On April 27, 2016, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule that would establish the new Quality Payment Program, which includes the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). These policies were established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
The proposed rule applies to Medicare payment for physicians and many other non-physician practitioners, such as physician assistants, nurse practitioners, clinical nurse specialists, and Certified Registered Nurse Anesthetists (CRNAs).
These providers will be reimbursed according to one of two new payment methodologies: the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APM). These new payment methodologies will blend the metrics involved in three previous payment programs: the Physician Quality Reporting System, the Value Modifier Program, and the Medicare Electronic Health Record Incentive Program (also known as Meaningful Use).
Although the new payment systems will not begin until January 1, 2019; however, they will be based upon provider's experience starting in 2017.
Under the MIPS methodology, providers will still participate in Medicare under the Physician Fee Schedule but will receive merit-based bonuses or penalties based on various quality measures. The bonuses or penalties are significant: the bonus or penalty will be equal to 4% in 2019 and increase to up to 9% in 2022.
Quality measures fall into four separate categories:
Cost (which initially accounts for 10% of the physician’s overall score);
Quality (which initially accounts for 50% of the physician’s overall score);
Clinical practice improvement (which initially accounts for 15% of the physician’s overall score);
Advancing care information (which initially accounts for 25% of the physician’s overall score).
Under the Advanced APM, more financial risk is placed on providers. To qualify under this model the participants must meet three criteria:
Marginal risk levels: financial risk for at least 30% of the amount by which actual expenditures exceed expected expenditures;
Minimal loss rate: the amount of spending over the benchmark before shared losses are triggered may not be more than 4%;
Total potential risk: the total amount for which an organization is at risk must be at least 4% of expected expenditures.
MACRA Impact on Nursing
42 percent of Medicare Part B providers are not physicians.
Nurse Practitioners are the third largest group of “clinical specialists” participating in Part B and one in nine providers is an APRN.
The soon-to-be-replaced Physician Quality Reporting System (PQRS) was implemented in 2007. Despite the name, APRNs are included as “eligible professionals,” and those who bill Medicare with a National Provider Identifier (NPI) earn awards under this system.
From 2009 to 2013, APRNs earned 147,758 quality awards under the current Physician Quality Reporting System (PQRS), over $26 million in incentive payments. APRN participation has increased every year of the program.
What WOCN is Advocating for in MACRA Implementation
MACRA implementation should ensure robust patient access to APRN services, and APRNs should be an integral part of its planning and implementation.
Quality measures should include and account for the professional role of the APRN and all appropriate stakeholders who provide clinical services to beneficiaries.
The Medicare Electronic Health Record (EHR) Incentive Program did not recognize the role of the APRN. CMS should ensure that the MACRA incentive programs include an EHR interoperability component for APRNs.
We urge CMS to ensure the committees and Technical Expert Panels (TEPs) tasked with developing quality measures include nurses. Nurses practice in a wide array of settings, and are uniquely qualified to offer insight into quality measures that are meaningful, useful and patient-centered.