Medicare Proposes New Doc Pay System

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By Mindy Yochelson

April 27 — A regulation proposed April 27 by the CMS would start the move toward a two-track doctor payment system under Medicare beginning in 2019.

The goal is to allow physicians who offer higher quality care to be paid more, Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services, told reporters during a briefing on the proposal.

The new system, called the Quality Payment Program, was required under the Medicare Access and CHIP Reauthorization Act of 2015, which replaced the sustainable growth rate formula as the Part B payment methodology.

Two Paths

The CMS rule offers doctors and other clinicians a choice of aligning themselves with an advanced alternative payment model (APM) and receiving a 5 percent annual bonus or being subject to a quality performance score that could lead to reductions or increases in their Medicare reimbursement.

Over time, professionals will be able to move from one path to the other, Slavitt said.

Comments are due June 27 and a final rule will be out in the fall.

Merit-Based Incentive Payment System

Most doctors will at least start out in the Merit-Based Incentive Payment System (MIPS), where they will have a range of measures on which to choose to report, CMS Chief Medical Officer Patrick Conway told reporters.

Stringent requirements for APMs are expected to keep most professionals in the MIPS track.

“The larger question will be how many doctors actually do align with these models, and how the change might affect their patients.”

Although the proposal “gives doctors automatic bonuses to join alternative payment models that take on risk for quality and spending,” Cristina Boccuti, an associate director of the Program on Medicare Policy at the Henry J. Kaiser Family Foundation, told Bloomberg BNA, “the larger question will be how many doctors actually do align with these models, and how the change might affect their patients.”

During an April 26 webinar, sponsored by the medical trade association AMGA, staff said the CMS expects that as many as 90 percent of professionals will start out in the MIPS track of the new system.

Under MIPS, payments to professionals will be adjusted based on performance measures to be developed over the next few years. MIPS will replace the current group of incentive payment programs: the Physician Quality Reporting System, Value-Based Payment Modifier and Electronic Health Records Meaningful Use Incentive Program.

‘Practice Driven.'

The measures used by the doctors are “practice driven,” in that professionals will be able to select those more relevant, Slavitt said.

Doctors and other Part B clinicians will receive a performance score that could lead to cuts or increases to their Medicare reimbursements. This will start at 4 percent in 2019, increasing to 9 percent in 2022.

Some will have an opportunity to earn more than 4 percent, as additional monies will be distributed to the highest performers, Conway said.

Although the new system doesn’t begin until 2019, the amounts doctors and others receive will likely be based on two-year-old performance data.

In 2017, physicians, physician assistants, nurse practitioners, clinical nurse specialists and nurse anesthetists will be graded for their 2019 payments.

The payment system will be expanded in 2019 to include physical and occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists and dietitians or nutrition professionals.

Advanced Alternative Payment Models

For the second path, providers who are part of APMs will be allowed to avoid MIPS scoring and receive the 5 percent bonus.

The rule has a table of models that, based on proposed criteria, both would and would not qualify for the beginning of the program in 2019. These include whether the models are considered a medical home and their level of financial risk.

The recently introduced Comprehensive Primary Care Plus model, which can accept as many as 5,000 practices, would qualify. Another one that makes the grade is the Comprehensive ESRD Care for beneficiaries with end-stage renal disease, along with accountable care organizations in the Medicare Shared Savings Program.

Medicare Advantage Inclusion

Although providers in Medicare Advantage have requested that they be considered eligible for the 5 percent APM bonus, physician participation in the managed care program isn't included in the APM track.

Conway, also CMS's principal deputy administrator, said that in the first two years, the payment system will be focused on doctors' services in fee-for-service. However, starting in 2021, other programs can be considered as part of the payment framework, he said.

MACRA requires the CMS to submit to Congress by July 1 a report examining the feasibility of incorporating MA in the APM scheme,

Doctor Reaction

Steven J. Stack, president of the American Medical Association, said the group's initial review suggests that the CMS has been listening to physicians’ concerns, including those about reducing quality reporting burdens.

The American Association of Family Physicians said in an April 27 statement that the proposed regulation moves “toward meeting congressional intent, which is to place greater priority on primary care that is comprehensive, continuous, coordinated, connected and a patient’s first contact with the health care system. “

The group praised “the significant attention paid to the patient-centered medical home in particular.”

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Janey Cohen at

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