2016-04-28 12:48:14 UTC

April 27, 2016

The MACRA proposed rule could significantly change physician reimbursement programs.

On April 27, CMS released the long-awaited proposed rule that implements the provisions of the Medicare Access and CHIP Reauthorization Act (MACRA).  

AGA is currently reviewing the 962-page regulation and will release a summary of key provisions soon. CMS will accept public comments on the rule over the next two months with final rules issued by the end of the year.
AGA is committed to representing the interests of gastroenterologists and will pursue any changes to the proposed rule that are necessary to advance the practice of gastroenterology and protect the patient population. Watch your email and gastro.org for updates on this important issue.  

What’s MACRA?
Enacted in 2015 to repeal the longstanding “sustainable growth rate” (SGR) formula, MACRA will revolutionize key programs that determine reimbursement for Medicare services. Instead of separate programs for meaningful use, quality reporting and value-based care, CMS will roll out the comprehensive Merit-based Incentive Payment System (MIPs) and incentivize the use of alternative payment models (APMs). 

When do changes take effect? 
Services provided beginning on Jan. 1, 2017, will directly impact reimbursement provided in 2019, the first year in which the MIPS program and APMs are effective. The most important thing you can do now is to become more familiar with the programs under MACRA and begin to prepare for the changes it will mean for your practice. 

What does this mean for GI? 

  • MIPS Reimbursement Changes: As expected, many requirements from existing programs, mentioned above, are folded into the new MIPS calculations. Participants in MIPS will be eligible to receive a positive payment adjustment, but are also at risk of negative adjustments. While the maximum adjustment is 4 percent for 2019, it will eventually reach 9 percent. CMS said it expects to achieve budget neutrality by providing approximately $833 million worth of incentives and $833 million in negative payment adjustments through MIPS beginning in 2019. CMS will also distribute $500 million for “exceptional” MIPS performance. 
  • Some Physicians Excluded from MIPS: MACRA allows physicians participating in APMs to avoid the MIPS process. In addition, CMS clarified that the statutorily-mandated “low-volume threshold” exclusion for physicians will apply to those with fewer than 100 Medicare Part B-eligible patients and less than $10,000 billed charges for Medicare. Across all exclusion types (including APM participants and new Medicare-enrolled eligible clinicians), CMS expects that 1,849 gastroenterologists will be excluded from MIPS.    
  • MIPS Financial Impact on GI: CMS estimates that 61.5 percent of GIs participating in MIPS will receive positive payment adjustments totaling $34 million. This increase would be partially offset by negative payment adjustments for 38.3 percent of GIs. Nearly 60 percent of colorectal surgeons are also expected to receive a positive adjustment.  
  • MIPS and Practice Size: Data provided by CMS indicates that the likelihood of receiving an upward performance adjustment goes up significantly as practice size expands. Among practices with two to nine eligible MIPS clinicians, only 29.8 percent are expected to receive a positive adjustment, but this number increases to 81.3 percent for practices with 100 or more. Solo practitioners will be hit hardest by MIPS, with 87 percent likely facing a negative adjustment totaling a loss of $300 million for solo practices across all specialties.

What’s Next
Over the coming months, AGA will continue to provide more detailed information and resources to help practices prepare for the upcoming policy and delivery changes.    

More on MACRA