V. Key Issues: Population Health >> H. Quality/Satisfaction >> General Approaches >> Pay-for-Performance >> Medicare Access and CHIP Reauthorization Act (MACRA) (last updated 2.20.17)
Lead Editor: Dana Beezley-Smith, Ph.D.
- 1 Overview
- 2 Timeline for MACRA Implementation
- 3 Alternative Payment Model (APM)
- 4 Merit-Based Incentive Payment System (MIPS)
- 5 MIPS Reimbursement
- 6 Analysis of MACRA Legislation
- 7 MACRA Proposed Rule (NPRM) (April 27, 2016)
- 8 MACRA Final Rule (October 14, 2016)
- 9 Impact of the 2016 President Election
- 10 Resources
The Medicare Access and CHIP Reauthorization Act (MACRA), was passed by the U.S. House of Representatives on March 26, 2015, (by a vote of 392 to 37) and the Senate on April 14, 2015, (by a vote of 92 to 8), and signed into law on April 16, 2015. The legislation repealed the Sustainable Growth Rate (SGR) formula for Medicare physician and other EC (eligible clinician) payments. Medicare payments will transition to P4P programs and away from a volume-driven, fee-for-service system. MACRA establishes an alternative set of predictable annual baseline payment updates and two payment tracks: the Alternative Payment Model (APM) track and the Merit-Based Incentive Payment System (MIPS) track.
If House Doc Fix Adds $141 Billion to Deficit, Can Medicare Survive ‘Reform’? “The Congressional Budget Office has released its score of the Medicare ‘doc fix’ legislation scheduled for consideration Thursday in the House. Among other things, the score provides some sense of the difficulty in enacting reforms to improve Medicare’s solvency… CBO projected that the bipartisan legislation to repair Medicare’s physician payment structure would add $141 billion to the deficit. As I wrote in an earlier post, Congress paid for temporary patches in the past in part by cutting spending and in part by planning on bigger payment reductions in future years. While the legislation’s prospective increases in payment levels would be paid for, the future payment reductions already on the books would not be covered, thus raising the deficit. That unpaid-for increase in Medicare spending would also raise the basic Medicare Part B monthly premium by $10 monthly in 2025, CBO concluded.” (Wall Street Journal, 3.25.15)
Timeline for MACRA Implementation
A visual representation of the MACRA timeline is found here.
- July 2015-December 2015: Medicare EC payments increase by 0.5 percent.
- 2016: The last performance period for PQRS, VBM and Medicare MU began January 1, 2016, and expires on December 31, 2016.
- 2016–2019: Medicare EC payments increase by 0.5 percent each year.
- January 2017: Based on eligibility, ECs enter either the APM track or the MIPS track. The first performance period for MIPS is expected to be January 1, 2017, through December 31, 2017.
- 2020–2025: Medicare fee-for-service payments remain at 2019 levels with no updates.
- 2026 and beyond: All ECs participating in the MIPS will be eligible for a 0.25 percent increase in their payments each year.
Alternative Payment Model (APM)
Congress defined any of the following as an alternative payment model:
- An innovative payment model expanded under the Center for Medicare & Medicaid Innovation (CMMI), including Comprehensive Primary Care (CPC) initiative participants but not Health Care Innovation Award recipients
- A Medicare Shared Savings Program accountable care organization (ACO)
- Medicare Health Care Quality Demonstration Program or Medicare Acute Care Episode Demonstration Program, or another demonstration program required by federal law.
However, only six current APMs made the Advanced APM list in CMS’ April 2016 proposed rule, one of which is not available until 2018:
- Next Generation Accountable Care Organization (ACO) Model (21 current participants)
- Medicare Shared Savings Program (MSSP) Track 3 (16 current participants)
- Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) – Large Dialysis Organization (LDO) arrangement (12 current participants)
- MSSP Track 2 (6 current participants)
- Comprehensive Primary Care Plus (CPC+) (available in 2017)
- Oncology Care Model (OCM) two-sided risk arrangement (available in 2018)
The rules excluded as qualifying APMs many existing programs, including the Comprehensive Care for Joint Replacement (CJR) model, the Bundled Payments for Care Improvement (BPCI) initiative, and Track 1 Medicare Shared Savings Program (MSSP) ACOs, which comprise 95 percent of the 434 MSSP ACOs. According to Medscape Medical News (7.7.16), many patient-centered medical homes are ineligible for classification as advanced APMs. “CMS has added yet more limitations. For clinicians in advanced APMs to become qualified providers (QPs) exempted from MIPS, they would have to earn a minimum of 20% of Medicare payments and have 10% of patients through the advanced APM, CMS says in the proposed rule. Furthermore, CMS says that even among this group of QPs, many would not qualify as ‘full QPs,’ who get an automatic bonus equal to 5% of their Medicare reimbursements. This second tier, called ‘partial QPs,’ are those who get 20%-25% of the Medicare payments and 10%-20% of their patients through advanced APMs.”
Expansion of APM Models
- New MACRA Proposed Rule Provisions Impact Orthopaedic Bundled Payments. “On July 25, 2016, the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) released a new proposed rule… (that) alters an existing bundled payment model for total joint arthroplasty and potentially allows it to qualify as an Advanced Alternative Payment Model (APM). Inclusion of the Comprehensive Care for Joint Replacement (CJR) bundled payment model and a new Bundled Payments for Care Improvement (BPCI) voluntary model expands the original proposed Quality Payment Program rules on Advanced APMs under MACRA and creates new pathways for physicians to qualify for increased payment incentives beginning in 2018. According to the CMS proposed rule:
- A new surgical hip/femur fracture treatment (SHFFT) bundled payment model initiated by hip and femur procedure claims may qualify as an Advanced APM.
- Two different tracks will be implemented within the SHFFT and CJR models:
- Participants who meet proposed requirements for use of Certified Electronic Health Record Technology (CEHRT) and financial risk would be in Track 1 (an Advanced APM track).
- Participants who do not meet CEHRT and financial risk requirements would be in Track 2 (a non-Advanced APM track).” (American Academy of Orthopedic Surgeons, 8.10.16)
- On December 20, 2016, CMS announced adjustments to the Comprehensive Care for Joint Replacement (CJR) Model, allowing the model to qualify as an Advanced APM under the Quality Payment Program as well as aligning the model’s policies with the episode payment models around financial arrangements and beneficiary engagement incentives, compliance enforcement, appeals processes, and beneficiary notifications.
