HHS issues road map for Medicare's shift to quality

The path to quality-based payments for the U.S. government's massive Medicare system just got a little clearer after the U.S. Department of Health and Human Services (HHS) issued a proposed rule outlining its ideas for how the new system will work.

In an April 27 announcement, HHS issued a notice of proposed rulemaking, the first step in implementing provisions of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. MACRA eliminated Medicare reimbursement changes using the sustainable grow rate (SGR) formula and called for the establishment of payment policies based on healthcare quality, rather than the fee-for-service system that has been the cornerstone of U.S. healthcare for decades.

MACRA seeks to consolidate the patchwork of alternative payment models and incentive initiatives -- such as the meaningful use program for healthcare IT -- into a single framework called the Quality Payment Program. The program would have two main paths:

  • The Merit-Based Incentive Payment System (MIPS)
  • Advanced alternative payment models (APMs)

Most Medicare physicians will participate in the Quality Payment Program through MIPS, HHS said in statement. MIPS will enable clinicians to be paid for high-value care by demonstrating success in four categories: cost, quality, advancing care information, and clinical practice improvement activities.

On the other hand, clinicians can choose instead to be exempt from MIPS by participating in advanced alternative payment models. These include the new Comprehensive Primary Care Plus (CPS+) model, the Next Generation ACO model, and others in which clinicians accept risk and reward for providing coordinated, high-quality care.

HHS is accepting comments on the proposed rulemaking through June 27.

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