MACRA 101

Overview

The Medicare Access and CHIP Reauthorization Act (MACRA) focuses on restructuring Medicare Part B payments for professional services by shifting from fee-for-service (FFS) Volumeto Value-based reimbursements Quality” This is being accomplished through:

  1. Ending the Sustainable Growth Rate (SGR) formula by cutting payment rates for participating clinicians.
  2. Addition of the Quality Payment Program initiative program which rewards values and outcomes through:
    • The Merit-based Incentive Payment Systems (MIPS)

      • Submission of evidence-based and practice-specific quality data
    • Advanced Alternative Payment Models (APMs)

      • Incentive for Qualified Participants in key identified programs that take on financial risk related to their patients’ outcomes
    • APM Scoring Standard (MIPS APM)
      • Not excluded from MIPS but receive special scoring standards
      • Reduces reporting burden by accounting for APM involvement/requirements

Eligibility

2017 & 2018 Performance Years
  • Physician
  • Physician Assistant
  • Nurse Practitioner
  • Clinical Nurse Specialist
  • Certified Registered Nurse Anesthetist
2019 Performance Year
  • Physical Therapist
  • Occupational Therapist
  • Qualified Speech-Language Pathologist
  • Qualified Audiologist
  • Clinical Psychologist
  • Registered Dietitian or Nutrition Professionals

 


Quality Payment Program Tracks

Merit-Based Incentive Payment System (MIPS)

MIPS has effectively consolidated the Physician Quality Reporting System (PQRS), Value Based Payment Modifier (VM), and EHR Incentive Program (Meaningful Use) programs into one MIPS program that compares each Eligible Clinician’s (EC) performance against their peers. EC’s who outscore their counterparts will receive a positive MIPS Payment Adjustment, which will be offset by a negative MIPS Payment Adjustment to those EC’s with scores below the performance threshold.

 

Eligibility

Low-Volume Threshold Criteria –  To be excluded from MIPS, clinicians or groups would need to meet one of the following three criteria:

  • ≤ $90,000 in Part B allowed charges for covered professional services
  • ≤ 200 Beneficiaries
  • ≤ 200 covered professional services under the Physician Fee Schedule *New*

Opt-in Policy *New*

  • Clinicians who meet or exceed at least one of the low-volume threshold criteria may choose to participate in MIPS.
  • Once an election has been made, it CANNOT be Changed
Payment Adjustment

Payment Adjustment

2018:

  • Threshold = 15 Points
  • Exceptional Performer = 70 Points
  • Payment Adjustment = -5% to +5%

 

2019:

  • Threshold = 30 Points
  • Exceptional Performer = 75 Points
  • Payment Adjustment = –7% to +7%

 

 


Scoring Threshold

2019 MIPS Threshold is 30 out of 100

  • <= 25% MIPS Threshold (7.5 Points) – Full Negative Adjustment (-7%)
  • = Threshold (30 Points) -No Adjustment (0%)
  • >0% Threshold – Positive Adjustment (>0%)

Exceptional Performance Bonus Threshold = 75 Points

  • CMS allocates $500M per year (available each year through 2022) to an exceptional performance bonus pool for high performing clinicians. Clinicians who score at or above the threshold receive a bonus in proportion to how far they exceed the score.

Performance Categories

 

 

CategoryPerformance PeriodCategory Weight
Quality12 Months45%
Promoting Interoperability90 Days25%
Improvement Activities90 Days15%
Cost12 Months15%

Quality


 

Weight: 45% (50% in 2018)

  • Selection of 6 individual measures
    • 1 must be an Outcome OR High-Priority measure
  • You may also select a specialty-specific set

Bonus Points

  • Additional Outcome OR High-Priority Measures & End-to-End Electronic Submission
    • Each Bonus is capped at 10% Category Denominator
  • Small Practice Bonus
    • 6 Points applied to the numerator of the Quality category (Previously 5 points to the overall CPS)
      • Must submit data on at least 1 quality measure
      • Individual clinicians, group practices, or virtual groups must consist of 15 or fewer clinicians.

