The Medicare Accessibility and CHIP Reauthorization Act (MACRA) was signed into law in April 2015 and introduces several changes to the current physician reimbursement framework. MACRA repeals the Sustainable Growth Rate formula and replaces it with a payment method that incentives value and quality of care over volume. It also streamlines three existing quality reporting programs (PQRS, Value-Based Payment Modifier and Medicare EHR Incentive Program) and a fourth (Clinical Practice Improvement Activities) into a single program known as the Quality Payment Program.
Clinicians can participate in the Merit-based Incentive Payment System (MIPS) or in Advanced Alternative Payment Models (APMs) in order to avoid downward payment adjustments and potentially receive upward adjustments. The performance period for MIPS begins January 1, 2017, and the first payment adjustments will be applied in 2019.
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MIPS allows Medicare clinicians to be paid for providing high-quality, efficient care through success in four performance categories:
During the 2017 reporting year, these four categories will be weighted according to the following chart:
* The majority of ACR members will likely be reweighted to zero for the Advancing Care Information category on the basis that non-patient-facing eligible clinicians and hospital-based eligible clinicians will be automatically reweighted by CMS without needing to manually apply for an exemption. In such case, the quality category would have a weight of 85 percent.
** The Cost category will not be included in reporting requirements until 2018.
The quality measures tables below contain instructions for reporting MIPS measures.
Note: Some of the above links have not yet been updated with 2017 information, but the reporting mechanisms will be the same as 2016 PQRS.
The performance period for the Merit-Based Incentive Payment System begins January 1, 2017, and the first payment adjustments will be applied in 2019. Reimbursement adjustments will be based on a 0 to 100 point scoring scale known as the MIPS Final Score. A MIPS-eligible clinician’s payment adjustment percentage is based on the relationship between their Final Score and the MIPS performance threshold.
A CPS below the performance threshold will yield a negative payment adjustment; a CPS above the performance threshold will yield a neutral or positive payment adjustment.
Unified scoring system:
Non-reporters and low-scoring providers will receive a downward adjustment of up to -4% in 2019, while high-performing providers may see upward adjustments of up to +4%. These figures will increase to +/-5% in 2020, +/-7% in 2021 and +/-9% from 2022 onward. Positive adjustments are also subject to additional scaling of up to 3x based on exceptional performance.
Note: MIPS will be a budget-neutral program. Total upward and downward adjustments will be balanced so that the average change is 0%.
During the first two performance years, MIPS will apply to physicians, PAs, NPs, clinical nurse specialists and certified registered nurse anesthetists. In the third year and onward the list of eligible clinicians will expand to include additional practitioners.
Three groups of clinicians will be excluded from MIPS participation: those in their first year of Medicare Part B participation, physicians below the low patient volume threshold and certain participants in Advanced Alternative Payment Models (APMs).
Affected clinicians are called "MIPS-eligible clinicians" and will participate in MIPS. The types of Medicare Part B eligible clinicians affected by MIPS may expand in future years.
For Alternative Payment Models (APMs) to allow Medicare clinicians to qualify for incentive payments, clinicians would have to receive enough of their payments or see enough of their patients through Advanced APMs. Advanced APMs are the CMS Innovation Center models, Shared Savings Program tracks, or statutorily required demonstrations where clinicians accept both risk and reward for providing coordinated, high-quality and efficient care. The proposed rule includes a list of models that would qualify as Advanced APMs.
APM participants who are not in Advanced APMs will be required to participate in MIPS and will receive favorable scoring in certain MIPS categories.