Other APM Criteria
An APM requires participants to meet all of the following criteria:
- Uses quality measures comparable to measures under the MIPS
- Uses certified electronic health record (EHR) technology
- Bears more than nominal financial risk or is a medical home expanded under the CMMI
- Has increasing percentage of payments linked to value through Medicare or all-payer APMs
The proposed rule also established three criteria that APM participants will need to meet to satisfy MACRA’s nominal financial risk requirement:
- Marginal risk of at least 30 percent
- Minimal loss rate of no more than 4 percent
- Total potential risk of at least 4 percent of expected expenditures
APM Incentive Payments
- The Brookings Institute reports (5.4.16) that “in order to receive the APM track bonus, physicians must have a minimum of 25 percent of their revenue from Medicare come through eligible APMs in 2019, with the minimum increasing through 2023 up to 75 percent. In 2021, a new all-payer Advanced APM option becomes available, allowing providers in APM contracts with other payers to participate in the Advanced APM incentive. To do so, they must meet the same minimum thresholds—50 percent in 2021, 75 percent in 2023—but through all provider contracts, not solely Medicare revenue, while still meeting a significantly lower Medicare-specific threshold. By creating an all-payer option, CMS hopes to enable greater provider participation by allowing all payer revenue to count toward the same minimum threshold.”
- According to law firm Proskauer (5.12.16), “between 30,658 and 90,000 eligible clinicians will become QPs (Qualified Professionals) through participation in Advanced APMs, with between $146 million and $429 million APM Incentive Payments estimated to be distributed in 2019.”
- According to Mediscape Medical News (7.7.16), “unable to get the (APM) 5% bonus, partial QPs might decide to stay in MIPS, where they might actually earn more money than as full QPs. High-performing MIPS clinicians might earn bonuses of as much as 12% in MIPS. In MIPS, partial QPs have many advantages, such as not having to report certain metrics and getting ‘favorable weights,’ according to the proposed rule.”
- Why MIPS is Only Half the Story. “We had some hints that APMs would be big in the new program, but the big news in the Proposed Rule was that not just any APM will do. The APM must be an Advanced Payment Model. There is a complex formula for determining if an APM falls definitively in the Advance realm, but the biggest differentiator is that the APM must carry some downside financial risk. That’s why your average Track 1, Accountable Care Organization under the Medicare Shared Savings Program (MSSP) will not qualify. They will still need to participate in MIPS. Because they are participating in an MSSP, they will receive additional points in the category ‘Clinical Practice Improvement Activities.’ Medicare is aggressively pushing practices to Advanced APM by incentivizing them 5%. Though being an Advanced APM exempts the eligible clinicians from MIPS, they are required to show that they use Certified Electronic Health Record Technology (CEHRT) and they will continue to have to rigorously measure quality.” (Mingle Analytics)
- Many Existing APMs Excluded Under Proposed Physician Pay Rules. “The limited number of existing models qualifying as APMs drew concerns from several provider organizations, including Premier. “As we have learned through members in our Population Health Management Collaborative, these programs require providers to not only forgo revenue through a lower volume of services, but also invest millions of dollars in redesigning care through new technologies, data analytics, additional staff, etc.,’ Blair Childs, a premier spokesman, said in a written statement. ‘We think most businessmen would call that more than nominal risk, yet CMS choses to define it as only cases where there is risk to the government.’ Not including Track 1 ACOs and bundled payment programs could lead physicians to leave APMs and return to fee-for-service payment, Childs warned. Another possible consequence, according to Mulvany, was departures from the MSSP for other APMs. ‘If an MSSP ACO is struggling under Track 1 and about to be compelled to take risk, CPC+ might be a more attractive alternative if it’s available in the ACO’s market,’ Mulvany said. Even experienced practices may face struggles under the proposed rule. Donald Fisher, PhD, president and of AMGA, formerly the American Medical Group Association, said in a release that ‘we remain concerned that qualifying as an APM remains challenging at best, even for AMGA members, many of whom are very experienced with risk-based payment models.’” (HFMA, 4.28.16)
Merit-Based Incentive Payment System (MIPS)
The Merit-Based Incentive Payment System is a new program in the Medicare fee-for-service payment system. It consolidates three existing programs—meaningful use (MU), the Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBPM)—into a single program. MIPS is mandatory for providers not participating in Advanced Payment Models.
According to the April 2016 Notice of Proposed Rulemaking (NPRM), there is a two-year delay between performance year and payment year. The MIPS will grade individual EC performance in four categories to generate a composite score on a 0- to 100-point scale.
Exemptions: Clinicians newly enrolled in Medicare are exempt from MIPS, as are those with less than or equal to 100 Medicare patients and less than or equal to $10,000 in Medicare receipts and those participating in an Advanced APM. MIPS does not apply to hospitals or facilities.
The Quality performance category makes up 50 percent of an EC’s total score in year one. The Physician Quality Reporting System (PQRS) and the quality component of VBM are replaced by this category. The NPRM proposes that ECs select six measures, as opposed to the currently required nine measures under PQRS, to satisfy the Quality category. CMS proposed expanded measure options to allow ECs to select the six measures that are most applicable to their specialty.
- According to Mingle Analytics (6.22.16) “Reporting as an individual or a group, using individual measures, instead of reporting on 50% of your eligible patients, you will be required to report on 90% of ALL patients from all payers. Since a cross-cutting measure will still be required, and cross-cutting measures, by definition, are broadly applicable to almost all your patients, this means that you could have to report on every single patient in your practice. These two changes significantly increase the workload to successfully submit data for the Quality Performance Category. Given our experience, the burden of reporting for these types of practices—on paper, or without reporting from their EHR will be ENORMOUS.”
Cost and Resource Use are used interchangeably in the NPRM. Cost will account for 10 percent of the total score in year one. This performance category replaces the cost component of the Value-based Modifier (VBM) program and is based on Medicare claims. Since this performance category is based on Medicare claims, ECs are not required to report on requirements; instead, CMS will calculate this category based on Medicare claims submitted. To remove the one-size-fits-all standard previously held by VBM, CMS will use over 40 episodic-specific measures when calculating an EC’s score under the Cost category to account for differences between specialties.