Scoring Measures – Measures are scored based on the following:

  • Each Submission method has different percentage benchmarks which equate to points
  • Case Minimum for each measure is 20
  • Data Completeness is 60% – Percentage of Patients seen and documented in the EMR

Submission – Ability to Submit Same Measure across multiple Collection Types

  • Awarded Points from Highest Submitted Collection Type

Promoting Interoperability


 

Weight: 25% (25% in 2018)

  • Performance based scoring at the individual measure level
  • Must report the required measures under each Objective, or claim the exclusions

Required: 2015 Edition Certified EHR Technology (CEHRT)

New Performance-Based Scoring:

  • Elimination of base, performance, and bonus score methodology
  • Individual Measures scored on Performance and calculated together for a final score
    • If exclusions are claimed, points will be allocated to other measures

Failure to report or claim an exclusion on any measure results in a zero for category

 

Promoting Interoperability Objects & Measures

ObjectivesMeasuresMax PointsIf Excluded, Reassigned to:
e-Prescribinge-Prescribing10 PointsHealth Information Exchange
Query of Prescription Drug Monitoring Program (PDMP) (New)5 Bonus Points
Verify Opioid Treatment Agreement (New)5 Bonus Points
Health Information Exchange (HIE)Support Electronic Referral Loops by Sending Health Information (Send a Summary of Care)20 Points
Support Electronic Referral Loops by Receiving and Incorporating Health Information (New)20 PointsSupport Electronic Referral Loops by Sending Health Information
Provider to Patient ExchangeProvide Patients Electronic Access to their Health Information (Provide Patient Access)40 Points
Public Health and Clinical Data ExchangeReport to two of the following:10 PointsProvide Patients Electronic Access to their Health Information
• Immunization Registry Reporting
•• Electronic Case Reporting
•• Public Health Registry Reporting
•• Clinical Data Registry Reporting
• Syndromic Surveillance Reporting
Security Risk AssessmentNot considered an objective or measure but still an attestation requirement0 Points

Improvement Activities


Weight: 15% (15% in 2018)

  • Select and attest to completing 40 points of Improvement Activities
  • Activity weights
    • Medium = 10 points
    • High = 20 points
  • Double weight for small practices, non-patient facing, & rural clinicians

  • Retained: Group will receive credit for an improvement activity that was completed by one eligible clinician.

 

  • Removed: Promoting Interoperability Category bonus for attesting to specified Improvement Activities using CEHRT.

Cost


Weight: 15% (10% in 2018)

  • Administrative Claims Data Measures:
    • Medicare Spending Per Beneficiary (MSPB)
    • Total Per Capita Cost
    • Episode-Based Measures

  • Addition: 8 Episode-Based Measures
MeasureCase MinimumAttribution
Total Per Capita Cost20 CasesPlurality of primary care services
MSPB35 CasesPlurality of Part B services billed during the index admission
Episode-Based Measures (NEW)Procedural = 10 Cases
Acute Inpatient Conditions = 20 Cases
Procedural Episodes: Performing Clinician
Acute Inpatient Condition Episodes - Clinicians
who bill > 30% of evaluation and management during hospitalization

8 New Episode-Based Measures

  • Procedural:
    • Elective Outpatient Percutaneous Coronary Intervention (PCI)
    • Knee Arthroplasty
    • Revascularization for Lower Extremity Chronic Critical Limb Ischemia
    • Routine Cataract Removal with Intraocular Lens (IOL) Implantation 2
    • Screening/Surveillance Colonoscopy
  • Acute Inpatient Medical Condition:
    • Intracranial Hemorrhage or Cerebral Infarction
    • Simple Pneumonia with Hospitalization
    • ST-Elevation Myocardial Infarction (STEMI) with PCI

Complex Patient Bonus

Bonus of up to 5 points to the overall Composite Performance Score (CPS) for complex patients based on the combination of:

  • The dual eligibility ratio (enrolled in both Medicare and Medicaid)
  • The average Hierarchical Conditions Category (HCC) (Risk Adjustment predicting medical spending)

Reporting

2019 Timeline

MIPS has a two-year time period from performance to payment adjustment:

Reporting Options

Individual:

  • Single clinician, identified by their individual National Provider Identifier (NPI) tied to a single Taxpayer Identification Number (TIN).

