Massachusetts Medical Society: Frequently Asked Questions about H.R. 2

Frequently Asked Questions about H.R. 2

The American Medical Association, the Massachusetts Medical Society, and over 750 national and state-based physician and specialty organizations have gone on record in support of H.R. 2, the “Medicare Access and CHIP Reauthorization Act.” 

What are some of the key features of H.R. 2?

Many features of this bill represent improvements over current law. Some of the most important include the following:

  • The sustainable growth rate (SGR) is permanently repealed, effective immediately.
  • Positive payment updates of 0.5 percent are provided for four and a half years, through 2019.
  • Physicians in alternative payment models (APMs) receive a 5 percent bonus from 2019 to 2024.  
  • In 2026 and beyond, physicians in APMs qualify for a 0.75 percent update; all others will receive a 0.25 percent annual update
  • The fee-for-service payment model is retained, and physician participation in APMs is entirely voluntary.
  • Technical support is provided for smaller practices, funded at $20 million per year from 2016 to 2020, to help them participate in APMs or the new fee-for-service incentive program.
  • Funding is provided for quality measure development, at $15 million per year from 2015 to 2019. Physicians retain their preeminent role in developing quality standards.
  • Current quality incentive and payment programs are consolidated and streamlined, and the aggregate level of financial risk to practices from penalties has been mitigated in comparison to current law.

 Are there provisions that the AMA opposes?

This is not the bill we would have written ourselves. There are still some things about the quality programs, for example, that we will continue working to improve. Nothing in this bill prevents us from advocating for future legislation. In fact, because the SGR and its accumulated debt are eliminated, future modifications will not face the same budgetary obstacles.

How does the legislation support transitions to APMs?

The bill provides incentives and a pathway for physicians to develop and participate in new models of health care delivery and payment. Physicians participating in patient-centered medical homes, widely recognized to lower costs of care, would not be required to assume downside financial risk. Other models would require some degree of downside risk in addition to the opportunities for increased revenues that many APMs provide if the physician practice generates savings. To encourage physicians to assume this risk, and to provide a financial cushion, the legislation provides 5 percent bonus payments from 2019 to 2024 for those who join new models. This provides a transition period to support successful implementation of new models. Another advantage is that physicians would only be subject to the quality reporting requirements for their APM; they would be exempt from the new Merit-based Incentive Payment System (MIPS) quality program described below. The bill also supports the use of telemedicine in new models of care and creates an advisory panel to consider physicians’ proposals for new models.

What is the Merit-based Incentive Payment System or MIPS?

Beginning in 2019, H.R. 2 provides for bonuses ranging from 4 to 9 percent for physicians who score well in the MIPS, a new pay-for-performance program under the current Medicare fee-for-service payment system. The current matrix of penalties under the Physician Quality Reporting System (PQRS), Electronic Health Records/Meaningful Use (MU), and the value-based payment modifier (VBM), would end at the close of 2018. In 2019, the MIPS program would become the only Medicare quality reporting program. Performance under the MIPS would be based upon four categories: quality, resource use, meaningful use, and clinical practice improvement activities. These would build and improve upon the current quality measures and concepts in PQRS, MU, and VBM. Physicians are specifically encouraged to report quality measures through certified EHR Technology or qualified clinical data registries. Participation in a qualified clinical data registry would also count as a clinical practice improvement activity.

In many respects, the MIPS program would be more attainable for physicians than current quality programs. The MIPS program presents the first real opportunity for high-performing physicians to earn substantial bonuses, and for all physicians to avoid penalties if they meet prospectively-established quality thresholds. Several new aspects of the MIPS program support physicians scoring better, and receiving more credit for their efforts, than under current programs.

Would the MIPS do a better job of rewarding physicians for high quality performance than current programs?