Clinical Practice Improvement Activities (CPIA)
Unlike the other three performance categories under MIPS, CPIA is new. It is proposed that CPIA would make up 15 percent of the total score in year one. Similar to the Quality measure, ECs will have the opportunity to select from a large list (more than 90 activities) that allow the EC to meet both the reporting requirements and their practices’ goals. Clinicians are expected to be rewarded for activities that focus on care coordination, patient safety and beneficiary engagement. Additionally, CMS proposes awarding full credit under CPIA to ECs who participate in patient-centered medical homes (PCMHs) and half credit to those participating in non-Advanced APMs.
Advancing Care Information (ACI)
ACI replaces Medicare meaningful use (MU) and accounts for 25 percent of the total score in year one. The NPRM suggests that ECs select from customizable measures that reflect their day-to-day activities, emphasizing interoperability and information exchange. The biggest difference between Medicare MU as it stands today and the ACI performance category is that there will no longer be an all-or-nothing approach and ECs can receive partial credit.
MIPS clinicians can report as an individual, group or through third-party data submission entities specifically, qualified registries, QCDRs, health IT vendors, and CMS-approved survey vendors who would have the ability to act as intermediaries on behalf of MIPS eligible clinicians and groups for submission of data to CMS across the quality, CPIA, and advancing care information performance categories.
- Gear Up Now to Get Higher Medicare Payments in 2019. According to CPA and MBA Ronald Sterling, MIPS Advancing Care Information (ACI) “consists of two separate components: a base score and a performance score. In 2017, physicians can earn credit toward the base score by performing five action items: protecting patient information; e-prescribing; providing patient access; sending a summary-of-care record; and accepting a summary-of-care record. Earning base credit requires only one instance of a measurable item, such as providing one patient access to their medical records. However, failure in any one of the base score measures results in an ACI score of zero because you cannot receive any performance credit if you haven’t met all base measures. To earn credit toward the performance score, you must maximize your support of several other measures, including providing electronic patient education and sending a secure message to a patient. For example, you only need to provide a single patient with electronic access to meet the base requirement, but the performance score is calculated from your total patient counts for each relevant measure. If 30% of your patients can access electronic information and you send half of them a secure message, then you get 6 points out of 20 for patient access and 1.5 points out of 10 for secure messages. The combined base and performance score is structured so that you can achieve a less-than-perfect performance and still earn the full 25% ACI portion of the MIPS score. You have the opportunity to earn more than 130 points, but 100 points earns you the maximum 25% ACI portion of MIPS.” (Medscape Business of Medicine, 12.29.16)
Physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists will receive payment adjustments in 2019 for their 2017 performance; other health professionals are expected to become eligible in 2021. ECs are scored on a 100-point scale, with each performance category accounting for a specific percentage of points. CMS will calculate the total performance score for each EC, then compare it with all other MIPS ECs to determine the respective Medicare Part B payment adjustments.
ECs participating in the MIPS will be eligible for positive or negative Medicare payment adjustments that start at 4 percent and gradually increase to 9 percent for 2022. The threshold for these payment adjustments will be the mean composite score for all MIPS-eligible professionals during the previous performance period. Distribution of payment adjustments will follow a bell-shaped curve, (i.e., will be budget-neutral).
- ECs who score at the threshold (i.e., earn the mean composite score) will receive no payment adjustment.
- ECs whose composite score is above the mean will receive a positive payment adjustment on each claim for the following year.
- ECs whose composite score is below the mean will receive a negative payment adjustment on each claim for the following year.
- ECs with high composite scores will be eligible for a positive payment adjustment that is up to three times the baseline positive payment adjustment for a given year. For example, the baseline positive payment adjustment for 2019 will be 4 percent, so high performers will be eligible for a positive payment adjustment of up to 12 percent. For 2019 through 2024, an additional positive payment adjustment of up to 10 percent will be available to exceptional performers.
- Beginning in 2026, all ECs participating in the MIPS will be eligible for a 0.25 percent increase in their payments each year.
- According to law firm Proskauer (5.12.16), “MIPS would distribute payment adjustments to between 687,000 to 746,000 eligible clinicians in 2019 based on MIPS eligible clinicians’ performance in the four performance categories. CMS hopes to achieve budget neutrality with equally distributed negative payment adjustments ($833 million) and positive payment adjustments ($833 million), with approximately $500 million distributed in exceptional performance payments.”
Analysis of MACRA Legislation
- Party on Medicare SGR’s Grave May End in Hangover. “Physicians have been the most significant holdout in the industry’s movement away from the fee-for-service payment system, said Blair Childs, senior vice president of public affairs at Premier, an alliance of hospitals and other providers working on alternative payment models. ‘This makes it starkly clear. There’s no question that everyone’s being pushed to alternative payment models,’ Childs said. ‘Physicians are going to start to engage in a way they haven’t before.’…’The idea that this is a permanent fix is false,’ said James Capretta, a visiting scholar at the American Enterprise Institute who previously served as a top GOP healthcare staffer in both the House and Senate. ‘I just think that’s total folly.’ But Paul Van de Water, a senior fellow at the left-leaning Center on Budget and Policy Priorities, points out that nothing is permanent in healthcare because the dynamics are constantly shifting.” (Modern Healthcare, 4.15.15)
- The Fix to the Doc Fix is No Fix At All. “The heart of [MACRA] is a new, two-tiered indexing system for physician fees. Physicians who agree to participate in Medicare Accountable Care Organizations (ACOs) — or in similar structures established by the Medicare bureaucracy — will receive a permanent 0.75 percent increase in their fees each year. Physicians that don’t join an ACO will be placed into a new Merit-Based Incentive Payment System, or MIPS. Under MIPS, the Medicare bureaucracy will assess the ‘quality’ of a physician’s services to patients and reward or penalize them accordingly…By 2019, the actuaries assume that 60 percent of all physicians taking care of Medicare beneficiaries will be part of an ACO, up from 25 percent today. By 2038, they assume that 100 percent of physicians participating in Medicare will be a part of an ACO or a similar structure invented by the Medicare bureaucracy.” Capretta, James. (American Enterprise Institute, 4.15.15)
- Physician Analysis of MACRA. “This is an analysis of HR2, the Medicare Access and CHIP Reauthorization Act of 2015, referred to as the ‘doc fix’ bill. The bill does end SGR permanently and provide 0.5% payment increased for a few years. However it vastly expands the pay for performance control structure over Medicare patients and their doctors. This expansion is done in ways that violate large amounts of FMA and AMA policy. There is far more harm contained in this bill than benefit. Some may describe this bill as a ‘reality’ we must accept. They may say that we must be ‘pragmatic’ and that we can minimize the impact on doctors later in rule making. However, the FMA has never merely accepted bad legislation and bad health care policy as a ‘reality’ we must ‘pragmatically’ accept and hope to address through damage control later on.” McKalip, David, MD. (Florida Medical Association, May, 2015)
