The changes for healthcare providers launched by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) are still being realized. At a basic level, this act changes the way physicians are reimbursed by phasing out fee-for-service payments in favor of value-based payments.
This payment reform system was designed to encourage and reward quality and efficiency within our healthcare system. Some OB/GYN practices stand to benefit, but the payment process can be complicated, and not every practice will qualify for reimbursements.
Here's what clinicians need to know to navigate MACRA while offering patients the best care possible during these changes.
How Does MACRA Cover Services?
Payments under MACRA's Quality Payment Program (QPP) are based on two reimbursement structures:
- The Merit-Based Incentive Payment System (MIPS) is based on the fee-for-service (FFS) model and determined by four performance standards: quality, cost, clinical improvement and meaningful use of electronic health record (EHR) technology. From 2019 through 2022, payments can be adjusted up or down depending on how providers score on the four standards.
- Providers who participate in Alternative Payment Models (APMs) — such as Accountable Care Organizations, patient-centered medical homes and those that use bundled payment models — may be eligible for lump sum bonus payments during 2019 and 2024 and higher annual premiums beginning in 2026. Advanced APMs increase reimbursement based on performance.
How Do These Changes Affect OB/GYN Practices?
The American College of Obstetricians and Gynecologists (ACOG) has been paying special attention to 2019 MACRA changes that apply specifically to OB/GYN physicians and practices. At ACOG's 2019 annual meeting, attendees were given a platform to discuss instances when these repayment changes affected their practices.
Smaller OB/GYN practices may be exempt from MACRA in 2019. Both individuals and group practices are exempt from MIPS if they do not reach the "low-volume threshold." ACOG defines the low-volume threshold as meeting only one of the following:
- Seeing a maximum of 200 Medicare Part B patients (excluding patients who have Medicare as a secondary insurance).
- Submitting no more than $90,000 in Medicare Part B charges for specified professional services.
- Providing a maximum of 200 professional services covered by Medicare Part B.
Others exempt from MIPS are those with less than a full year's worth of Medicare claims or those use the Medicare Physician Fee Schedule instead of participating in APMs. Individual OB/GYNs or practices that exceed at least one low-volume threshold can opt into MIPS in 2019 and become eligible for payment adjustments beginning in 2021.
How Reporting Requirements Are Tallied
Data from all four reporting categories must be kept beginning January 1, 2019, and can result in a positive or negative payment adjustment of up to 7 percent. This data must include six quality measures from the entire year (for example, biopsy followup or breast cancer screening), which make up 45 percent of the overall MIPS score.
Promoting interoperability makes up 25 percent of the MIPS score, and includes measures such as e-prescribing, sending and receiving health information electronically and providing patients with electronic access to their health records.
Improvement activities — such as integrated behavioral and mental health and timely reporting of test results — will make up 15 percent of 2019's MIPS score. OB/GYNs can fulfill part of their improvement activity credit by completing the Safety Certification in Outpatient Practice Excellence for Women's Health (SCOPE).
Cost makes up 15 percent of the MIPS score. Medicare will measure costs based on a practice's claims data (using per capita cost and spending per beneficiary) and provide feedback to OB/GYN practices.
Resources for Clinicians
The Centers for Medicare and Medicaid Services (CMS) provides online tutorials and user guides to help providers participate in the QPP program effectively. Participants can receive feedback through a web interface if they sign up by July 1.
MACRA payments are intended to reflect the excellence of care provided. OB/GYN practices that strive to offer the best care should continue to thrive under these new changes — both financially and in patient t satisfaction.
