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Medicare Payment Reform: EvidenceNOW Helps You Prepare

By Heidi S. Berthoud, MPH, staff writer and project manager at the MacColl Center for Health Care Innovation at Group Health Research Institute

On April 16, 2015, President Obama signed the Medicare Access and CHIP Reauthorization Agreement of 2015 (MACRA) into law, ushering in a new value-based system for provider payment and laying the groundwork for rewarding providers for higher quality care. MACRA was a major legislative shift away from the previous, often controversial, system of the Sustainable Growth Rate (SGR) provider payment formula, which was set to reduce provider payments by 21 percent in April of 2015, the same month MACRA became law.


MACRA created two new paths for provider payment, and most primary care clinicians participating in Medicare will be reimbursed using at least one of these new paths. The Merit-Based Incentive Payment System (MIPS) will reward providers based on their performance in four key areas: quality, resource use, electronic health record (EHR) use based on Meaningful Use, and clinical practice improvement. A composite score in all four areas will determine providers’ increased, decreased, or neutral payment amount. Alternative Payment Models (APMs) are the second track for providers making the change under MACRA. APMs focus on quality and value and have a tiered system for incentive bonuses. The most advanced APMs require the providers to bear some of the financial risk for losses.

On April 11, 2016, President Obama announced the first large-scale application of MIPS and APM into primary care: the Comprehensive Primary Care Plus initiative (CPC +). It is a five-year test model to be rolled out across up to 20 states starting in January 2017. It has the dual goal of improving how primary care is delivered and how providers in primary care are reimbursed, giving them the increased latitude to organize and deliver care. In addition to enhanced prospective payment for care management, the program will also reward practices for their performance on patient experiences, clinical quality, and utilization measures through performance-based incentive payments.

EvidenceNOW and Payment Reform

EvidenceNOW is an Agency for Healthcare Research and Quality (AHRQ)-funded initiative to improve the ability of smaller primary care practices to conduct quality improvement with a focus on the delivery of heart health care in primary care practices nationwide. The ultimate goal is to better understand exactly what helps these practices achieve improved clinical quality outcomes and reach their value-based targets. Practices enrolled in EvidenceNOW receive tailored practice coaching to help improve practice performance and many receive one-on-one support to improve EHR infrastructure which will help your practice prepare for the upcoming payment changes.

What Should my Practice Do?

The timeline for MACRA implementation has begun and CPC + is slated to start in 2017. Practices should focus on improving their clinical quality reporting and working with practice coaches to improve practice performance. If you are enrolled in one of the six EvidenceNOW projects nationwide, you’re already on your way to reaching these targets. By 2017, practices will be required to start reporting quality measures in order to have their MIPS composite score calculated, and financial incentives for both MIPS and APMs will begin in 2019.

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