- The Repeal of Medicare’s Sustainable Growth Rate for Physician Payment. “The momentum in Washington for continued payment reforms, however, is strong. The repeal of the SGR is the carrot; the far-reaching payment reforms that the legislation facilitates are the stick… In 2025, the $500 million in annual updates for exceptional performance and the 5% annual bonus are scheduled to expire, ‘resulting in a payment reduction for most physicians,’ as the CMS Office of the Actuary has noted.3 The momentum for payment reform and the specific payment mechanisms notwithstanding, physicians are likely to advocate for Medicare payment updates that at least keep up with inflation and the cost of living. At some point, the cumulative effect of the new payment updates will not keep up with physician costs, unless the volume and cost of services substantially decrease, which is the same underlying issue as with the old payment updates. The SGR formula lasted 18 years. Within the decade, its replacement is likely to be under scrutiny as well.” Steinbrook, R. (JAMA Network, 5.26.15)
- Physician Payment Reform In A Post-SGR World: Challenges Remain. “Value-based health care should be the goal of any health reform initiative. However, even with SGR out of the way, there are major challenges to achieving that goal, including the lack of an agreed-upon, patient-centered definition of value; a shortage of meaningful performance metrics; and a deficiency of accounting systems capable of reflecting the true cost of delivering care… According to a 2014 RAND report that looked at 49 studies examining the effect of P4P on process and intermediate outcome measures, the overall results of the studies were mixed, and any identified effects were relatively small. In short, ‘The evidence from the past decade is that pay for performance had modest effects on closing the quality gap,’ according to Cheryl Damberg, the study’s lead author… Linking more and more physician income to meaningless quality measures or mandating participation in undeveloped APMs will do little more than add to the already considerable non-clinical burden that physicians face and may force many physicians to abandon private practice in favor of employment, thereby accelerating the current trend toward consolidation. Worse yet, physicians may choose to leave practice altogether. Greater effort should be made to develop small, easily reportable, meaningful, specialty-specific core sets of patient-centered outcome measures. In addition, clearer principles and a realistic blueprint are needed before rushing ahead on physician payment reform.” O’Shea, John. (Health Affairs, 9.3.15)
- Meaningful Use is Not Dead: It’s Reincarnated. “MIPS will entail parts of both the PQRS and MU programs. And doctors no longer have any choice in it. If we want to be paid for our services, we must comply. It is now federal law. Doctors and other providers will be paid based on their data and outcomes, not the services they provide to their patients… Who will get paid more under MIPS? The doctor who spent more time and effort with the pt or the doctor with healthier patients? It seems counter-intuitive but time and effort will not be appreciated under this system. We will be penalized for our patients’ bad choices and disincentivized to make the effort to get them to change. In fact, patients who are more complicated and have more chronic diseases are going to be greatly harmed under this system. They need more time and care but doctors cannot afford to do it for free. The more ill patients will find it hard to access the medical system.” (Med City News, 1.18.16)
- If You Can’t Measure Performance, Can You Improve It? “MIPS is an outgrowth of a decade of smaller pay-for-reporting and pay-for-performance programs. Realizing that physicians basically ignored the small rewards and penalties limited to 2% of Medicare physician payments, Congress raised the financial stakes enormously, making sure physicians pay attention… Within a few years, MIPS will publish a performance scorecard for each physician participating in Medicare. But performance on a few, random and often unreliable measures of performance can provide a highly misleading snapshot of any physician’s value (http://bit.ly/1cU6jtK)… Having government rate physicians would be a step too far even if we had important and valid measures of physician performance. Practical challenges aside, pay for performance for health professionals may simply be a bad idea. Behavioral economists find that tangible rewards can undermine motivation for tasks that are intrinsically interesting or rewarding. Furthermore, such rewards have their strongest negative impact when they are perceived as being large, controlling, contingent on very specific task performance (http://bit.ly/1OB5Lx9), or associated with surveillance, deadlines, or threats, as with MIPS (http://bit.ly/1qhAzql).” (JAMA, 2.16.16)
- MACRA: A New Law, but with what Consequences? “MACRA creates a way to monitor and pay for exceptional care, encourage quality and cost effective care, and weed out poor and inefficient care. MACRA also decreases budgetary costs for the federal government. However, MACRA may bring with it some unintended consequences as well. Doctors and hospitals may limit or alter care as a result of the new regulations, believing that less is now more. Complex cases and unreliable patients may be avoided as they will increase the cost of care and decrease profit. Providers may manipulate data in order to meet the requirements, limit penalties, and maximize profits. EHR data may be hacked and personal health information may not be protected. Because the government wants to remain budget neutral, it could lead to draconian reimbursement cuts similar to SGF, causing doctors to eventually drop out of Medicare completely. The final effect of this new legislation, whether intended or unintended, may be a forceful shift into a single system that is run by the federal government. Socialized healthcare in America, whether good or bad, is a separate debate.” Ferenz, V. (Seton Hall, 2016)
MACRA Proposed Rule (NPRM) (April 27, 2016)
The Future Of Medicare Physician Reimbursement: 10 Major Takeaways From The MACRA Proposed Rule. “On April 27, 2016, just over a year after the Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law, the Department of Health and Human Services (HHS) unveiled the long-awaited proposed rule to begin its implementation. The 962-page notice offers important insight for health care providers into how the Center for Medicare and Medicaid Services (CMS) will link physician payments to quality care through MACRA.” (Mondaq, 5.16.16)
Analysis of Proposed Rule
- Many Existing APMs Excluded Under Proposed Physician Pay Rules. “The limited number of existing models qualifying as APMs drew concerns from several provider organizations, including Premier. ‘As we have learned through members in our Population Health Management Collaborative, these programs require providers to not only forgo revenue through a lower volume of services, but also invest millions of dollars in redesigning care through new technologies, data analytics, additional staff, etc.,’ Blair Childs, a premier spokesman, said in a written statement. ‘We think most businessmen would call that more than nominal risk, yet CMS choses to define it as only cases where there is risk to the government.’ Not including Track 1 ACOs and bundled payment programs could lead physicians to leave APMs and return to fee-for-service payment, Childs warned.” (HFMA, 4.28.16)
- A Deep Dive on the ‘Overwhelmingly Complex’ MACRA Proposed Rule. “The 962 pages of MACRA are so overwhelmingly complex, that no mere human will be able to understand them. Above, I have only covered the HIT related concepts, which are a small subset of all the changes to payment processes. This may sound cynical, but there are probably only two rational choices for clinicians going forward – become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness. The folks at CMS are very smart and well meaning, but it’s hard for me to imagine implementing the NPRM as written in the timeframes suggested… Maybe the upcoming presidential transition (whoever is elected) will give us time to pause and reflect on what we’ve done to ourselves. As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.” Halamka, John. (Healthcare IT News, 5.6.16)
