quality or value, rising to 90 percent by the end of 2018.

© Polsinelli PC, Polsinelli LLP in CaliforniaNational Law Review, Volume VI, Number 174
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About this Author

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Janice Anderson offers a unique perspective to health care clients that is based on her extensive clinical and health care operational background (including serving on the senior executive team for a large regional health system for 14 years). She focuses her practice on corporate health care and transactional law, as well as mergers and acquisitions, hospital/physician and other joint ventures, physician relationships and contracting, and compliance.

Her areas of emphasis include:

 

  • ...
312-873-3623
Bruce Johnson, Health Care Organization Attorney, Polsinelli Law FIrm
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Bruce Johnson assists clients with a strategic, forward-thinking and pragmatic approach. He brings more than 25 years of legal and management consulting experience to his health care organization clients. Bruce assists hospitals, medical groups, academic practice plans and other health care enterprises in crafting effective relationships to promote business objectives while taking into account strategic, compensation, business operations, compliance, and other issues in today’s changing payment and delivery environments.

303.583.8203
Laura Little, Polsinelli PC, Stark Compliance lawyer, anti kickback statute Attorney
Associate

Drawing on her business, policy, and legal background, Laura Little assists clients in navigating the ever-changing regulatory health care landscape. Laura’s practice centers on representing physicians, hospitals and health systems, and health care technology corporations in a variety of regulatory and transactional matters, including: 

  • Hospital-physician relationships 

  • Health care mergers and acquisitions 

  • Medicare and Medicaid reimbursement 

  • ...
404.253.6055
Cybil G. Roehrenbeck, Polsinelli PC, Precision Medicine Lawyer, Genomics Attorney
Counsel

Focusing on emerging health care sectors, Cybil Roehrenbeck is dedicated to helping clients achieve their objectives by employing a comprehensive, interdisciplinary approach to their legal and business challenges. She counsels clients on federal legislative and regulatory opportunities in the following areas:

  • Health information technology  

  • mHealth and telehealth

  • Precision medicine and genomics

  • Innovative health care delivery...

202.777.8931
Associate

In a regulatory environment where even the most minor details matter, Rebecca Frigy Romine thrives on helping clients find practical and creative solutions and action plans.

Her practice focuses on many facets of the general health care business with a specific emphasis on the privacy and security of health information and medical staff issues.

Rebecca has significant experience in and frequently writes on these topics and remains abreast of regulatory changes and best practice.

314-889-7013
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