Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Final rule with comment period.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare sustainable growth rate (SGR) methodology for updates to the physician fee schedule (PFS) and replaces it with a new approach to payment called the Quality Payment Program that rewards the delivery of high-quality patient care through two avenues: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) for eligible clinicians or groups under the PFS. This final rule with comment period establishes incentives for participation in certain alternative payment models (APMs) and includes the criteria for use by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) in making comments and recommendations on physician-focused payment models (PFPMs). Alternative Payment Models are payment approaches, developed in partnership with the clinician community, that provide added incentives to deliver high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. This final rule with comment period also establishes the MIPS, a new program for certain Medicare-enrolled practitioners. MIPS will consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs), and will continue the focus on quality, cost, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies. In this final rule with comment period we have rebranded key terminology based on feedback from stakeholders, with the goal of selecting terms that will be more easily identified and understood by our stakeholders.

Regulatory and tax issues for worksite wellness programs.

Worksite wellness programs continue to grow and find expression in employer organizations of all types. As these programs mature and are offered to larger and larger numbers of employees in more worksites increased opportunity exists for regulatory problems. Applicable legislation and major federal regulatory issues affecting worksite wellness programs are explored and categorized. Final rules regarding Title I non-discrimination provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are described and implications for employers are identified. Due to the increasing importance of incentive rewards in programming, the tax implications of various types of program expenditures are also described. Finally, suggestions for legislative amendments and regulatory changes that would enhance wellness program effects are described.

Physician fee schedule update for calendar year 1992 and physician performance standard rates of increase for federal fiscal year 1992--HCFA. Notice.

This notice announces the calendar year 1992 update to the Medicare physician fee schedule and the Federal fiscal year 1992 performance standard rates of increase for expenditures and volume of physician services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848 (d) and (f) respectively of the Social Security Act. The fee schedule update for calendar year 1992 is 1.9 percent. The physician performance standard rates of increase for Federal fiscal year 1992 are 10.0 percent for all physician services, 6.5 percent for surgical services, and 11.2 percent for nonsurgical services.

HMO malpractice: have the floodgates opened?

The U.S. Supreme Court's holding in Pegram v. Herdrich--that decisions by an HMO's physician employees in which eligibility issues and reasonable medical treatment are inextricably mixed are not fiduciary acts under the Employee Retirement Income Security Act (ERISA)--was applauded by the managed care industry. By delineating issues on which it was not ruling, however, the Court's decision may have given a boost to additional lawsuits against managed care plans on both ERISA and malpractice grounds.

E-prescribing adoption and use increased substantially following the start of a federal incentive program.

E-prescribing, or the electronic generation of a prescription and its routing to a pharmacy, is generally believed to improve health care quality and reduce costs. However, physicians were slow to embrace this technology until 2008, when Congress authorized e-prescribing incentives as part of the Medicare Improvements for Patients and Providers Act. Using e-prescribing data from Surescripts, we determined that as of December 2010, close to 40 percent of active e-prescribers had adopted the technology in response to the federal incentive program. The data also suggest that among providers who were already e-prescribing, the federal incentive program was associated with a 9-11 percent increase in the use of e-prescribing-equivalent to an additional 6.8-8.2 e-prescriptions per provider per month. We believe that financial incentives can drive providers' adoption and use of health information technology such as e-prescribing, and that health information networks can be a powerful tool in tracking incentives' progress.

Assessing the impact of rural provider services mix on the Primary Care Incentive Payment Program.

Key Findings. (1) Based on analysis of 2009 Medicare claims data, more than 70% of rural primary care physicians (PCP) and non-physician practitioners (NPP) qualify for payments under the Primary Care Incentive Payment Program (PCIP) threshold (i.e., meet the > 60% of allowable Medicare charges). (2) The average incentive payment for qualifying rural PCPs would result in an additional $8,000 in Medicare patient revenue per year. For qualifying NPPs, the result is an additional $3,000 in Medicare patient revenue per year. (3) Only 9% of non-qualifying rural primary care providers were within 10 percentage points of the minimum threshold (60%) of Medicare allowed charges to qualify for PCIP payments.