Group:

  • 2 or more clinicians (NPIs) who have reassigned their billing rights to a single TIN

Virtual:

  • Made up of solo practitioners and groups of 10 or fewer eligible clinicians who come together “virtually” (no matter what specialty or location) to participate in MIPS for a performance period for a year

 

Submission Type: The mechanism by which a submitter type submits data to CMS includes:

  • Direct: Users transmit data through a computer-to-computer interaction via Application Programming Interface (API).
  • Log in and Upload: Users upload and submit data in the form and manner specified by CMS with a set of authenticated credentials.
  • Log in and Attest: Users manually attest that certain measures and activities were performed in the form and manner specified by CMS with a set of authenticated credentials.
  • Medicare Part B Claims: Available to MIPS eligible clinicians in small practices 15 or fewer in the TIN.
  • CMS Web Interface: Available to groups of 25 or more eligible clinicians

 

Submission Methods:

MIPS - CategoriesMIPS – IndividualMIPS – Group
Quality••Direct
••Log-In and Upload
••Medicare Part B Claims
••Direct
••Log-in and Upload
••CMS Web Interface
••Medicare Part B Claims
Promoting Interoperability••Direct
••Log-in and Upload
••Log-in and Attest
••Direct
••Log-in and Upload
••Log-in and Attest
Improvement Activities••Direct
••Log-in and Upload
••Log-in and Attest
••Direct
••Log-in and Upload
••Log-in and Attest
CostN/A – CMS CalculatesN/A – CMS Calculates
Submission & Scoring Example

CMS calculates the MIPS Composite Performance Score by adding each individual category score after it has been multiplied by its category weight.

Quality

Promoting Interoperability

Improvement Activities

Cost

Achievement Points/Available Points = Cost Performance Category Percent Score

  • Achievement Points:
    • Performance on each attributable measure is compared to a benchmark determined annually
  • Available Points:
    • Each measure is worth a maximum of 10 when the measure’s minimum case threshold is met.

MIPS Composite Performance Score

MIPS APM Scoring Standard

An Alternative Payment Model (APM) is a payment approach that gives incentive payments for providing high-quality and cost-efficient care. Certain APMs include Merit-Based Incentive Payment System (MIPS) eligible clinicians as participants. These types of APMs are called MIPS APMs, and participants receive special MIPS scoring under the APM scoring standard including:

  • Reduce duplication of reporting allowing clinicians to focus on the goals of the APM.
  • Aggregated MIPS scores to the APM entity level (ACO)
  • Same MIPS composite performance score for all eligible APM scoring standard clinicians

2019 MIPS APM List:

  • Comprehensive ESRD Care (CEC) Model – One-Sided Risk
  • Medicare Shared Savings Program Accountable Care Organizations – Track 1 & Basic Levels A-D
  • Oncology Care Model (OCM) – One-Sided Risk

*Note* Information within this section pertains to Medicare Shared Savings Program participants

Eligibility

APM Participation List:

Eligible Clinicians must be on the APM Entity’s Participation List at one of the three “snapshot” dates to be scored under the APM scoring standard:

  • March 31
  • June 30
  • August 31

If an eligible clinician joined a full TIN APM (Medicare Shared Savings Program), CMS will use a fourth “snapshot” date (December 31st) to determine APM Participation.

Low-Volume Threshold:

To be excluded from MIPS, the APM Entity (ACO) would need to meet one of the following three criteria:

  • ≤ $90,000 in Part B allowed charges for covered professional services
  • < 200 Beneficiaries
  • ≤ 200 covered professional services under the Physician Fee Schedule *New*
Payment Adjustment

Payment Adjustment

2018:

  • Threshold = 15 Points
  • Exceptional Performer = 70 Points
  • Payment Adjustment = -5% to +5%

 

2019:

  • Threshold = 30 Points
  • Exceptional Performer = 75 Points
  • Payment Adjustment = –7% to +7%

 

 


Scoring Threshold

2019 MIPS Threshold is 30 out of 100

  • <= 25% MIPS Threshold (7.5 Points) – Full Negative Adjustment (-7%)
  • = Threshold (30 Points) -No Adjustment (0%)
  • >0% Threshold – Positive Adjustment (>0%)

Exceptional Performance Bonus Threshold = 75 Points

  • CMS allocates $500M per year (available each year through 2022) to an exceptional performance bonus pool for high performing clinicians. Clinicians who score at or above the threshold receive a bonus in proportion to how far they exceed the score.