- Death by Regulation. “Organized medicine, having fought for the ‘reform’ that resulted in MACRA and its 962 pages of regulations, is applauding the rule’s likely positive impact on quality of care, outcomes, and efficiency, while acknowledging that small practices are likely ‘losers.’ The American College of Physicians (ACP) is urging internists to ‘be prepared’ and learn about the overwhelmingly complex rule in ‘bite-size pieces.’ Small practices are ‘not always set up to do the necessary large data analyses,’ said ACP vice president Shari Erickson. ‘One of the key things is to start to understand it. It is complex and will become more complex as we move toward implementation, but if you can start to do the items on the top 10 list that we’ve come up with—maybe not all at once, just identify a couple to start now—you can make progress.’” (American Association of Physicians and Surgeons, 5.12.16)
- Macra: The Quiet Health-Care Takeover. “This new set of rules uses the power of Medicare to put the federal government in charge of almost every aspect of physician care in the U.S. Macra adopts the same theory of cost control embedded in ObamaCare. It assumes that the federal government has the knowledge and wherewithal to engineer better health care through ‘delivery system reforms,’ forgetting the utter failure of the bureaucracy’s previous effort. ObamaCare and now Macra use Medicare’s payment regulations to force hospitals and physicians to change how they care for their patients. The administration’s regulations will force doctors to comply with scores of new reporting requirements and intrusions into their practices. Physicians who refuse to bend will see their Medicare fees cut… The not-so-hidden agenda of the Obama administration is to use Macra and related regulations to force physicians into joining accountable-care organizations. ObamaCare nudged hospitals and physician groups to form these organizations to manage patient care. But they are an unproven concept.” Capretta, J., Chen, L. (Wall Street Journal, 5.31.16)
- MACRA Proposed Rule Creates More Problems Than It Solves. Describes several shortcomings of the MACRA program. Subtitles include: An Open Invitation To Game The System; Rewarding Reporting Capabilities Instead Of Medical Excellence; An Unreliable Quality Score; Inadequate Feedback Loops; Undermining Patient Privacy. “While HHS had the best intentions in creating MIPS, the proposed rules are so abundant with flaws and weaknesses that it is very difficult to imagine the program could ever be successfully implemented.” Yaragh, Niam. (Health Affairs, 10.12.16)
- Relax, It’s Only MACRA. “So the real question is, is MACRA better than what doctors currently have to put up with PQRS, Meaningful Use, and Value-Modifier programs? Yes, by combining reporting of quality data into one program instead of the three separate ones, MACRA can substantially ease the burden of reporting. Yes, because MACRA’s maximum potential penalties for failing to successfully report quality and cost data for the next four years are less than under the current reporting programs. Yes, because MACRA allows physicians to earn positive payment adjustments while the current PQRS and Meaningful Use programs only allow physicians to avoid penalties (no positive adjustments allowed). Yes, because under the current PQRS and Meaningful Use programs, Medicare keeps the money from negative adjustments to some physicians while MACRA keeps it in the physician payment pool. Yes, because MACRA allows the thousands of physicians in certified Patient-Centered Medical Homes (or who decide to get certified) to get favorable scoring, helping them qualify for positive payment adjustments. Yes, because under MACRA, physicians in Advanced Alternative Payment Models can to earn 5% Medicare FFS bonus payments each year from 2019-24 (and more favorable updates afterwards), plus whatever payment incentives and additional revenue opportunities apply to their advanced APM.” Doherty, Bob. (American College of Physicians Blog, 5.19.16)
- MACRA: The ACP’s Take. “The plus sides: an end to the long-derided sustainable growth rate (SGR) formula and introduction of a successor to the equally maligned meaningful use (MU) incentive program. The down sides: The proposed rule, released in April 2016 and scheduled to take effect in January 2017, is almost 1000 pages long, is difficult to digest, and includes several yet-to-be-defined provisions. The American College of Physicians (ACP), while acknowledging the complexity of these sweeping changes, lauds the new legislation as an important step forward. Medscape spoke with Shari Erickson, MPH, vice president of governmental affairs and medical practice at ACP, about the legislation and ACP’s efforts to support physicians in this transition.” (Medscape Internal Medicine, 6.15.16)
Impact on Small Practices
Center for Medicare and Medicaid Services
- New Medicare Penalty Hits Small Groups, Solo Physicians Hardest. “Medicare’s new compensation formula will bestow performance bonuses as high as 4% on an estimated 412,000 physicians and other clinicians in 2019 and impose corresponding penalties on another 346,000, mostly in practices of from one to 24 members, according to proposed regulations released yesterday by the Centers for Medicare & Medicaid Services (CMS). One physician organization is expressing dismay about a payment system that seems to work against smaller practices. ‘It’s extremely concerning,’ said Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA), in an interview with Medscape Medical News. ‘Any program like this should give physicians the opportunity to succeed regardless of practice size. Why wouldn’t you structure it so it will lift all boats?’… ‘It’s inconsistent with the congressional intent, and inconsistent with what CMS has been saying, that they would make [MIPS] so much more difficult for physicians in anything but a megapractice,’ said Gilberg.” (Medscape Medical News, 4.28.16)
- CMS: Dire MACRA Estimate for Small Practices Not ‘Reality.’ “The Centers for Medicare and Medicaid Services (CMS) is backing off from an estimate in table form showing that most clinicians in groups of 24 or less will incur a penalty come 2019 in one track of Medicare’s new payment system. ‘I don’t think that table represents the reality,’ Acting CMS Administrator Andy Slavitt told apprehensive members of Congress in a hearing last week. Instead, small practices can prosper just as much as large ones in the new system as long as they report performance data to CMS, said Slavitt. And the agency will lend a hand to help them succeed. The orphaned estimate appeared in last month’s proposed regulations for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which replaces the sustainable growth rate formula for physician compensation.” (Medscape Medical News, 5.17.16)
- Slavitt Details MACRA Commentators’ 5 Priority Areas. “Slavitt aimed to demonstrate at last week’s meeting how providers’ feedback is being used to ensure MACRA will not just make things better in terms of costs and patient care, but in solving some of physicians’ problems that are currently leading to burnout… He detailed how providers’ feedback falls into five priority areas for the CMS:
- Impact on patients, including keeping the focus on patient care;
- Simplified reporting and feedback, including putting the burden on technology rather than the user to adapt to workflow;
- Impact on small and rural practices, including providing a level playing field by ensuring MACRA is not too ‘administratively burdensome’ and deploying technical assistance;
- Pathway for Advanced Alternative Payment Models, which notes that a one-size-fits-all program won’t work, necessitating multiple pathways to models that qualify for Advanced APMs that pay a 5% bonus for participation; and
- Physician readiness for new program, which ensures physicians are prepared for the coming changes and are ‘set up for success.’
