May 06, 2016

ACR Offers Basic Outline on MIPS APM Proposed Rule

On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) released the proposed MACRA rule outlining the new physician payment system mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The rule proposes specifics to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) mandated under this landmark legislation, and offers a 60-day comment period ending June 27. It is to be published in the Federal Register on May 9, 2016.

Moving forward, CMS will now refer to this new payment paradigm as the Quality Payment Program, and allows for physicians to choose fee-for-service payments tied to consolidated quality programs under MIPS or participate in a qualified APM.

For the MIPS program, CMS outlines four performance categories for which physicians will earn a composite performance score tied to a potential bonus, penalty or neutral adjustment. The four categories and the maximum possible points to be earned are:

Quality (50 points) — Replaces PQRS and the applicable negative adjustment, while incorporating any useable existing measures into this new category. Clinicians can choose six measures to report from a menu which should include an outcome measure (or alternatively a high quality measure) and a cross-cutting measure. The measures no longer have to belong to a specific National Quality Strategy (NQS) domain; however, additional bonus points maybe earned if one chooses measures considered high priority. Additional bonus points maybe earned for those who report measures with electronic techniques such as Certified Electronic Health Records (CEHRT) or Qualified Clinical Data Registries (QCDR). Three population-based measures (Acute and Chronic Prevention Quality Indicators, as well as an all-cause hospital readmission rate measure) will be calculated from claims data; therefore, do not require additional submission from the clinician. Flexibility is built in for those specialties, such as radiology, who are not patient-facing, lack the minimum number of reported measures or who lack attributed patients (i.e., population measures).

Advancing Care Information (25 points) — Rebrands and revamps the meaningful use (MU) of electronic health records (EHRs) while replacing the MU-specific payment adjustments. This category promotes interoperability and electronic information exchange, as well as replaces the previously existing all-or-nothing, one-size-fits-all program with a program which allows customization and flexibility matching the reporting clinicians’ needs. Potential reweighting of the performance category to “zero” exist in the proposed rule for clinicians deemed “non-patient” facing.

Resource Use (10 points) — Clinicians would not report measures in this category but instead CMS will calculate the costs of providing care to Medicare beneficiaries from available claims data. This category incorporates the concept of evaluating costs savings as was outlined under the Value Modifier (VM) program and sunsets the previously existing bonus structure. Potential reweighting of the performance category to “zero’ exist in the proposed rule for clinicians deemed “non-patient” facing.

Clinical Practice Improvement Activities (15 points) — This is a new performance category as mandated by MACRA. CMS offers a list of over 90 activities under which clinicians can report. Those participating in medical homes automatically receive full credit and those participating in Advanced APMs will receive at least 50 percent credit in this category. Diverse activities are offered, including participation in Transforming Clinical Practice grants such as ACR R-Scan, as well as an activity achievable with the use of QCDRs such as ACR NRDR.

Under MIPS, clinicians are paid fee-for-service tied to an annual payment adjustment based on a total composite performance score calculated from specific weighting of the above four performance categories. The payment adjustment increase over time as mandated by MACRA:

  • 2019: capped at +/-4 percent;
  • 2020: +/- 5 percent;
  • 2021: +/- 7 percent; and
  • 2022 and beyond: capped at +/-9 percent
MIPS applies to Medicare part B clinicians including physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified nurse anesthetists. Under MIPS, these clinicians are encouraged to report measures in as many categories as they can. A variety of considerations are made for those who do not have adequate measures to report in any of the four performance categories including reweighting categories to zero with transfer of weight to categories in which they qualify. Reporting under approved registries is encouraged. ACR’s National Radiology Data Registry (NRDR™) is an approved Qualified Clinical Data Registry (QCDR) that can assist with the reporting of measures and attestation under this new program.

It is anticipated that all clinicians who are enrolled in the Medicare program will begin to report measures in the relevant categories by January 1, 2017 which will affect their score for an aggregate pay out or penalty for 2019.

Alternatively, clinicians may become qualified APM participants (QPs) or partially qualified APM participants (PQPs) if their percent of revenue or number of Medicare patients is significant enough from participating in advanced alternative payment model entities. If a clinician can meet these thresholds, they do not need to report measures under MIPS. The QP revenue thresholds are:

  • 25 percent for 2019 and 2020;
  • 50 percent for 2021 and 2022; and
  • 75 percent for 2023 and beyond

In order for an APM to be considered an Advanced APM it must meet the following criteria:

  1. Use certified EHR technology
  2. Provide payments based on quality measures (QMs) comparable to MIPS QMs
  3. Have two-sided (bonus/penalty) financial risk meeting certain thresholds
Currently only a few types of APMs qualify as Advanced APMs which are Next Generation ACOs, Comprehensive ESRD Care, Comprehensive Primary Care Plus, Medicare Shared Savings Programs Track 2 and 3, and the two-sided risk Oncology Care Model. If clinicians end up only partially qualifying, a new intermediate pathway has been created to prevent potentially duplicative reporting requirements in groups caught in between MIPS and APMs This intermediate option gives partially qualifying APM clinicians the option to have an assigned composite performance score under MIPS, as well as receive the associated MIPS payment adjustments.

CMS intends to gradually phase-in intensity and complexity of reporting requirements over time. This will also give CMS time to consider how these new payment systems could expand beyond Medicare to include third-party payers.

CMS is proposing similar timelines, deadlines and measure reporting requirements throughout the Quality Payment Program in order to simplify as much as possible the implementation and ongoing participation in the program.

CMS also discusses potential criteria for the Physician-Focused Payment Model Technical Advisory Committee (PTAC). The PTAC is mandate by MACRA as an independent body that would evaluate all proposed alternative payment models by the medical community and is tasked with making recommendations to CMS. The ultimate authority for deeming a model as a qualified APM still lies with CMS.

CMS intends to notify the public of approved MIPS measures, list of Advanced APMs and other relevant data prior to the implementation date of January 1, 2019. This information would be released after there has been opportunity for stakeholders to comment during the current 60-day comment period and final decisions are release in a formal final rule process.

The ACR is currently analyzing this proposed rule and will continue to publish more detailed information as it relates to radiology.