Performance Categories

 

 

CategoryPerformance PeriodCategory Weight
Quality12 Months50%
Promoting Interoperability12 Months30%
Improvement Activities12 Months20%
CostN/A0%

Quality

 

Weight: 50% (50% in 2018)

  • The MSSP required Quality Measures are submitted on behalf of the participating MIPS eligible clinicians
    • Aggregated at an APM Entity level for one overall category score

Retiring:

  • 4 Claims Based Measures
    • ACO–35—Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM).
    • ACO–36—All-Cause Unplanned Admissions for Patients with Diabetes.
    • ACO–37—All-Cause Unplanned Admission for Patients with Heart Failure.
    • ACO–44—Use of Imaging Studies for Low Back Pain
  • 5 Web Interface Measures
    • ACO–12 (NQF #0097) Medication Reconciliation Post-Discharge
    • ACO–15 (NQF #0043) Pneumonia Vaccination Status for Older Adults.
    • ACO–16 (NQF #0421) Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up.
    • ACO–41 (NQF #0055) Diabetes: Eye Exam.
    • ACO–30 (NQF #0068) Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic.
  • 1 Quality Payment Program Data Measure
    • ACO–11—Use of Certified EHR Technology

Additions:

  • 2 Survey Measures
    • ACO–45–CAHPS: Courteous and Helpful Office Staff
    • ACO–46–CAHPS: Care Coordination

Promoting Interoperability

 

Weight: 30% (30% in 2018)

  • Performance based scoring at the individual measure level
  • Must report the required measures under each Objective, or claim the exclusions

Required: 2015 Edition Certified EHR Technology (CEHRT)

New Performance-Based Scoring:

  • Elimination of base, performance, and bonus score methodology
  • Individual Measures scored on Performance and calculated together for a final score
    • If exclusions are claimed, points will be allocated to other measures

Failure to report or claim an exclusion on any measure results in a zero for category

 

Promoting Interoperability Objects & Measures

ObjectivesMeasuresMax PointsIf Excluded, Reassigned to:
e-Prescribinge-Prescribing10 PointsHealth Information Exchange
Query of Prescription Drug Monitoring Program (PDMP) (New)5 Bonus Points
Verify Opioid Treatment Agreement (New)5 Bonus Points
Health Information Exchange (HIE)Support Electronic Referral Loops by Sending Health Information (Send a Summary of Care)20 Points
Support Electronic Referral Loops by Receiving and Incorporating Health Information (New)20 PointsSupport Electronic Referral Loops by Sending Health Information
Provider to Patient ExchangeProvide Patients Electronic Access to their Health Information (Provide Patient Access)40 Points
Public Health and Clinical Data ExchangeReport to two of the following:10 PointsProvide Patients Electronic Access to their Health Information
• Immunization Registry Reporting
•• Electronic Case Reporting
•• Public Health Registry Reporting
•• Clinical Data Registry Reporting
• Syndromic Surveillance Reporting
Security Risk AssessmentNot considered an objective or measure but still an attestation requirement0 Points

Improvement Activities

 

Weight: 20% (20% in 2018)

  • This category gauges participation in activities that improve clinical practice and care coordination
  • CMS will assign scores to the improvement activity category for participation in MIPS APMs.

Retained:

  • All eligible clinicians in the MIPS APM will receive the same improvement activity score
  • MSSP Track 1 program participants:
    • Receive FULL credit in this category
    • Are not required to submit category information to CMS

Cost

 

 

Weight: 0% (0% in 2018)

  • Administrative Claims Data measures the following:
    • Medicare Spending Per Beneficiary (MSPB)
    • Total Per Capita Cost
    • Episode-Based Measures

Retained:

  • MIPS APM participants are NOT measured on cost

 

Complex Patient Bonus

Bonus of up to 5 points to the overall Composite Performance Score (CPS) for complex patients based on the combination of:

  • The dual eligibility ratio (enrolled in both Medicare and Medicaid)
  • The average Hierarchical Conditions Category (HCC) (Risk Adjustment predicting medical spending)

