MACRA 101

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

Payment Adjustment

Performance Categories

 

 

Category	Performance Period	Category Weight
Quality	12 Months	45%
Promoting Interoperability	90 Days	25%
Improvement Activities	90 Days	15%
Cost	12 Months	15%

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

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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

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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

Objectives	Measures	Max Points	If Excluded, Reassigned to:
e-Prescribing	e-Prescribing	10 Points	Health 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 Points	Support Electronic Referral Loops by Sending Health Information
Provider to Patient Exchange	Provide Patients Electronic Access to their Health Information (Provide Patient Access)	40 Points
Public Health and Clinical Data Exchange	Report to two of the following:	10 Points	Provide 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 Assessment	Not considered an objective or measure but still an attestation requirement	0 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

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• 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

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• Addition: 8 Episode-Based Measures

Measure	Case Minimum	Attribution
Total Per Capita Cost	20 Cases	Plurality of primary care services
MSPB	35 Cases	Plurality 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

Submission & Scoring Example

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

Payment Adjustment

Performance Categories

Reporting

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 

*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.

• Quality Payment Program Year 3: Final Rule
• Quality Payment Program Year 3: Executive Summary
• Quality Payment Program Year 3: Final Rule Overview
• Quality Payment Program