Health Care

In order to navigate the complicated and ever-changing laws surrounding health care and your business, you need attorneys who understand your challenges. The Pittsburgh health care lawyers at Houston Harbaugh, P.C., have the knowledge and experience to help you manage everyday issues, as well as plan for the future.

New CMS Payment Models Imminent

After years of talking about paying physicians for performance instead of volume, the Centers of Medicare and Medicaid Services (CMS) has recently proposed regulations (the “Proposed Rule”) that will place greater emphasis on quality indicatorsThe Proposed Rule has been promulgated to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and provides details on two key provisions of MACRA – the Merit-Based Incentive Payment System and the Advanced Alternative Payment Models. Data reporting under these systems will begin during the 2017 calendar year with providers first receiving payments based on this reporting in 2019.

Merit-Based Incentive Payment System (MIPS)

MIPS is a four-part program that will replace and supplement the current Physician Quality Reporting System (PQRS) and the Meaningful Use Program. Based on the composite score generated by a provider through MIPS, the provider will experience an upward or downward adjustment (initially up to 4% in either direction, with this percentage increasing over time.) Medicare fee-for-service reimbursements based on the comparison of the provider’s scores to MIPS is designed to be more streamlined and flexible than the predecessor programs and to provide greater opportunities for providers in different specialties to report on measures which are meaningful to the provider’s particular specialty. The four components of MIPS are as follows:

  • Quality
    Initially comprising 50% of the total MIPS score, the quality component replaces the current PQRS system. Providers will select and report on six quality measures out of a total of 200 measures, 80% of which will be tailored to different medical specialties. This is a reduction from the nine quality measures currently required for PQRS reporting.
  • Advancing Care Information (ACI)
    Initially comprising 25% of the total MIPS score, ACI replaces the Meaningful Use Program. Like the adjustments between PQRS and the Quality metric described above, ACI will require providers to report on fewer measures and will expand the number of available measures, including several specialty-specific measures. All providers will be required to attest to having completed a security risk assessment as required by the HIPAA regulations. Most important, ACI will eliminate the “all or nothing” compliance standard featured in the Meaningful Use Program, thereby allowing providers to demonstrate partial compliance while earning some points toward the composite MIPS score.
  • Clinical Practice Improvement Activities (CPIA)
    Initially comprising 15% of the total MIPS score, providers will report on practice improvement activities such as care coordination, expanded practice access, and patient safety. There will be more than 90 options to amass a total of up to 60 points, with certain options (such as participating in a patient-centered medical home) being weighted more heavily than other activities.
  • Cost
    Initially comprising 10% of the total MIPS score, the Cost metric will be solely based on Medicare claims data.

The Proposed Rule provides for MIPS data to be collected through third parties such as Qualified Clinical Data Registries or other certified vendors.

Advanced Alternative Payment Models (Advanced APMs)

The Proposed Rule provides for additional incentive payments for providers (including physicians, physician assistants, nurse practitioners, clinical nurse specialists and CRNAs) who participate in Advanced APMs. An Advanced APM is a recognized program whereby clinicians accept financial risk and use certified EHR technology while providing high quality and coordinated care. For 2017 the following programs have been recognized as qualified Advanced APMs:

  • Comprehensive End Stage Renal Disease Care Model
  • Comprehensive Primary Care Plus
  • Medicare Shared Savings Program – Tracks 2 and 3 only
  • Next Generation ACO Model

In addition, Oncology Care Model Two Sided Risk Arrangement will become available in 2018. CMS will update the list of programs qualifying as Advanced APMs on an annual basis. The Proposed Rule will not make any changes to these pre-existing programs.

If a provider is receiving a sufficient percentage of payments through the Advanced APM and is treating a sufficient number of patients in each year (the required percentages will vary year-to-year), the provider will be exempt from the MIPS reporting requirements discussed above. Providers will, however, need to report through the MIPS program for at least the first year to determine whether they qualify for payments under Advanced APMs.

What’s Next?
As of publication, these regulations are only in proposed form. CMS is accepting comments on the Proposed Rule through June 27, 2016, with final regulations expected this fall.

We will continue to monitor the development of these programs. Your Houston Harbaugh attorney can assist you in determining how you can benefit from these programs.

About Us

In order to navigate the complicated and ever-changing laws surrounding health care and your business, you need attorneys who understand your challenges. The Pittsburgh health care lawyers at Houston Harbaugh, P.C., have the knowledge and experience to help you manage everyday issues, as well as plan for the future.

Jessica Ellel Pittsburgh health care lawyer

Jessica A. Ellel - Practice Chair

Chair of Houston Harbaugh’s Health Law Practice, Jessica works almost exclusively with health care entities and health practitioners. She has extensive experience with:

  • Drafting and negotiating physician employment agreements from both the physician and employer perspectives
  • Negotiating contracts between physicians and hospitals
  • Preparing purchase agreements to govern the sale of medical practices
  • Advising on corporate governance issues, from practice formation to dissolution
  • Developing comprehensive compliance plans for physician practices, hospitals, third-party billing administrators, and other health care and related entities
  • Organizing strategies for compliance with fraud and abuse laws
  • Addressing HIPAA compliance

Jessica is especially well-versed in HIPAA compliance and authors numerous client updates and bulletins on the subject. She conducts on-site and remote HIPAA training and also maintains Houston Harbaugh’s HIPAA compliance manual, ” Federal HIPAA Privacy Standards Simplified: A Comprehensive Tool-Kit”.