MACRA and MIPS Explanation

May 17, 2016  |  Company

There is confusion in the industry around MACRA, MIPs, and APMs. It begs the question, Is Meaningful Use dead? The confusion is justified as the topic is both broad and dense, especially since we’ve been operating in a world of acronyms under the “Medicare EHR incentive program”—more commonly called Meaningful Use—for years.

This article will outline old program terminology and how they’re being replaced with new incentive programs. It will dive into the new program structures and provide links to helpful resources so you can cut through the clutter.

Get to Know the Acronyms

Acronyms are no fun, but even worse are when old acronyms are replaced by new acronyms that mean essentially the same thing. It causes unnecessary confusion and wastes brain-power. This is partially what we are experiencing with MACRA and MIPS.

Old Acronyms Being Replaced by New Acronyms

Acronym Term Description
MU Meaningful Use The Medicare EHR incentive program is now a component of MIPS and is called Advancing Care Information. Will we start saying ACI? Probably.
EP Eligible Professional What we used to call an eligible professional under Meaningful Use is now called Eligible Clinician (EC) within MIPS.

Net-New Acronyms

Acronym Term Description
MACRA Medicare Access and CHIP Reauthorization Act of 2015 Replaced the old way of doing business with a new business model focused on value based care. Or, in CMS language, MACRA, bipartisan legislation, replaces the flawed Sustainable Growth Rate formula by paying clinicians for the value and quality of care they provide. MACRA created the Quality Payment Program.
QPP Quality Payment Program The single framework under which MIPS and APMs are administered. The goals of the QPP are described below.
MIPS Merit-Based Incentive Payment System Incentive program aligning old models into a single model made up of components.
CPS MIPS Composite Performance Score A clinician’s total MIPS score (a singular number) which is comprised of four scores from four weighted categories.
QP Qualifying APM Participant Someone that participates in an advanced APM model at a higher threshold.
APM Advanced Alternative Payment Models The QPP creates additional incentives for Qualifying Professional’s (QP’s) who participate in an Advanced Alternative Payment Models. It does not create the APM or alter the structure of APMs. (Some think these should have been called AAPMs.)

What is the overarching goal?

The goal of CMS is to increase the focus on quality and value-based care. By the end of this year, CMS plans to tie 30% of Medicare payments to alternative payment models and to tie 85% of fee-for-service payments to quality. To do that, the Quality Payment Program has been created and has two branches. Clinicians will either participate in MIPS or an APM. Most clinicians will be subject to MIPS. Clinicians will be excluded from MIPS if they meet a low volume threshold, are in their first year of Medicare Part B Participation, or if they participate in the other branch of the quality payment program, an advanced alternative payment model (APM).

What is MIPS?

MIPS is a single incentive program that streamlines three current programs within it: the physician quality reporting system (PQRS), Value Based Payment, and the Medicare EHR incentive program for eligible professionals (Meaningful Use for EP). It is important to note that the EHR incentive program for hospitals will continue; MIPS does not apply to hospitals. Also, the Medicaid EHR incentive program for eligible professionals will continue. MIPS will take effect in 2018 and MIPS begins adjusting payments in 2019. The fourth component of MIPS is new; Clinical Practice Improvement Activities.

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MIPS is comprised of four Performance Categories which make up a composite performance score (CPS) of a possible 100 points. Clinicians can submit their individual score or a score for their entire group. The four performance categories are Quality, Resource Use, Clinical Practice Improvement Activity, Advancing Care Information. CMS will report the physician’s score publicly on Physician Compare.

In 2017, groups will report year’s worth of data to CMS so a national threshold can be calculated. This is the MIPS performance threshold and it will be used as comparison to a clinician’s MIPS composite score (CPS) when determining the appropriate payment adjustment in year 2019. Clinicians with a CPS higher than the national performance threshold will receive an upward adjustment of MPFS payments (up to 4% in 2019, increasing to 9% by 2023), while a physician whose CPS is below that threshold will be subject to a corresponding downward adjustment.

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What is an APM?

Advanced Alternative Payment Models (APMs) are defined by CMS as new approaches to paying for medical care through Medicare that incentivize quality and value. MACRA doesn’t create new Advanced Alternative Payment Models. Just as MACRA created MIPS, a program to change the reimbursement model, that’s the exact goal of MACRA under APMs as well; additional incentives for APM participation.

Although the majority of clinicians will be subject to MIPS, those that participate in Advanced Payment Models at a certain threshold, such as Accountable Care Organizations, will be excluded from the MIPS program. To be considered as an APM, at least 50% of the participating clinicians must use a certified EHR technology. This threshold increases to 75% after year one. The group must also base payment on quality measures comparable to those in the MIPS program. Finally, APM entities are required to bear more than nominal financial risk. Eligible Clinicians can become Qualifying APM Participants if a certain percent of their patients or payments are through an APM. QP’s are eligible for a 5% lump sum bonus in years 2019 - 2024 and even higher in subsequent years. Only QP’s are excluded from MIPS.

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Cited resources and image attribution: * https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program.html * https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MACRA-NPRM-Slides.pdf * https://www.federalregister.gov/articles/2016/05/09/2016-10032/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm#h-13 * https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-LAN-PPT.pdf