Reporting

2019 Timeline

MIPS has a two-year time period from performance to payment adjustment:

Submission Methods:

Performance CategoryReporting RequirementData Submission Mechanism(s)
QualityACO submits measures on behalf of their participating clinicians.CMS Web Interface
Promoting InteroperabilityAll ACO participant TINs submit according to the MIPS group reporting requirements.• •Direct
• •Log-in and Upload
•• Log-in and Attest
Improvement ActivitiesNone. Full credit awarded.N/A
CostNone. Direct alignment with APMs goals.N/A

Advanced Alternative Payment Model (A-APM)

Advanced Alternative Payment Models (A-APMs) are a track of the Quality Payment Program that offers incentives for achieving certain Payment Amount or Patient Count thresholds. They are a subset of APMs that meet the following:

  • 75% of Participants within the Advanced APM entity use 2015 certified EHR Technology
  • Payments for covered professional services are based on quality measures comparable to those used in the MIPS quality performance category
  • Either:
    • Medical Home Model expanded under CMS Innovation Center authority
    • APM Entity bears more than nominal financial risk for losses.
      • 8% of estimated average total Medicare Part A and B revenues of participating APM Entities
      • 3% of expected expenditures for which an APM Entity is responsible for under the APM payment arrangement.

2019 Advanced APM List:

  • Bundled Payments for Care Improvement (BPCI) Advanced
  • Comprehensive ESRD Care (CEC) – Two-Sided Risk
  • Comprehensive Primary Care Plus (CPC+)
  • Medicare Accountable Care Organization (ACO) Track 1+ Model
  • Next Generation ACO Model
  • Medicare Shared Savings Program – Tracks 2, 3, Level E, & Enhanced
  • Oncology Care Model (OCM) – Two-Sided Risk
  • Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1-CEHRT)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)
  • Comprehensive ESRD Care (CEC) Model
  • Maryland All-Payer Model (Care Redesign Program)
  • Maryland Total Cost of Care Model (Maryland Primary Care Program)
  • Maryland Total Cost of Care Model (Care Redesign Program)

Based on the eligible clinician’s payment amount OR patient count threshold they are classified as:

  • Qualified Participant
    • 5% lump sum bonus payment 2019-2024
    • 0.75% increase in the Physician Fee Schedule 2026+
    • Exclusion from MIPS reporting
  • Partial Qualified Participant
    • Exclusion from MIPS reporting
  • Non Qualified Participant
    • Subject to MIPS APM Scoring Standard

Eligible Clinician Participation Requirements 

Eligible Clinician Status% of Payments% of Patients% of Payments - Min% of Patients - Min
Qualified Participant50%35%25%20%
Partial Qualified Participant40%25%20%10%

*Based on Medicare payment/patient percentage through participating A-APM*

All-Payer Advanced Alternative Payment Models Option

Beginning in 2019, the Advanced APM path provides 2 ways for eligible clinicians to become QPs:

  1. The Medicare Option, which takes into account the clinician’s participation solely in Medicare Advanced APMs
  2. The All-Payer Option, which takes into account the clinician’s participation in Advanced APMs both with Medicare and other payers.

To determine eligible clinician participation status, CMS considers the Medicare APMs first, then, looks to see if the Medicare minimum thresholds are met before considering Other Payer APMs. If the Medicare minimum thresholds of the Medicare APM are not met, eligible clinicians cannot qualify as a Qualified Participants or Partial Qualified Participants. If the Medicare minimum threshold is met by either patient count or dollar amount, eligible clinicians can meet the Qualified Participant or Partial Qualified Participant status requirements with either option.

Other-Payer Advanced Alternative Payment Models

Other-Payer Advanced APMs are non-Medicare Fee For Service (FFS) payment arrangements with other payers including:

  • Medicaid
  • Medicare Health Plans
  • CMS Multi-Payer Models
  • Commercial Payer that meet the criteria to be an Other-Payer Advanced APM (2020 Proposal)
    • 50% of Participants within the Advanced APM entity use 2015 certified EHR Technology
    • Payments for covered professional services are based on quality measures comparable to those used in the MIPS quality performance category
    • Participants bear a certain amount of financial risk, or participate as a Medicaid Medical Home Model that meets criteria comparable to Medical Home Models.

References