Accountable Care Network FAQ

Eligible clinicians under MACRA can participate in one of two payment paths:

1. Merit Based Incentive Payment System (MIPS); or
2. Advanced Alternative Payment Models (A-APMs)

Most Medicare Part B clinicians will be subject to MIPS. Under MIPS, providers will receive adjustments to their Medicare fee-for-service reimbursement based on a composite performance score measuring i) quality, ii) resource use (cost), iii) clinical practice improvement activities, and iv) advancing care information.

CMS incentivizes providers to participate in Advanced APMs, the alternative to payment under MIPS. Providers who participate in Advanced APMs can avoid MIPS and receive an annual 5 percent bonus on top of their Medicare Part B reimbursement. CMS applies thresholds to Advanced APMs to determine if the model is a qualifying participant. If the Advanced APM meets the thresholds, then the participants are excluded from MIPS and eligible for the annual 5 percent bonus.

Advanced APMs under MACRA include: MSSP ACO Tracks 1+, 2 and 3; Next Generation ACO Model; Comprehensive ESRD Care Model; Oncology Care Model; and Comprehensive Primary Care Plus Model.

Participants have the opportunity to receive shared savings from the ACO as the network demonstrates its ability to lower health care costs while meeting CMS quality standards.

UC San Diego Health shelters participants from downside risk for the first 3-year agreement period.

Because the ACO is a Track 1+ model, participants in UC San Diego Health Accountable Care Network benefit from prospective — rather than retrospective — beneficiary assignment for required reporting and financial reconciliation. That means that ACO participants know which Medicare patients are assigned to the population being cared for in the ACO.

Alignment with UC San Diego Health Accountable Care Network provides practices the opportunity to take advantage of several benefits, including full access to the Epic electronic health record and information systems integration, collaboration with UC San Diego Health specialty providers, a shared network infrastructure for care coordination and network administration, and a partner through the evolution of health care regulations.

• Addiction medicine
• Cardiology
• Endocrinology
• Geriatric psychiatry
• Gynecology/oncology
• Hematology
• Hematology/oncology
• Medical oncology
• Multispecialty clinic or group practice
• Nephrology
• Neurology
• Neuropsychiatry
• Osteopathic manipulative medicine
• Obstetrics/gynecology
• Physical medicine and rehabilitation
• Preventive medicine
• Primary care (e.g., internal medicine, general practice, family practice, geriatric medicine, or pediatric medicine)
• Psychiatry
• Pulmonary disease
• Sports medicine

In April 2015, Congress repealed the SGR (sustainable growth rate) formula that determined Medicare physician fees, replacing it with legislation called MACRA (Medicare Access and CHIP Reauthorization Act of 2015).

This landmark bipartisan legislation advances a forward-looking, coordinated framework for healthcare providers to successfully take part in the CMS Quality Payment Program (QPP) that rewards value and outcomes in one of two ways:

• Alternative Payment Model (APM)
• The Merit-Based Incentive Payment System (MIPS)

The QPP policy will reform Medicare payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire healthcare delivery system.

You can choose how you want to participate in the QPP based on your practice size, specialty, location or patient population. You’re a part of the QPP if you bill Medicare more than $30,000 a year AND provide care for more than 100 Medicare patients a year AND are a:

• Physician
• Physician Assistant
• Nurse Practitioner
• Clinical Nurse Specialist
• Certified Registered Nurse Anesthetist

A payment approach that provides added incentives to clinicians to provide high-quality and cost-efficient care. CMS is constantly developing new payment and service delivery models to encourage this mindset. One of those models is the Medicare Shared Savings Program (MSSP).

For the 2017 performance year, you may qualify as an aAPM if you meet all 3 requirements below:

• Use a certified Electronic Health Record (EHR)
• Currently report quality measures comparable to those used in MIPS
• You are in a medical home model OR bear more than a nominal amount of financial risk
  

For the 2017 performance year, you may qualify as an aAPM if you meet all 3 requirements below:

• Use a certified Electronic Health Record (EHR)
• Currently report quality measures comparable to those used in MIPS
• You are in a medical home model OR bear more than a nominal amount of financial risk
  

For the 2017 performance year, the following models are Advanced APMs:

Additional aAPM models for 2018:

In MIPS, you can earn a payment adjustment based on evidence-based and practice-specific quality data. MIPS is the category that will apply to most physicians:

• Moves Medicare Part B clinicians to a performance-based payment system
• Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice
• Reporting standards align with Advanced APMs wherever possible

Key Takeaway

Positive adjustments are based on the performance data of the performance information submitted, not the amount of information or length-of-time submitted. You can submit 90 days of information with great quality and receive a higher percentage than someone who submitted all year with acceptable quality.

Potential Financial Rewards

Although MACRA creates separate paths for payments under the Medicare Physician Fee Schedule (PFS), these paths are in addition to, not in replacement of, the PFS.

MACRA replaced SGR with a schedule that will increase baseline Medicare Part B payments by 0.5% per year until 2019. The first payment adjustments will be based on performance year 2017 and will reflect in your 2019 Medicare payments.

If you participate in an Advanced APM, you will receive a + payment adjustment of 5% every year, beginning in 2019. 

PQRS Payment Reminder: PQRS will be referred to as a “legacy program.” The last performance year of this program was 2016. If you participated this last year, your payment adjustment will take place in 2018. As a reminder, this is not associated with your 2018 MIPS performance.