The Medicare Access CHIP Reauthorization Act (MACRA) replaces the sustainable growth rate (SGR) formula creating annual physician payment updates in the initial years and beginning in 2019 basing physician payment on either of two payment tracks known as the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). The new payment system is also referred to as the Quality Payment Program (QPP).
Medicare payment to physicians will continue to be made under the fee schedule. Under MACRA physicians and certain non-physicians will receive a positive annual update of 0.5 percent starting July 1, 2015 and lasting through 2019. From 2020-2025, there will be a 0% update of the fee schedule. In 2019, eligible clinicians who meet the APM criteria will be eligible for a 5% bonus and those who perform well under MIPS may receive up to a 4% increase; top MIPS performers also will be eligible for a share of a $500 million annual pool for exceptional performers. From 2026 and on, APM participants will receive a 0.75% update and all others will receive a 0.25% update.
Beginning, January 1, 2019 physician payments will be determined, in part, by participation in the Merit-Incentive Based Program (MIPS) or an eligible alternative payment model. The payment in 2019 will be based on the physician’s performance in prior years. 2019 payment adjustments will be based on performance in 2017.
The first performance period is 2017. CMS allows maximum flexibility for eligible clinicians to “pick their pace” of participation for the first performance period by choosing from the following four options.
·Test the Quality Payment Program: submit some data to the QPP to avoid a negative payment adjustment
·Participate part of the calendar year:report information for a reduced number of days (i.e. performance period could begin later than January 1, 2017) and still qualify for a small positive payment adjustment
·Participate for the full calendar year: the performance period would begin Jan. 1, 2017 and eligible clinicians would qualify for a modest positive payment adjustment
·Participate in Advanced Alternative Payment Model: qualifying participants would qualify for a 5 percent incentive payment in 2019 and practices work with CMS to continue building this program.
MIPS is a new payment system that will provide annual updates to physicians(MD/DOs), nurse practitioners, physicians assistants, and clinical nurse specialists starting in 2019 based on performance in 2017 in four categories: quality, cost, improvement activities (IAs), and advancing care information (ACI). It consolidates the existing quality programs (PQRS, Value-Based Modifier program, and Meaningful Use). Physicians will receive a score under MIPS and depending on the score will receive a positive, neutral or negative update.
The penalties associated with the PQRS, VM, and Meaningful Use will sunset at the end of 2018 and will be replaced with the possibility of either a negative, neutral, or positive adjustment under MIPS. The PQRS program will be voluntary.
Beginning 2019, MIPS applies to physicians, optometrists, podiatrists, chiropractors, physician assistants, nurse practitioners, and clinical nurse specialists. Starting in 2021, CMS has the discretion to apply MIPS to other eligible professionals, including physical therapists, occupational therapists, speech language pathologists, psychologists, social workers, audiologists, and dieticians.
Yes, there are exemptions from MIPS for:
·Clinicians with billing charges less than or equal to $30,000 or provide care for 100 or fewer Medicare patients in during the historical time period (for group reporting purposes, entire group must meet this requirement).
·Clinicians who have met threshold of Medicare payments or patients through Advanced APM to be qualifying APM participant or partial qualifying APM participant.
·Clinicians enrolled in the Medicare program for their first year would not be treated as MIPS eligible clinician until the subsequent year (however, if these individuals elect to report as a group, they will be counted in the score but will not have their payments adjusted).
The MIPS categories on which the eligible clinician is scored include:
·Cost (Resource Use)
·Advancing Care Information (previously known as Meaningful Use)
Physicians participating in the MIPS program will receive a composite performance score of 0-100 based on their performance on four performance categories (Quality, Cost, IAs, and ACI). Each of these categories is weighted as follows (weighting will vary under certain APMs):
| Performance Category | Year 1 (2019) | Year 2 (2020) | Year 3 (2021) |
|---|---|---|---|
| Quality | 60% | 50% | 30% |
| Cost | 0% | 10% | 30% |
| Improvement Activity | 15% | 15% | 15% |
| Advancing Care Information | 25% | 25% | 25% |
Each professional’s composite score will be compared to a performance threshold that consists of the mean or median of the composite scores for all MIPS eligible professionals. The threshold will be determined by CMS and resets each year.
Initially, the cost performance category will have a 0% weight for the 2017 transition year and the weight will increase in succeeding years. The performance in the cost category will be assessed using measures based on administrative Medicare claims data and would not require any additional reporting for this category. The total per capita cost measure, the MSPB measure, and 10 episode-based measures were finalized for future assessment.
Group reporting via CMS Web Interface (reporting option for groups of 25 or more):
The submission criteria for quality measures for group reporting via CMS web interface for the 12 month performance period is the following:
An all-cause hospital readmission measure was finalized for groups of 15 or more clinicians and with 200 attributed cases.
