The latest in a series of steps taken by the Centers for Medicare and Medicaid Services (CMS) to incentivize care quality over volume; MACRA was signed into law in 2015 and replaces the previous Medicare reimbursement schedule to a new pay-for-performance program that’s focused on quality and accountability. Starting January 1, 2017, all Medicare Part B providers will enter a new payment framework called the Quality Payment Program, replacing the Sustainable Growth Rate formula.
The Program has two paths for participation:
- The Merit-based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models (APMs)
Merit-based Incentive Payment System (MIPS)
MIPS streamlines current Medicare value and quality program measures — the Physician Quality Reporting System (PQRS), Value Modifier (VM) Program and Meaningful Use Electronic Health Record (EHR) Incentive Program — into one MIPS score. Post calculating the MIPS score, eligible professionals (EPs) may receive a payment bonus, a payment penalty or no payment adjustment. Unlike previous payment programs, scoring is no longer all-or-nothing but rather proportional to performance.
MIPS score will be based on four performance categories as follows:
Quality: Replaces the VM quality component and PQRS. Clinicians choose six measures to report to CMS that best reflect their practice. These are measures related to patient outcomes, appropriate use of medical resources, patient safety, efficiency, patient experience and care coordination. Clinicians also can choose to report a specialty measure set. 80 to 90 points will be required to get a full score per performance category, depending on the group size. This category score is valued at 50% of MIPS total score.
Cost: Also known as Resource Use. Replaces the VM cost component. These are specialty-based measures focused on efficient resource use. Cost measures would be solely based on Medicare claims, with no additional reporting requirements and will be calculated on the claims and availability of sufficient volume. Average score of all resource measures that can be attributed, will be required to get a full score per performance category, depending on the group size. This category score is valued at 10% of MIPS total score.
Clinical Practice Improvement Activities: These measures would focus on care coordination, beneficiary engagement and patient safety. Clinicians can choose the activities best suited for their practice; the rule proposes over 90 activities from which to choose. Clinicians participating in medical homes earn full credit in this category, and those participating in Advanced APMs will earn at least half credit. 60 points will be required to get a full score per performance category. This category score is valued at 15% of MIPS total score.
Advancing Care Information: Replacing Meaningful Use, these are measures that reflect on how well clinicians use EHR technology, especially when it comes to interoperability and information exchange. Clinicians will be rewarded for their performance on measures that matter most to them. 100 points will be required to get a full score per performance category. This category score is valued at 25% of MIPS total score.
Advanced Alternative Payment Models (APMs)
This path is for providers who go the furthest in delivering high-quality, coordinated, and efficient care. CMS will provide a list of care models each year that qualify for APM incentive payments. Clinicians who meet the criteria for APM incentive payments do not receive a payment adjustment under the Merit-based Incentive Payment System (MIPS) and instead receive a 5% Medicare Part B incentive payment. All Medicare Part B clinicians should expect to report through MIPS in the first year with a few exceptions. While some will qualify for APM bonus payments, CMS will inform clinicians if they qualified only after the first performance year.
Only providers that participate in qualifying APMs are eligible for APM bonus payments. Providers who are participating in another Medicare Alternative Payment Model — such as an Accountable Care Organization (ACO), Patient Centered Medical Homes or bundled payment model — are not necessarily eligible for APM incentive payments unless their program qualifies as an Advanced Alternative Payment Model under CMS rules. However, participation in a non-qualifying Alternative Payment Model may score points on the MIPS score.
According to the standards set forth by CMS, a qualifying APM must:
- Bear a certain amount of financial risk. CMS proposes clinicians would need to reduce their rates, withhold payments, or pay CMS when actual expenditures exceed expected expenditures.
- Base payments on quality measures comparable to those used in the MIPS quality performance category. CMS proposes providers base payments on evidence-based, reliable and valid quality measures. One measure must be a MIPS outcome measure if applicable to the provider’s practice.
- Use certified electronic health record (EHR) technology. In the first performance year, CMS proposes 50% of clinicians use certified EHR technology to document and communicate care information.
CMS will update their list of qualifying APMs each year. Under the proposed rule, CMS would update this list annually to add new payment models that qualify to be an Advanced APM. Starting in performance year 2019, clinicians using APMs developed by non-Medicare payers, such as private insurers or state Medicaid programs, could start to qualify for APM bonus payments.
MIPS vs. APM
| MIPS | APM | |
| Purpose | Current Medicare value and quality program measures — the Physician Quality Reporting System (PQRS), Value Modifier (VM) Program and Meaningful Use Electronic Health Record (EHR) Incentive Program — are streamlined into one MIPS score. | Qualifying APMs go further than MIPS to deliver high quality, efficient care, requiring clinicians to take on more risk. Only a subset of alternative payment models qualifies for APM bonus payments. |
| Participation | All providers should plan on receiving a payment adjustment through MIPS for the first performance year. Clinicians who do not meet APM criteria will be given a MIPS score instead. | All providers should plan on receiving a payment adjustment through MIPS for the first performance year. CMS will inform clinicians at end of first performance year if they qualified for an APM bonus payment. |
| Eligibility | Eligible professionals for 2019 and 2020 include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. However, in an individual program year, new Medicare eligible professionals in their first year of enrollment will be excluded. Participant must meet a volume threshold of a minimum number of one or more of the following: Medicare beneficiaries, items/services, and/or allowable charges; OR have submitted Medicare Part B reimbursement for more than one year. | Any one of the following: A Medicare Shared Savings Program Accountable Care Organization; a model expanded under the Center for Medicare & Medicaid Innovation (CMMI) that is not a Health Care Innovation Award recipient; Medicare Health Care Quality Demonstration Program or Medicare Acute Care Episode Demonstration Program; or a demonstration program required by federal law. Where the practice: Uses quality measures comparable to measures under MIPS; uses a certified electronic health record; assumes more than a “nominal financial risk” or is a medical home expanded under the CMMI. To qualify, a participant must meet a volume threshold of Medicare payments or beneficiaries paid through the alternative payment model. |
| Payments | For the first year in MIPS, the maximum negative adjustment can be no more than 4%, with the maximum negative adjustment increasing over time as follows: 2019 4% 2020 5% 2021 7% 2022 onwards 9% Positive adjustments follow the same schedule, with the potential to receive a 3x bonus adjustment for top performers. By 2022, clinicians’ MIPS scores can impact their Medicare reimbursement from -9% to +27%. |
5% Medicare Part B incentive bonus payment. Those who attempt to qualify for an APM payment but don’t meet all requirements will receive a payment adjustment under MIPS instead. |
References
- MACRA. (2016). Retrieved October 24, 2016, from www.cms.gov: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
- Medicare Alternative Payment Models (APMs). (2016). Retrieved October 24, 2016, from www.ama-assn.org: http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-alternative-payment-models.page
- MIPS vs. APMs. (2016). Retrieved October 24, 2016, from www.practicefusion.com: https://www.practicefusion.com/blog/what-is-macra-and-mips/
- Understanding the Merit-Based Incentive Payment System (MIPS). (2016). Retrieved October 24, 2016, from www.ama-assn.org: http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-merit-based-incentive-program.page
