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Medicare Payment Reform

In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) eliminated the much-maligned sustainable growth rate (SGR) payment formula for Medicare and replaced it with the Quality Payment Program, which includes two paths for physician reimbursement: the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). There are two types of APMs: Advanced and non-Advanced.

The Centers for Medicare & Medicaid Services have released the first proposed rule for the new payment framework as of October of 2016, with the final rule expected in November.

What You Should Know

Under MIPS, payment adjustments for the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM), and the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program will sunset at the end of 2018, while other key components of these programs will be consolidated and carried forward as a single streamlined program. There are four distinct areas of the MIPS of which providers should be aware:

In 2019, the MIPS program will make positive or negative adjustments to a physician’s payment based on a composite score of their performance in 2017 across these four performance categories.

In contrast, physicians who qualify to participate in an Advanced APM are exempt from MIPS and are eligible for a five percent lump sum bonus payment on Medicare Part B services from 2019 – 2024, and will receive higher annual increases in their payments starting in 2026 and onward. Participants in and Advanced APM must take on more than nominal risk (or be part of a medical home), report quality measures comparable to those adopted under MIPS, and use certified electronic health record (EHR) technology. Only risk-bearing ACOs, patient-centered medical homes, and certain bundled payment models qualify as Advanced APMs. Physicians participating in non-Advanced APMs are subject to MIPS and are ineligible for the five percent lump sum bonus payment.


What the AUA is Doing

The AUA is in the process of developing a set of urology-specific tools to assist practices as they begin to implement MIPS/APMs in 2017. More information about that toolkit will be shared as it becomes available.

The AUA has actively engaged regulators on topics related to MIPS/APMs , including providing comments on the proposed rule issued in early 2016.

Useful Resources

Top 10 FAQs about MIPS
Urology Measures Set [pdf]
QPP Acronym Guide
American College of Surgeons: What Surgeons Can Do to Prepare for MIPS in 2017
AUA Side-by-Side Comparison of PQRS, Quality Payment Program [pdf]
American Medical Association MACRA/MIPS Resources
Flexibilities and Support for Small Practices Fact Sheet [pdf]
CMS Quality Payment Program Resources


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