The final rule is set to be released by November 1. See the CMS Blog: Remarks by Andy Slavitt before the American Osteopathic Association.” (Healthcare Dive, 7.25.16)
Delay on Penalties
Feds Announce First-Year Break on MACRA Penalties. “Responding to strong concerns from the Texas Medical Association and other physician organizations, a top federal official announced Thursday that physicians who at least try to comply with new Medicare payment rules next year will see no penalty in their 2019 payments. Under the Medicare Access and CHIP Reauthorization Act (MACRA) physicians’ 2017 performance on various quality, cost, technology use, and practice improvement measures will determine cuts or bonuses in their 2019 Medicare payments. ‘During 2017, eligible physicians and other clinicians will have multiple options for participation,’ Andy Slavitt, the acting director of the Centers for Medicare & Medicaid Services (CMS), said in an agency blog post. ‘Choosing one of these options would ensure you do not receive a negative payment adjustment in 2019.’ In response to TMA’s request for clarification, CMS spokesperson Aisling McDonough tweeted, ‘As long as you submit something for 2017, then no penalty. If you submit nothing, then you do get a penalty.’ Mr. Slavitt said details for MACRA’s first year will come when the agency releases its final MACRA rules by Nov. 1. TMA analysts cautioned that Mr. Slavitt’s comments and exactly how they will be implemented are unofficial until the final rules come out.” (Texas Medical Association, September, 2016)
- MACRA Regulations Out, Ensuring the Demise of Private Practice. “On April 27, 2016, CMS released the components of this new bill. While it does set out to balance the budget, it does so at the expense of physician reimbursements. There are bonuses for some and negative adjustments for others. But, those hit hardest will be solo doctors and those in small practices. Over the past decade or so, our reimbursements did not increase despite soaring overhead costs. Yet, data released by CMS suggests that solo doctors will face negative adjustments to the tune of $300 million. We simply cannot afford that… CMS apparently is extolling assembly line medicine and patients will be the biggest losers here.” (MedCity News, 4.28.16)
- FAQ: Medicare Lays Out Plans For Changing Doctors’ Pay. “Robert Berenson, a fellow at the Urban Institute, said a key question for the law is ‘have they set it up so small practices can actually stay in business and report so they don’t have to throw in the towel and get hired by somebody because the reporting burden is too great?’… Payment increases under either system may not be generous enough to keep up with other costs, such as increases in practice expenses.” (Kaiser Health News, 4.29.16)
- Confession of an Ex-regulator: Farzad Mostashari on How Government Should Work. “Now that he’s running his own company — on the other side of those federal regulations — Mostashari sees numerous problems with how government rulemaking works, he told POLITICO this week… As the CEO of a company working with physicians to set up accountable care organizations, Mostashari has his own lobbying priorities. In the past week, he’s argued that Medicare’s new physician payment rule would be ‘financial suicide’ for small practices. ‘I regret [saying that], a little bit,’ Mostashari said. ‘I don’t believe that there is a campaign out there to kill the small practice of medicine. But without real attention to the unintended consequences of the policies we’re doing, that’s exactly where we’re going to end up,’ he added. ‘And it’s not a good place.’” (Politico, 5.6.16)
- The Future of Medicare Physician Reimbursement. “The cost burden of compliance, in the context of overall Medicare payment increases over the next four years that will be substantially less than the rate of inflation, may make it increasingly difficult for smaller practices to survive, and may increase the number of doctors who opt out of Medicare in some high end urban markets.” (Proskauer, 5.12.16)
- According to Shari Erickson of the American College of Physicians (ACP) (6.15.16), a “key opportunity for smaller practices that will happen pretty much right away within the advanced APM pathway is the Comprehensive Primary Care Plus (CPC+) program, which is a new program building on the existing comprehensive primary care initiative that’s been under way within the Center for Medicare & Medicaid Innovation (CMMI) for several years. The CPC+ program is planned to start in the beginning of 2017, and it will be in 20 market areas across the country. It is expected to involve approximately 5000 practices and 20,000 clinicians. Those primary care practices, particularly those with 50 or fewer clinicians, will be part of the advanced APM pathway and will receive not only the care management fees that are included with the program, but also the 5% bonus on their fee-for-service payments. In addition, owing to feedback received from ACP and others, CMMI recently announced that primary care practices participating in the Medicare Shared Savings Program (Medicare’s accountable care organization program) can also participate in CPC+.”
