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Medicare Unveils Flexible Choices for Doctors in Pay Overhaul

By Kerry Young, CQ Roll Call

April 27, 2016 -- Medicare officials on Wednesday unveiled a plan to offer doctors and other health care providers choices about how their performance will be judged under an overhauled payment system. The concession is unlikely to prevent further fights with lobbying groups about one of the largest federal medical expenses.

The Centers for Medicare and Medicaid Services (CMS) released its draft rule for carrying out last year's congressional overhaul (PL 114-10) of payments for doctors, physician assistants, and other providers of care routinely delivered in medical offices. The rule is intended to further tie payments for the care of more than 35 million Americans in traditional government-run Medicare to judgments about the quality of care by doctors and other providers. Medicare paid about $69 billion in 2014 for services covered by the physician fee rule, which also sweeps in related fields.

Doctors and other physicians will see their 2019 payments adjusted to reflect how well they fared on Medicare's metrics in 2017. CMS officials stressed on Wednesday that they want to allow flexibility in the new reimbursement system.

"By proposing a flexible, rather than a one-size-fits-all program, we are attempting to reflect how doctors and other clinicians deliver care and give them the opportunity to participate in a way that is best for them, their practice, and their patients," said Patrick Conway, the chief medical officer for the Centers for Medicare and Medicaid Services.

The draft rule fleshes out the mandates in the so-called "doc fix" law,  in which lawmakers undid a previous budget mechanism—known as the sustainable growth rate—that threatened for many years to cut Medicare payments to doctors.

Doctors now face a choice of moving into alternative payment models in which they face greater financial risks or rewards based on how Medicare judges their performance, or adapting to the new merit-based incentive payment system, or MIPS. The draft rule spells out how doctors can avoid the MIPS program by joining certain alternative payment models, which may carry increased financial risk and rewards.

Doctors in the new merit-based program would choose the metrics for judging their performance from among a range of approved quality measures, with an emphasis on those that reflect the actual results in their patients. MIPS also will be structured to try to reward doctors for increased care coordination, CMS said.

The draft MIPS rule outlines four performance categories—quality, advancing care information, clinical practice improvement activities and cost. The quality measure would represent 50 percent of the total score in the first year. Doctors and other health care providers would choose to report six measures from among a range of options that accommodate differences among specialties and practices.

The advancing care information category would account for 25 percent of the score in the first year. In this field, doctors and other providers of health care can choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. The clinical practice improvement activities would account for 15 percent of the total score. This category would reward activities focused on care coordination and patient safety. Doctors and providers of health care may select activities from a list of more than 90 options.

Cost would be 10 percent of the total score in the first year. The score would be based on Medicare claims, meaning no reporting requirements. This category would use 40 episode-specific measures to account for differences among specialties.

CMS will accept comments on the draft rule through June 26.

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