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MACRA – MIPS, APMs

Starting in 2017, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaces the Medicare Sustainable Growth Rate (SGR), the program with which CMS previously controlled the cost of Medicare Payments to physicians. MACRA is aimed at strengthening Medicare Access and improving physician payments among other enhancements. Outlined below is a high-level description of some of the key features of the MACRA as proposed in the 2017 CMS Physician Fee Schedule Proposed Rule. Within MACRA, the Quality Payment Program (QPP) streamlines several pay-for-performance programs in the new Merit-based Incentive Payments System (MIPS) and provides incentive payments for participation in Advanced Alternative Payment Models (APMs) like the Medicare Shared Savings Program ACO.

ReportingMD is a qualified registry, Qualified Clinical Data Registry (QCDR), and EHR vendor and is uniquely positioned to report on all aspects of MACRA.

Watch a recording of the 6/20/16 ReportingMD webinar on MACRA and the MIPS program by clicking here: 2016 Quality Payment Program: Merit-based Incentive Payment System (MIPS)

Advanced Alternative Payment Model (Advanced APM)

Qualifying Participants (QPs) in Advanced APMs like the Medicare Shared Savings Program (MSSP) ACO will not be considered MIPS eligible clinicians and therefore will not be subject to any MIPS payment adjustment. QPs will be rewarded with a 5% lump sum bonus for their participation in an Advanced APM.

Merit-based Incentive Payment System (MIPS) 

MIPS is the newly structured program that pulls activities and requirements from 3 known pay-for-performance programs and reassembles them into 1 cohesive program made up of 4 categories, which are: Quality (PQRS), Resource Use (VM), Advancing Care Information (MU), and the new Clinical Practice Improvement Activities (CPIA). Below is the payment adjustments schedule for MIPS as well as a summary of each MIPS performance category.

MIPS Performance Categories

Quality (formerly Physician Quality Reporting System, PQRS)

  • Quality makes up 50% of the MIPS Composite Performance Score (CPS)
  • Submission mechanisms include: qualified registry, QCDR, EHR, Part B Claims, CMS Web-interface, CAHPS for MIPS survey
  • There are 2 Global and Population-based measures plus an All-cause Hospital Readmissions measure, which will be automatically calculated using administrative claims and requiring no submission by the clinician
  • Each MIPS eligible clinician or group will select 6 measures to report on:
    • 1 of the 6 measures must be a cross-cutting measure if the clinician has at least 1 face-to-face encounter with a Medicare Part B patient
    • 1 of the 6 measures must be an outcome measure
      • If no outcome measure is available for a provider or practice, they must pick a high priority measure (from appropriate use, patient safety, efficiency, patient experience or care coordination) in lieu of an outcome measure
  • MIPS eligible clinicians or groups can choose to report on individual measures or they can report on a measures set
    • If they choose to report on a measures set, they must still meet the requirements to report on a cross-cutting measure (if patient-facing) and an outcome measure (or other high priority measure)
  • MIPS eligible clinicians can choose to report individually or as a group. Reporting as a group is similar to reporting under the Group Practice Reporting Option (GPRO)

Resource Use (formerly Value-based Payment Modifier, VM)

  • Resource Use makes up 10% of the MIPS Composite Performance Score (CPS)
  • The measures used for the Resource Use category will be calculated based on administrative claims so there will be no reporting requirements by eligible clinicians or groups.
  • The following measures will be used to assess performance on the Resource Use category:
    • Total per capital cost for all attributed beneficiaries
    • Medicare Spending Per Beneficiary (MSPB) measure
    • Several episode-based measures

Clinical Practice Improvement Activities

  • Clinical Practice Improvement Activities (CPIA) makes up 15% of the MIPS Composite Performance Score (CPS)
  • Submission mechanisms include: qualified registry, QCDR, EHR, and Part B Claims
  • MIPS eligible clinicians or groups choose from an inventory of over 90 proposed activities, each of which is categorized as high or medium
    • MIPS eligible clinicians must choose either 3 high (high activities = 20 points each) or 6 medium (medium activities = 10 points each) or a combination of high or medium that results in a score of 60 points in order to achieve the highest potential score for the category
      • Fewer activities would result in partial credit for the category
    • MIPS eligible clinicians in small groups (≤ 15 clinicians), in rural areas or geographic Health Professional shortage Areas (HPSAs), or non-patient-facing would only need to perform 2 CPIAs (either high or medium categorization) in order to receive full credit
  • Full category credit for those MIPS eligible clinicians in a certified patient-centered medical home
  • A minimum of half credit for those MIPS eligible clinicians who participate in any Alternate Payment Model (APM)
  • MIPS eligible clinicians or groups must perform an activity for at least 90 days during the performance period
  • For the 1st year of MIPS (2017), MIPS eligible clinicians or groups will designate a yes/no response for activities performed for the CPIA category

Advancing Care Information (formerly Meaningful Use, MU) 

  • Advancing Care Information (ACI) makes up 25% of the MIPS Composite Performance Score (CPS)
  • Submission mechanisms include: qualified registry, QCDR, EHR, Attestation, and Part B Claims
  • Scoring for the ACI category will be comprised of a score for participation and reporting, which is the “base score” and a score for performance, which is the “performance score”. There is also a 1 point bonus for public health reporting beyond the 1 required immunization registry reporting measure
    • To earn points for the base score, MIPS eligible clinicians or groups must report the numerator and denominator for measures that are based on measures adopted by the MU Stage 3 in 2015 final rule to account for the 50% score available for the base score
      • There is a primary and an alternate methodology to reporting on the Advancing Care Information objectives and measures for the base score
      • There is also a modified approach to reporting the ACI objectives for those practices that will still be on 2014 certified EHR technology (CEHRT) in 2017
    • To earn points for the performance score, MIPS eligible clinicians or groups can earn points by reporting on the measures under the following objectives: Patient Electronic Access, Coordination of Care through Patient Engagement, and Health Information Exchange
      • The 8 measures under those 3 objectives would each have the potential of earning 10 points
  • It is proposed to reweight the ACI category to zero for NPs, PAs, CRNAs, Clinical Nurse Specialists and for certain hospital-based clinicians for the 1st year of MIPS
  • It is also proposed that the following hardships would result in a reweighting of the ACI category to zero
    • Insufficient Internet Connectivity – if unsurmountable barriers exist, the MIPS eligible clinician or group must submit application for category reweighting
    • Extreme and Uncontrolled Circumstances – the MIPS eligible clinician or group must submit application for category reweighting
    • Lack of control over availability of CEHRT – the MIPS eligible clinician or group must submit application for category reweighting
    • Lack of face-to-face patient interaction – Non-patient-facing MIPS eligible clinicians would automatically have their ACI category reweighted to zero

MIPS Composite Performance Score (CPS) 

  • The MIPS CPS will be compared to the MIPS performance threshold to determine the adjustment percentage the MIPS eligible clinician or group will receive
  • A CPS below the performance threshold will yield a negative payment adjustment down to – 4%
  • A CPS at or above the performance threshold will receive an upward payment adjustment of 0 to 12% for the 2017 performance period.
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