MACRA, or the Medicare Access and CHIP Reauthorization Act of 2015, from the Centers for Medicare & Medicaid Services (CMS), has certainly brought its share of questions as it replaces the previous Medicare payment formula. Recently, Kelly Whittle of Whittle Advisors answered 5 questions that have been on physicians minds during this transition year.
What are the primary differences between MIPS and APM?
MACRA has two tracks that physicians may choose to follow:
- MIPS (Merit-Based Incentive Program) is designed for providers that care for traditional Medicare beneficiaries. It offers these providers an opportunity to earn bonuses or incur penalties based on reporting as individuals or groups. This program gives providers maximum flexibility in picking their pace.
- APMs (Advanced Alternative Payment Models) provide potential bonuses of up to a 5% Medicare incentive payment for participating in an innovative payment model. APMs have a defined framework and carry positive or negative payment risk. Providers can report as individuals or groups.
What are the four MIPS categories?
In 2017 a composite score for MIPS will be built out of the following 4 categories:
- Quality – is worth 60% of the 2017 MIPS composite score. There are over 270 quality measures available to choose from. If you are reporting for the full year you must pick 6 measures to report and one must be an outcome or high-priority measure. Not all measures are weighted equally.
- Cost – will not contribute to your composite score in 2017. CMS will take a benchmark level of the scores pulled from claims data. There’s not much you can do in 2017 to influence this.
- Improvement Activity – is worth 15% of the 2017 MIPS composite score. It’s designed to drive operational improvements. Providers choose 4 out of more than 90 activities, which are divided into 9 subcategories of improvement classifications.
- Advancing Care Information – is worth 25% of the 2017 MIPS composite score. It is designed to increase patient engagement and exchange of information utilizing Electronic Health Records (EHRs). There are two measure set options for reporting based on your EHR certification: you will need a 2014 or 2015 certified EHR.
How will MIPS be used to determine payment adjustment?
To determine your MIPS score for each category, use these formulas:
- Quality – 60% of score. Add points earned on the 6 quality measures you report, plus any bonus points, and divide by the maximum number of points (60).
- Cost – 0% of score. In 2018 there will be points for score measures / 10X (# of score measures). Maximum of 100 points.
- Improvement activities – 15% of score. Add your total number of points earned for completed activities and divide it by the total maximum number of points (40). That number is multiplied by 100 to achieve the final score.
- Advancing Care Information – 25% of score. Add base, performance, and bonus.
CMS has designed MIPS to be a net neutral program. This means that once fully implemented, the penalties collected will pay for the bonuses. CMS has set aside $500 million to pay for initial bonuses as the program is established.
There is currently no historical data available to determine a break-even score. But CMS has planned for providers earning 3 points of the 100-point composite score to avoid a penalty in 2017. This is also known as a neutral payment adjustment and is likely to be the lowest bar in the beginning. Those with zero points for not participating will see a negative payment adjustment of 4%. Those earning 4 to 69 points will see a positive payment adjustment, but are not eligible for an exceptional performance bonus. Those earning 70 points and over will receive a positive payment adjustment and are eligible for an exceptional performance bonus of an additional 0.5%.
In what formats can MIPS eligible clinicians submit data in 2017?
In 2017 MIPS providers may pick their pace when it comes to participation. The logical next step after determining your amount of involvement in 2017 is to determine your practice’s plan for submitting data. Not every submission mechanism allows you to access the full set of quality measures; therefore, it’s important to think strategically about how data will be submitted and which of those submission measures offer the broadest opportunity for success. For 2017 MIPS allows the following reporting methods:
- CMS web interface – supports 15 quality measures. Many use the Group Practice Reporting Option (GPRO) web interface. If you are a physician group with 25 or more providers and GPRO is your method to submit data, you must register to use that interface by June 30, 2017.
- EHR – supports 53 quality measures.
- Qualified Clinical Data Registry (QCDR) – supports 243 quality measures. This aggregates the broad variety of quality measures across multiple specialties.
- Claims – supports 74 quality measures. Note that CMS uses initial claims only as the basis for your quality performance score, not reworked claims.
Is there a clear benefit to either APM or MIPS, if eligible?
As you know, the industry is transitioning from fee-for-service to value-based reimbursement. As it evolves, it will progress from the MIPS payments to APM payments, and then from APMs to population-based payment.
The benefit of an APM is that multiple payments are associated with it. An APM allows a practice to earn its fee-for-service as well as the shared savings and 5% incentive payment.
MIPS is quality-based, and payments cap out at 10-11% for the performance bonus. Most practices reporting under MIPS will break even or pay the 4% penalty in the first year for not reporting.
If you are a MIPS provider, you should perform well and plan to move to an APM as you develop the skills and framework to do so. If your practice is participating in an APM, stay in it and perform well. Put into place the reporting capabilities, follow-up capabilities, and operational efficiency.
By 2026 there will be a clear benefit to being in an APM. CMS says that by 2026 the annual increase for Medicare Part B payments will be 0.25% to providers participating in MIPS. Participants in APMs will get a 0.75% increase for participating in APMs.
Quest Diagnostics helps providers connect across the healthcare landscape to help improve quality, health, and financial outcomes. The Quanum certified EHR can help you report for MACRA in 2017 and beyond. To learn more about MIPS, view our recorded webinar with Kelly Whittle on this subject, “Inside MACRA: The MIPS track explained,” or call us at 1.888.491.7900.