- CMS Needs to Halt the March to Health Care Gigantism.“Too many sectors of the economy are being dominated by a few big players. In American health care, this is not only the case, but has been the default preferred stance. In health care, there is an almost Darwinian belief that the evolution to bigger is better. This is why last year saw 112 hospital mergers (up 18 percent from 2014), and the percentage of physician practices owned by hospitals doubled between 2004 and 2011. Yet, there is no evidence that consolidation of hospitals and physician practices leads to better clinical outcomes or cost reductions. In fact, recent studies suggest that small, physician-owned practices have a lower average cost per patient, fewer preventable hospital admissions, and lower readmission rates than hospital-owned practices. That is why it is so unfortunate that, as part of the largest rewriting of doctor payment rules in a generation, the Centers for Medicare and Medicaid Services (CMS) unwittingly has drafted regulations that—as currently proposed—further neglect the power of physician independence and create strong incentives for further consolidation in health care… There are a few changes they could easily make to improve the program.” Mostashari, Farzad, MD. (The Hill, 7.22.16)
- Physicians Wary of MACRA’s Potential to Hasten the Demise of Independent Practices. “According to a May 2016 survey of 1,300 physician groups of five or less clinicians by Black Book™, 67% of high Medicare-volume doctors foresee the end of their independence due to the so-called doc fix bill or MACRA, which repeals the Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaces it with a new value-based reimbursement system, will not have the technology, capital or staffing to sustain under the conditions of the Merit-based Incentive Payment System (MIPS). Despite small practice education, training and technical assistance programs promised from CMS to help onboard physicians with the MACRA programs, 89% of the remaining solo practices expect to minimize Medicare volumes as to not be required to submit reports for the quality and clinical practice improvement activities or report in the cost performance category. 77% of small practices identified themselves as financially struggling currently due to physician staffing losses to larger group practices and hospital IDNs directly. 72% also blame their under-performing billing technology and compounding payment issues for their troubles.” (Black Book Market Research, 6.13.16)
- Many Physicians Predict Mass Exodus From Medicare Over MACRA. “Almost four in 10 physicians in solo and small group practices predict an exodus from Medicare within their ranks on account of the program’s new payment plan and its punishing penalties, a Medscape Medical News survey reveals. Fifty-nine percent of physicians in practices with fewer than 25 clinicians also said they expect to receive a performance penalty as high as 4% under proposed regulations that implement the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Only 9% of physicians in under-25 groups expect a bonus, with another 12% counting on no change in compensation. Roughly one third of physicians in small practices said merger into larger groups promises to be the most likely fallout from MACRA. This pessimistic outlook was more than matched by reader comments on the survey, posted on May 5. ‘Death by bureaucratic strangulation, one emergency medicine physician wrote.” (Medscape Medical News, 6.30.16)
- Deloitte Survey Finds Low Physician Awareness and Many Needed Changes by Physicians for Medicare’s MACRA Program. “A transformative law is on track to fundamentally change how physicians and other clinicians are reimbursed under the Medicare Physician Fee Schedule (PFS), but half of recently surveyed physicians have never heard of it, according to the ‘Deloitte Center for Health Solutions 2016 Survey of U.S. Physicians.’… Additionally, more self-employed physicians and those surveyed in independently-owned medical practices (21 percent) – as compared to surveyed physicians employed by hospitals, health systems, or medical groups owned by them (9 percent) – report that they are somewhat familiar with the law. The survey also found that physicians with a high share of Medicare payments are just as unaware of MACRA as others… Many physicians surveyed (58 percent) said they would opt to be part of a larger organization to diminish individual physician risk and/or to have access to a full spectrum of resources and capabilities. Additionally, 80 percent of physicians surveyed expect MACRA to drive physicians to join larger organizations or networks.” (Deloitte, 7.13.16)
- More Doctors To Retire As MACRA And Value-Based Pay Hit. “The nation’s doctors, facing a tsunami of changes in how they are paid, plan to retire in droves as value-based pay replaces fee-for-service medicine and they are forced to implement more new regulations, according to a new report. The biennial survey from the Physicians Foundation shows 46% of physicians plan to ‘accelerate’ their retirements, cut back on patients or seek ‘non-clinical roles,’ according to the group’s survey, which is conducted by physician staffing and recruitment firm MerrittHawkins. More than 17,000 physicians are polled, Merritt said. Not all of these doctors will leave medicine right away, with 14.4 % of physicians saying they will retire in the next one to three years compared to 9.4% in 2014. Meanwhile, 21% say they will cut back on hours and another 13.5% say they will seek a ‘non-clinical’ job in healthcare. Doctors are being dogged by ‘poor morale’ and ‘invasive regulations,’ according to the survey… ‘Many physicians are dissatisfied with the current state of the medical practice environment and they are opting out of traditional patient care roles,’ said Dr. Walker Ray, president of the Physicians Foundation.” Japsen, Bruce. (Forbes, 9.21.16)
MACRA Final Rule (October 14, 2016)
On October 14, 2016, CMS released the final rule for implementation of MACRA, adding more flexibility than provided by the April 2016 proposed rule. Although many had hoped for a delay, the law is still imposed on January 1, 2017, the beginning of what CMS calls the “transition year.” The rule finalizes parameters of the Advanced Alternative Payment Models (APMs) and Merit-Based Incentive Payment System (MIPS) collectively referred to as the Quality Payment Program (QPP). It also provides for guidance and financial support for smaller practices, expands the definition of Alternative Payment Models (APMs), lowers performance standards to make it easier to earn financial incentives, and simplifies prior ‘all or nothing’ requirements for the use of electronic health record technology.
Billy Wynne writes at Health Affairs (10.17.16) that “highlights of the rule include, first, formalization of the ‘transition year’ during calendar year (CY) 2017 that significantly modifies the reporting requirements of the QPP for that year. Second, CMS took steps to weaken the thresholds by which providers may participate. Third, CMS reduced the amount of measures required for reporting under the Advancing Care Information and other MIPS categories. Finally, the Agency softened the degree of risk providers must accept in Advanced APMs, though it preserved the requirement that such entities face downside risk (i.e., the possibility of losing money due to poor performance). We’ll catch a few additional changes along the way.”
CMS lowered the cost performance category to 0 percent in the 2017 transition period and gave clinicians three reporting options under MIPS and one under Advanced Alternative Payment Models (APMs).
- Option one: Report to MIPS for a full 90-day period or full year on quality, clinical performance improvement activities (CPIA) and advancing care (EHR), and maximize the chance to qualify for positive payment adjustments.
