The long-sought-after repeal of the failed Sustainable Growth Rate (SGR) formula has finally happened. Earlier this week the Senate passed the Medicare Access and CHIP Reauthorization Act of 2015 (HR 2), which repealed SGR and extended several key programs of importance to family medicine.
Changes to Physician Payments
The bill permanently replaces the SGR formula with stable annual payment increases of 0.5% for 5 years. It also includes incentives for physicians to move into one of two value-based payment systems, based on their practice model, beginning in 2019.
Merit-Based Incentive Payment System (MIPS)
MIPS consolidates existing Medicare fee-for-service incentive programs (PQRS, Meaningful Use, and Value-based Modifier). One can think of this payment system as the default system. Payments will be based on improved performance of specific criteria, resulting in a base payment being increased or decreased up to 4% beginning in 2019, rising to up to 9% by 2022. Starting in 2026, physicians participating in the MIPS will be eligible for a 0.25% annual increase in their payments.
- This consolidation is intended to streamline complex quality reporting measures.
- It adds incentives for physicians to engage in clinical improvement activities (e.g., same-day appointments, care coordination, etc.).
- It rewards physicians based on their own measured improvement, rather than through a “tournament style” system that mandates winners and losers.
Of note, the legislation includes ABFM maintenance of certification as a MIPS clinical-improvement activity.
Alternative Payment Methodology (APM)
The other method of payment is for physicians who receive a certain percentage of their revenue from alternative payment models such as patient-centered medical home and accountable care organizations. Eligible practices paid under the APM model will receive a 5% bonus on their Medicare billings for years 2019 to 2024. Starting in 2026, physicians participating in an APM qualify for a 0.75% annual increase.
- APM provides safe harbor from the downside of MIPS assessment and most EHR meaningful use requirements.
- It rewards movement away from the fee-for-service model and into models that reward value and outcomes rather than activity or volume.
Our hope is that both of the tracks will allow family medicine practices to garner better payment for providing improved care; however, the larger bonus payments in the alternative payment models intentionally encourage a shift from focusing on solely on patients to improved care of communities and populations. The underlying premise is that this type of payment system, in contrast to fee-for-service, will incentivize practices to achieve the triple aim of improving the health of the population, enhancing the patient outcomes and reducing costs.
Funding of Critical Programs
There were several other primary care priorities that were included in the bill that our advocacy staff and many of our members have worked very hard to achieve. The bill includes 2 years of additional funding for:
- Children’s Health Insurance Program
- Community health centers
- National Health Service Corps
- Teaching Health Center Graduate Medical Education program.
Our academic family medicine advocacy staff has been actively working for over 3 years to achieve an extension of the Teaching Health Center GME program. Its 2-year extension in this legislation provides funding for the current crop of residents—including those who just matched into these programs for the 2015–2016 academic year. Without this extension the program was at risk of running out of money. The HRSA had given notice that the per-resident amount might be reduced from its current $150,000, to as low as $70,000, depending on this year’s match and fill rates. The bill allows us some breathing room to continue to work for a more permanent solution—but we don’t have time to rest on our laurels!
Thank You CAFM Advocacy Network and Members!
Take a moment to enjoy the success! I would like to extend a very great thank you to those who advocated for this bill and the programs contained in it. Many of you answered our call and were committed to moving the process forward. We will need to continue our advocacy efforts to move our national agenda forward. I look to your help in efforts to obtain overall graduate medical education reform, increased funding for primary care research, and better funding for primary care training under Title VII.
Advocacy is not all about national agendas, either of our specialty, or of academic family medicine. I’d also like to hear ideas about your personal advocacy journey.
What issues, causes, or problems matter to you? What do you see as your next personal advocacy cause? And when you read the summary above of what’s contained in the SGR legislation, what ideas did it stimulate in you for your advocacy agenda in the future?
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It is indeed important to consider health insurance programs and community health centers when it comes to something such as this. My last job had a great subsidized program for hospice care, which is important for me because my mother is on my insurance and she is elderly. It gave me great peace of mind to know that she was taken care of through a legitimate care program. I hope more of these programs will be instituted in years to come.