Performance scoring under the MIPS program has several advantages over current quality programs:

  • The MIPS does not employ the VBM’s “tournament model” which requires both winners and losers, thereby potentially penalizing even-high performing physicians since someone has to be a loser. In the MIPS, if all physicians perform at or above the performance threshold, no one would get a penalty.
  • Performance assessment under the MIPS program would be according to a “sliding scale”—versus the current “all or nothing” approaches used in PQRS and MU. Credit would be provided to those who partially meet the performance metrics.
  • The bill has guidelines for the weighting of the four performance categories, yet specifically allows administrative flexibility for those in practices or specialties that are at a disadvantage in meeting quality or MU requirements.
  • At the start of each performance period, physicians would know the threshold score for successful performance, and they would receive timely (such as quarterly) feedback on their individual performance.
  • Physicians could receive substantial credit for clinical practice improvement activities and for improving (and achieving) quality of care.
  • Physicians with a low level of Medicare claims, and those who are in APMs, would be exempt from the MIPS requirements and payment adjustments.

The MIPS also presents the first real opportunity for physicians to earn substantial bonuses for providing high quality of care. For exceeding the performance threshold, physicians could earn bonuses of up to: 4 percent in 2019; 5 percent in 2020; 7 percent in 2021; and 9 percent in 2022 and beyond. Additional funding is provided for exceptional performance, up to $500 million per year, from 2019 through 2024. So even if all physicians score above the threshold, some will still receive incentive payments. Unlike current law, the MIPS penalties provide greater certainty, and have a maximum range in future years.

Is H.R. 2 consistent with AMA policy on pay-for-performance

The AMA has worked throughout the negotiations on this legislation to bring it more closely in line with our extensive policy on pay-for-performance. As a result of AMA advocacy, the pending legislation more closely aligns with our P4P policy than previous legislative proposals and is an improvement over current law.

Does the bill include any liability protection for physicians?

Yes, the bill contains a provision similar to the Standard of Care Protection Act. This will protect physicians by preventing quality program standards and measures (such as PQRS/MIPS) from being used as a standard or duty of care in medical liability cases.

How does the bill support chronic care management services?

H.R. 2 would require Medicare to reimburse, under at least one payment code, monthly care management services for individuals with chronic care needs. Payment would go to one professional practicing in a patient-centered medical home or comparable specialty practice certified by a recognized organization. No linkage is required to an annual wellness visit or initial preventive physician examination.

What does the bill say about the release of physician claims data?

Starting in 2014, CMS began to publicly release physician-identified Medicare claims data on an annual basis. The bill would continue to allow the public release of these data. The bill retains provisions that the AMA has supported that allow the sale of non-public data and analyses by Qualified Entities, with certain safeguards.

Does the bill address private contracting?

Physicians who choose to opt out of Medicare to engage in private contracting could elect to automatically renew their status; they would no longer be required to renew their opt-out status every two years. The bill also requires regular reporting about physicians who choose to opt out of Medicare.

Does H.R. 2 make any positive changes to the EHR Meaningful Use program?

The bill sets a target of achieving interoperability of electronic health records by the end of 2018. It also prohibits the deliberate blocking of information sharing.

Will Medicare’s plans to eliminate the 10-day and 90-day global surgical service bundles be addressed?

The decision by the Centers for Medicare & Medicaid Services (CMS) to eliminate bundled payments for 10-day and 90-day global surgical services has been reversed; instead, CMS will collect data on these services beginning in 2017 to determine the accuracy of payment rates. These data will be collected from a sample of physicians, rather than from all who bill global surgical services. To encourage participation, a 5 percent payment withhold may be applied until the required data are submitted.

-- From the American Medical Association

Share on Facebook

Find Your Legislator

Click here to enter your address and get a list of your federal representatives, state legislators, and your local polling place.

Find Your Legislator »

Mass. State Agencies

State House - Mass. State AgenciesRapid access to resources about MassHealth, Public Health, Board of Medicine, and more.

Read More »


Copyright © 2018. Massachusetts Medical Society, 860 Winter Street, Waltham Woods Corporate Center, Waltham, MA 02451-1411

(781) 893-4610 | (781) 893-3800 | Member Information Hotline: (800) 322-2303 x7311