- Option two: Report less than a year, but for the full 90-day period on one quality measure, more than one CPIA or more than the required measures in advancing care information to avoid penalties and receive a possible positive update.
- Option three: Report one quality measure, one CPIA or report measures of advancing care to avoid penalty.
- Option four: Join an Advanced APM.
- No participation will result in an automatic 4 percent negative payment adjustment.
- Submission of a minimum amount of data — i.e. one quality measure — yields a neutral payment adjustment.
- Submission of 90 days of data potentially yields a small positive payment adjustment or a neutral adjustment.
- Submission of a full year of data offers the potential to earn a moderate positive payment adjustment.
CMS will provide additional information in 2017 regarding payment adjustments for 2020 and beyond.
Impact on Small Practices
According to Oncology Live (10.16.16), the Final Rule “eases the pressure on small, rural practices to meet reporting and performance standards and explains more about the intentions behind the recently announced 2017 transition year, which is intended to make it easier for all practices to gradually move away from fee-for-service style billing… MACRA also allows for small practices to pool financial risk and join as ‘virtual groups’ in order to combine their MIPS reporting. CMS said virtual groups won’t be allowed in 2017 and that it wants to be sure that this system will be workable before implementation.”
- Support for Small Practices. “In the final rule, CMS assured small, independent practices that they are making it a goal to meet their unique needs. The final rule excludes small practices from reporting requirements in 2017 due to low-volume threshold, which has been set at less than or equal to $30,000 in Medicare Part B allowed charges or less than 100 Medicare patients. It provides $100 million in education and technical assistance to small and rural practices in 2017.” (American Gastroenterological Association, October, 2016)
- How Will Small Practices be Able to Participate? Reflecting feedback from providers, CMS made adjustments to the proposed rule to help small, independent practices participate. Those who fall below the requirements of at least $30,000 Medicare Part B charges or 100 Medicare patients are exempt from participating in 2017. CMS estimates this represents 32.5 percent of clinicians, but accounts for only 5 percent of Medicare spending. CMS is also offering an option for small practices and solo physicians to join together in virtual groups and submit combined MIPS data. The final rule also allots $20 million a year for five years for training and education of physicians in practices of 15 or fewer and those who work in underserved areas. (Becker’s Hospital Review, 10.14.16)
Advanced Alternative Payment Models (APMs)
The final rule establishes standards for Advanced APM financial risk to encourage additional participation, and establishes criteria for Other Payor Advanced APMs, which recognizes private payor initiatives and provides an opportunity to qualify under APMs. CMS estimates this will allow more clinicians to participate in APMs
The final rule identifies the following as advanced APMs for 2017:
- Comprehensive ESRD Care Model (LDO and non-LDO two-sided risk arrangements)
- Comprehensive Primary Care Plus Model
- Medicare Shared Savings Program, Tracks 2 and 3
- Next Generation ACO Model
On October 25,2016, CMS included the Oncology Care Model with two-sided risk as an Advanced APM beginning in the 2017 performance year.
On December 20, 2016, CMS announced it was adding the Comprehensive Care for Joint Replacement (CJR) Model as an Advanced APM; the ACO Track 1+ model will be a new Advanced APM in 2018.
Impact of the 2016 President Election
With the election of President Donald Trump, and orthopedic surgeon and former Georgia representative Tom Price at the helm of the Department of Health and Human Services, changes to MACRA regulations are considered a possibility.
- Republicans Face Headaches Replacing ACA. “Predictions are split as to the new administration’s impact on the ACA’s pay-for-performance (P4P) programs. ‘Value-based’ projects developed by the Center for Medicare and Medicaid Innovation (CMMI) are here to stay, according to Modern Healthcare. Joseph Antos of the conservative American Enterprise Institute says the new administration may lessen regulatory burdens on providers and revisit the Medicare Access and CHIP Reauthorization Act and its emphasis on accountable care organizations (ACOs). ‘ACOs are a top-down approach that has shown limited success in producing shared savings,’ he argues. ‘The real success stories in making health care more efficient come from individual organizations, like Geisinger and Mayo, which did it voluntarily. They didn’t have Washington telling them what to do.’ Managed Care Magazine maintains that private entities will continue their P4P experiments, and that Congress, previously skeptical of CMMI, could find Medicare P4P ‘more appealing under their own supervision.’ Trump’s pick for HHS secretary, Georgia Rep. Tom Price, MD, for example, supports quality measurement, but believes outcome targets should be approved by medical specialty organizations.” (The National Psychologist, 1.23.17)
- MGMA Advises New HHS Secretary on MACRA Implementation. “In a letter to HHS Secretary Tom Price, MD, MGMA made suggestions regarding topics including administrative simplification, the Merit-based Incentive Payment System (MIPS), alternative payment models (APMs), EHR certification, and the Stark Physician Self-Referral Law. In terms of simplifying the administrative process, MGMA suggests the HHS cut costs by improving HIPAA and engaging with leaders of medical groups in the healthcare industry to identify appropriate administrative standards to reduce costs in other ways.
- To ease the transition to MIPS, MGMA suggests reducing the cost and reporting burden of the program through a 90-day reporting period, among other suggestions. A 90-day reporting period has been a frequent recommendation since the program’s inception.
- Advance APMs, the other pathway for eligible clinicians to benefit from MACRA incentives, should be pushed as a way to save health organizations expenditure, according to MGMA, which also suggests HHS push the Physician-Focused Payment Models Technical Advisory Committee (PTAC) to accelerate the development of qualifying payment models for providers.
- Additionally, HHS should work directly with the physician community when developing new models of care delivery and episode payments to speed the APM approval process.
- MGMA suggests the Office of the National Coordinator for Health Information Technology (ONC) delay requirements to move to the 2015 CEHRT requirements and provide greater flexibility in certification standards and simplify the Federal Physician Self-Referral Law.” (EHR Intelligence, 2.14.17)
- An Everything Guide to MACRA and Beyond. AthenaHealth.
- AMA Introduces New Tools to Help Physicians Prepare for 2017 Medicare Changes (MACRA)
- AAFP: Frequently Asked Questions: Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
- CMS Releases MACRA Final Rule: 10 Things to Know. Becker’s Hospital Review (10.14.16).
Guidance for Behavioral Health Organizations
- National Council for Behavioral Health (October 2016)