Definition: MACRA is legislation signed in April 2015 that is designed to transform the basis of health care clinician payment from volume to value.1 MACRA created the Quality Payment Program (QPP), which repealed the sustainable growth rate formula used to determine physician and other clinician FFS payment rates in Medicare as well as creating the MIPS.2,3 It also created bonus payments for entities participating in APMs.4
QPP gives clinicians 2 choices for participation:
- Merit-based Incentive Payment System
- MIPS-eligible clinicians receive payment adjustment for the services they provide for Medicare patients based on performance in 4 categories: quality, cost, improvement activities, and promotion of interoperability. Performance in these categories results in a MIPS payment adjustment to the FFS rate 2 years after the performance measurement (for example, performance in 2019 impacts MIPS payment adjustment in 2021). Payment adjustments can be positive or negative depending on the clinician’s performance score.
- Advanced Alternative Payment Models
- Participation in APMs allow clinicians to earn incentive payments for providing high-quality, cost-effective care to Medicare patients. There are multiple advanced APMs available to clinicians.
How it relates to ACO/PCMH: Performance-based payment is increasingly common. Team-based care is imperative to improving the quality of care provided for patients. Pharmacists working in ACO/PCMH models have the expertise to positively impact quality measures and other performance metrics that are increasingly determining payment to practices and organizations.
Involved organizations/oversight: CMS
- MACRA. Available at: www.cms.gov/Medicare/Quality CMS. -Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs/
- CMS. Quality Payment Program. Available at: www.cms.gov/Medicare/Quality-Payment-Program/Quality-Payment-Program
- CMS. Merit-based Incentive Payment System. Available at: https://qpp.cms.gov/mips/overview
- CMS. Advanced Alternative Payment Models. Available at: https://qpp.cms.gov/apms/advanced-apms
Kelli Barnes, PharmD, BCACP
The Ohio State University Division of General Internal Medicine Clinics