The New Reimbursement Model Debate

Carter L. Alleman, J.D.

The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) changed the Medicare reimbursement landscape. MACRA removed the threat of the SGR; however in doing so, Congress moved the Medicare reimbursement model from a fee-for-service model to a system for paying for quality care. Congress did not explicitly state how this quality care reimbursement would work, but left it to Centers for Medicare & Medicaid Services (CMS) and Health and Human Services (HHS) to decide. Congress did provide two frameworks: Merit-Based Incentive Payment Systems (MIPS) and Alternative Payment Models (APMs). Physicians will have to choose which reimbursement model they will participate in by 2019.

MIPS, preserve the fee-for-service model. The MIPS will streamline Meaningful Use, Physician Quality Reporting System, and the Value-Based Modifier and Clinical Practice Improvement into one reporting program. The reasoning for this is to reduce the administrative burden which physicians face with the differing quality reporting systems. The MIPS also will include bonuses to the quality reporting along with the penalties. The caveat with the bonuses and penalties will be that these will be determined on a sliding scale by comparing composite performance score to average all physicians.

APMs, exempt physicians from participating in MIPS. The physicians participating in APMs will earn a shared savings, plus annual bonuses. The models which fall under APMs include: Accountable Care Organizations, Patient-Centered Medical Homes (PCMH), bundled payments, and others to be developed by specialty APMs. The participation in APMs rely on two requirements: the use of certified EHR technology and the physician must bear financial risk for losses or be a PCMH.

If this sounds confusing, you are not alone. The models provide more questions than answers. The American Medical Association, American Osteopathic Association, and American College of Surgeons have held preliminary meetings with ACOS and other specialty associations to discuss the models and to start to compile questions for HHS and CMS to answer. ACOS has raised questions of its own, especially how all of this will ultimately effect osteopathic surgeons. As the reimbursement model discussions move forward, ACOS will be at the table advocating for you.