MACRA  Education and Resources

The change to value-based reimbursement accelerated with the passage of The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). As a result of MACRA, physicians and other clinicians will be paid for the value of care they provide rather than the volume of care for their Medicare patients.

MACRA creates a Quality Payment Program (QPP) with two incentive programs; the Alternative Payment Model (APM), and the Merit-based Incentive Payment System (MIPS). Although MACRA becomes effective in 2019, the incentives are based on data from 2017. So, 2017 data determines your Medicare payment in 2019. 

Alternative Payment Model (APM)

APMs are payment models run by the Centers for Medicare & Medicaid Services (CMS). They include:

  • CMS Innovation Center Model
  • Medicare Shared Savings Program
  • Demonstration under the Health Care Quality Demonstration Program
  • Demonstration required by federal law

Clinicians may qualify for a 5 percent Medicare Part B incentive payment, and be excluded from MIPS, if they participate to a sufficient extent in an Advanced APM.  An Advanced APM is a subset of the APM. In order to be considered an Advanced APM, the APM must meet defined criteria:

  • Requires use of certified EHR technology (CEHRT)
  • Bases payments on quality measures comparable to those in MIPS
  • Bears more than ‘nominal financial risk’ for monetary losses, or the APM is a Medical Home Model expanded by the CMS Innovation Center

Merit-based Incentive Payment System (MIPS)

CMS indicates that most clinicians will initially qualify and participate through MIPS, where CMS will apply upward, downward or neutral adjustments to the Medicare fee schedule based on a physician’s performance in four categories: 

  • Resource Use 
  • Quality 
  • Clinical Practice Improvement Activities 
  • Advancing Care Information

These categories build upon Medicare’s existing payment programs — the Physician Quality Reporting System, the Value Modifier Program and Meaningful Use— and include a new category for patient-centered medical home capabilities. The categories are not equally weighted and the weights change each year. 

The four categories roll up into a Composite Performance Score that reflects a 100-point scale. In 2017, the quality measures will make up 50 percent of the composite, advancing care information, (formerly Meaningful Use), will be 25 percent of the score, clinical practice improvement activities will be 15 percent, and resource use the final 10 percent.

The 2019 Composite Score Guide is a one-page reference which includes links to all of the measures, how they are submitted, and how they are scored for your 2017 performance/2019 payment. 

Graphic 1: MIPS Performance Category Weights for 2017

Graphic 1: MIPS Performance Category Weights for 2017

Adjustments to the Medicare fee schedule are based on the distance of the clinicians score to the average. There is an additional bonus pool that rewards clinicians in the top 25th percentile with up to 10 percent. The potential MIPS incentive for 2017 could range from -4 percent to +14 percent (4 percent base adjustment plus the 10 percent bonus).

CMS Acting Administrator Andy Slavitt highlighted changes to the original MACRA implementation in September, 2016. Now, clinicians that provide any data in the three Composite Performance Score (CPS) categories that require reporting (the Resource Use catagory is calculated by CMS using claims data) will be exempt from any penalties in 2019, the first payment period under MACRA, and may be eligible for a small bonus. Only those who do not report any data would have payment reductions.

CMS outlines three options for MIPS performance reporting in 2017.

  1. Test the Quality Payment Program. This option allows a practice to test its capability for reporting data. As long as some form of data is reported electronically at some point in 2017 they will avoid the penalty. The goal is to ensure a practice's electronic system is functioning properly and can handle broader reporting in future years.
  2. Report for Part of the Calendar Year. Under the second alternative Slavitt described, a practice must report performance in all three CPS categories but can do so starting after January 1. According to the CMS blog, this could qualify a clinician for a "small" bonus in 2019.
  3. Report for the Full Calendar Year. This "ready, set, go" approach requires practices to report for the full calendar year in all three categories. These clinicians would be eligible for a "modest" bonus in 2019.

Eligible Clinicians

Eligible clinicians for 2017 in MIPS include physicians (including optometrists, chiropractors, podiatrists, dentists, and oral surgeons), physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such professionals.

Exempt Clinicians

CMS will decide which clinicians qualify for the Advanced APM. The only providers who are exempt from MIPS include: 

  • Those billing Medicare $10,000 or less, with 100 or fewer Medicare patients in one year
  • Participants in an Advanced APM 
  • First-year Medicare providers

Reputational Impact

MIPS - CMS will publish each clinician’s annual Composite Performance Score, along with the scores for each performance category about 12 months after the end of the performance year. Also, all the significant measures in the Quality, Resource Use and Advancing Care Information (ACI) categories for each clinician will be available for a free download. Activities reported for the Clinical Practice Improvement Activities (CPIA) category will be listed for each clinician.

APM – Clinicians listed as participating in an APM with a link to the clinician’s performance data, such as published by the Medicare ACO programs. 

Both MIPS and APM data will be published on the Physicians Compare website for consumers to browse and download. As health plans increase out-of-pocket costs, consumers become more conscious of the cost and quality components of health care. Clinicians need to be aware of both the potential for reputational damage from low scores and a possible strategic advantage from posting higher scores. 

Timeline

MACRA employs a two-year look back period for both the APM and the MIPS programs.