Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and…

Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models

SUMMARY: The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare sustainable growth rate (SGR) methodology for updates to the physician fee schedule (PFS) and replaces it with a new approach to payment called the Quality Payment Program that rewards the delivery of high-quality patient care through two avenues: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) for eligible clinicians or groups under the PFS. This final rule with comment period establishes incentives for participation in certain alternative payment models (APMs) and includes the criteria for use by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) in making comments and recommendations on physician-focused payment models (PFPMs). Alternative Payment Models are payment approaches, developed in partnership with the clinician community, that provide added incentives to deliver high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. This final rule with comment period also establishes the MIPS, a new program for certain Medicare-enrolled practitioners. MIPS will consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs), and will continue the focus on quality, cost, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies. In this final rule with comment period we have rebranded key terminology based on feedback from stakeholders, with the goal of selecting terms that will be more easily identified and understood by our stakeholders.

DATES: Effective date: The provisions of this final rule with comment period are effective on January 1, 2017.

Comment date: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on December 19, 2016.

ADDRESSES: In commenting, please refer to file code CMS-5517-FC. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission. You may submit comments in one of four ways (please choose only one of the ways listed):

1. Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the "Submit a comment" instructions.

2. By regular mail. You may mail written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-5517-FC, P.O. Box 8013, Baltimore, MD 21244-8013.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By express or overnight mail. You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-5517-FC, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. Alternatively, you may deliver (by hand or courier) your written comments ONLY to the following addresses prior to the close of the comment period:

a. For delivery in Washington, DC--Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201.

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.

If you intend to deliver your comments to the Baltimore address, call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members.

Comments erroneously mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Molly MacHarris, (410) 786-4461, for inquiries related to MIPS. James P. Sharp, (410) 786-7388, for inquiries related to APMs.

SUPPLEMENTARY INFORMATION:

Table of Contents

I. Executive Summary

II. Provisions of the Proposed Regulations and Analysis of and Responses to Comments

A. Establishing MIPS and the Advanced APM Incentive

B. Program Principles and Goals

C. Changes to Existing Programs

D. Definitions

E. MIPS Program Details

F. Overview of Incentives for Participation in Advanced Alternative Payment Models

III. Collection of Information Requirements

IV. Regulatory Impact Analysis

A. Statement of Need

B. Overall Impact

C. Changes in Medicare Payments

D. Impact on Beneficiaries

E. Impact on Other Health Care Programs and Providers

F. Alternatives Considered

G. Assumptions and Limitations

H. Accounting Statement

Acronyms

Because of the many terms to which we refer by acronym in this rule, we are listing the acronyms used and their corresponding meanings in alphabetical order below:

ABC(TM) Achievable Benchmark of Care

ACO Accountable Care Organization

APM Alternative Payment Model

APRN Advanced Practice Registered Nurse

ASPE HHS' Office of the Assistant Secretary for Planning and Evaluation

BPCI Bundled Payments for Care Improvement

CAH Critical Access Hospital

CAHPS Consumer Assessment of Healthcare Providers and Systems

CBSA Non-Core Based Statistical Area

CDS Clinical Decision Support

CEHRT Certified EHR technology

CFR Code of Federal Regulations

CHIP Children's Health Insurance Program

CJR Comprehensive Care for Joint Replacement

CMMI Center for Medicare & Medicaid Innovation (CMS Innovation Center)

COI Collection of Information

CPIA Clinical Practice Improvement Activity

CPOE Computerized Provider Order Entry

CPR Customary, Prevailing, and Reasonable

CPS Composite Performance Score

CPT Current Procedural Terminology

CQM Clinical Quality Measure

CY Calendar Year

eCQM electronic Clinician Quality Measure

ED Emergency Department

EHR Electronic Health Record

EP Eligible Professional

ESRD End-Stage Renal Disease

FFS Fee-for-Service

FR Federal Register

FQHC Federally Qualified Health Center

GAO Government Accountability Office

HIE Health Information Exchange

HIPAA Health Insurance Portability and Accountability Act of 1996

HITECH Health Information Technology for Economic and Clinical Health

HPSA Health Professional Shortage Area

HHS Department of Health & Human Services

HRSA Health Resources and Services Administration

IHS Indian Health Service

IT Information Technology

LDO Large Dialysis Organization

MACRA Medicare Access and CHIP Reauthorization Act of 2015

MEI Medicare Economic Index

MIPAA Medicare Improvements for Patients and Providers Act of 2008

MIPS Merit-based Incentive Payment System

MLR Minimum Loss Rate

MSPB Medicare Spending per Beneficiary

MSR Minimum Savings Rate

MUA Medically Underserved Area

NPI National Provider Identifier

OCM Oncology Care Model

ONC Office of the National Coordinator for Health Information Technology

PECOS Medicare Provider Enrollment, Chain, and Ownership System

PFPMs Physician-Focused Payment Models

PFS Physician Fee Schedule

PHS Public Health Service

PQRS Physician Quality Reporting System

PTAC Physician-Focused Payment Model Technical Advisory Committee

QCDR Qualified Clinical Data Registry

QP Qualifying APM Participant

QRDA Quality Reporting Document Architecture

QRUR Quality and Cost Reports

RBRVS Resource-Based Relative Value Scale

RFI Request for Information

RHC Rural Health Clinic

RIA Regulatory Impact Analysis

RVU Relative Value Unit

SGR Sustainable Growth Rate

TCPI Transforming Clinical Practice Initiative

TIN Tax Identification Number

VM Value-Based Payment Modifier

VPS Volume Performance Standard

I. Executive Summary

1. Overview

--This is a summary of a Federal Register article originally published on the page number listed below--

Final rule with comment period.

CFR Part: "42 CFR Parts 414 and 495"

RIN Number: "RIN 0938-AS69"

Citation: "81 FR 77008"

Document Number: "CMS-5517-FC"

Federal Register Page Number: "77008"

"Rules and Regulations"