If reporting via cliams, QCDR, Registry, or EHR:
An all-cause hospital readmissions measure applies to groups of 15 or more physicians and with 200 attributed cases.
Base Score: Fulfill the 5 required measures for a minimum of 90 days: Security Risk Analysis, E-Prescribing, Provide Patient Access, Send Summary of Care, Request/Accept Summary of Care
Performance Score: Choose to submit up to 9 measures for a minimum of 90 days for additional credit
Bonus Points: Report public health and clinical data registry reporting measures or use certified EHR technology to complete certain improvement activities (IAs) for IAs performance category
Groups can report via attestation, QCDR, Qualified Registry, EHR, CMS Web Interface (for groups of 25 or more). A list of ACI measures is available at https://qpp.cms.gov/measures/aci/
Yes. Physicians must attest to two 20-point high weighted activities, four 10-point medium-weighted activities, or another combination of high and medium weighted activities equaling 40 points or more to achieve full credit in the IA category for which 90-day performance period is required for IAs. A list of IAs is available at: https://qpp.cms.gov/measures/ia
Beginning in 2019, ECs participating in MIPS will be eligible for positive, neutral, or negative Medicare payment adjustments. Physicians whose composite scores are above the threshold will receive positive payment adjustments. The adjustments can be up to 4 percent in 2019, 5% in 2020, 7% in 2021, and 9% in 2022 and beyond. Exceptional performers may be eligible for additional payments. For CY2019 payment adjustment year, exceptional performers are defined at 70 points. The top performers can be eligible for a positive payment adjustment of up to three times the baseline positive payment adjustment for a given year based on the scaling factor. For example, the 2019 adjustment of 4% could result in up to 12% positive adjustment. There is an additional $500 million bonus pool of money for exceptional performance. Physicians whose composite score is at the threshold will not receive any MIPS adjustment to their payment. Physicians whose composite score is below the threshold, will receive negative payment adjustments.
Beginning in 2026, all physicians participating in MIPS will be receive an annual 0.25 percent increase in their fee schedule payments.
APM qualifying participants will receive a 5 percent lump sum bonus on Medicare Part B payments each year from 2019 to 2024. Beginning in 2026, they will receive a fee schedule update of 0.75 percent each year. Qualifying APM participant will be excluded from MIPS and partial qualifying APM participants can elect to be excluded from the MIPS program.
MACRA defines the following as qualifying APM models:
·An innovative payment model expanded under the Center for Medicare and Medicaid Innovation (CMMI)
·A Medicare Shared Savings Program, Accountable Care Organizations, Medicare Health Care Quality Demonstration Program, or Medicare Acute Care Episode Demonstration Program; or
·Another demonstration program required by federal law
Below is a table that CMS has provided as a list of Advanced APMS for CY 2017 and 2018:
| 2017 Advanced APMs | 2018 Advanced APMs |
|---|---|
| Medicare Shared Savings Program Track 2 | Comprehensive Care for Joint Replacement (CJR) Payment Model (CEHRT) |
| Medicare Shared Savings Program Track 3 | Advancing Care Coordination through EPMs Track 1 (CEHRT) |
| Comprehensive End Stage Renal Disease Care Model (2-sided risk) | ACO Track 1+ |
| Comprehensive Primary Care Plus (CPC+ | New Voluntary Bundled Payment Models |
| Next Generation ACO Model | Vermont Medicare ACO Initiative (part of All-Payer ACO Model) |
| Oncology Care Model (2-sided risk) |
To receive the bonus payment of 5% under MACRA, the APM must be an eligible APM which meets the following criteria:
You must meet the patient or payment threshold requirements in order to be considered a qualifying participant and receive the 5% bonus payment. To be classified as “qualifying APM” participant or “partial qualifying APM participant” ECs have to meet or exceed certain thresholds related to eligible APM entities. The chart below shows the percentage of payments and patients that must be provided through the qualified APM to receive the 5% bonus payment. The percentage amount in gradually increased and incorporates all payers in future years.
The partial qualifying APM participant thresholds are slightly lower than the “qualifying APM thresholds. Partial qualifying APM participants would not receive the 5% bonus payment but can choose not to report through the MIPS program.
Min. Threshold for APM Participants (Payment)
| Years | Qualifying | Partial Qualifying |
|---|---|---|
| 2019-2020 | 25% | 20% |
| 2021-2022 | 50% | 40% |
| 2023 and beyond | 75% | 50% |
Min. Threshold for APM Participants (Patients)
| Years | Qualifying | Partial Qualifying |
|---|---|---|
| 2019-2020 | 20% | 10% |
| 2021-2022 | 35% | 25% |
| 2023 and beyond | 50% | 35% |