The Medicare Access and CHIP Reauthorization Act (MACRA) redesigns payment in the Medicare program beginning in 2019. The program MACRA creates is called the Quality Payment Program (QPP).
The payment changes and reporting that starts in 2019 will be based on data submitted by physicians in 2017. Andy Slavitt, Acting Administrator of CMS, announced a “Pick Your Pace” approach to data submission in 2017 that was settled upon in the final rule. Physicians who submit ANY data in 2017 can avoid a negative payment adjustment. Physicians who submit more data may get a positive payment adjustment.
CAFP urges California family physicians to prepare. The first step is to become familiar with the law, understand its structure and the new ways physicians will be measured and paid. A starting point to gain familiarity with the law is to explore the Quality Payment Program website and review the Quality Payment Program Overview Fact Sheet.
Physicians will participate in one of two tracks in the Quality Payment Program: 1) the Merit-Based Incentive Payment System (MIPS); or 2) Advanced Alternative Payment models (APMs). Most California family physicians will participate in the MIPS program. This is not a choice or the result of any action. In the final rule, CMS defined APMs narrowly and few California family physicians are in qualifying programs. CMS anticipates that the following will be deemed Advanced APMs in the 2017 performance year:
- Medicare Shared Savings Program (Track 2 and 3)
- Next Generation Accountable Care Organization Model
- Comprehensive End Stage Renal Disease Care – two-sided track
- Comprehensive Primary Care Plus
- Oncology Care Model (two-sided risk track available in 2018)
CMS intends to broaden opportunities for clinicians to participate in Advanced APMs by retrofitting existing models to qualify as Advanced APMs and using the CMS Innovation Center to create new models. For the 2018 performance year, CMS anticipates the following models will be added to the list above:
- ACO Track 1+
- New Voluntary Bundled Payment Model
- Advancing Cardiac Care through Episode Payment Models
Merit-Based Incentive Payment System
MIPS evaluates physicians in four performance categories: Quality, Resource Use, Clinical Practice Improvement Activities (CPIAs) and Advancing Care Information (ACI), however in the final rule CMS decided not to evaluate Resource Use in the first year of the Program. MIPS combines these three (2017) or four (2018 and beyond) evaluations to create a Composite Performance Score. CMS proposes to weight the four categories, as illustrated in the chart below, with a greater emphasis on quality in the first year. As a starting point to understanding these performance categories, recognize that three of them draw from existing CMS programs, as noted in this table:
|Performance Category||Weight||Draws on Existing Program|
|Quality||60 Percent||Physician Quality Reporting System (QPRS)|
|Resource Use||0 Percent||Value Based Payment Modifier (VM)|
|Clinical Practice Improvement Activities (CPIA)||15 Percent|
|Advancing Care Information||25 Percent||Meaningful Use|
MIPS evaluates "Eligible Clinicians” (ECs). ECs include physicians (MD/DO/DMD/DDS), physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. Some physicians are excluded from MIPS, including newly enrolled physicians, physicians participating in APMs and physicians below a low-volume threshold (i.e., a provider billing charges less than $30,000 OR who provides care for 100 or fewer Part B-enrolled Medicare beneficiaries annually).
ECs can have their performance assessed as a group if they meet a certain definition. Groups will have their performance assessed as a group across all four performance categories. For ECs who practice in rural health clinics or Federally Qualified Health Centers, who bill for services under the RHC/FQHC all-inclusive rate, the MIPS adjustment would not apply.
For each performance period, ECs or groups will report at least six quality measures, including one outcome measure. ECs will choose measures from a long list provided by CMS.
Resource Use is CMS’s way of measuring physician costs and will compare applicable resources used to treat similar care episodes across practices. CMS will not evaluate Resource Use until 2018.
Clinical Practice Improvement Activities
CPIA measures participation in quality improvement activities. There are more than 90 activities to choose from and physicians must participate in four activities for at least 90 days during the measurement year. Participants in certified Patient Centered Medical Homes (PCMH) automatically earn full credit. ECs who participate in an APM that does not qualify as an Advanced APM earn half of the highest potential score automatically and may report additional activities to increase their score.
Advancing Care Information
This category streamlines the current EHR Meaningful Use program with a new scoring methodology. There are five required measures in the final rule and all other measures are optional. Reporting on all five of the required measures will earn ECs 50 percent; reporting on optional measures will allow the EC to earn a higher score. For 2017, CMS will award bonus score for CPIAs that utilize EHRs and for reporting to public health or clinical data registries.
Resource Use will be measured using Medicare claims data and there is no separate reporting by ECs in that category. In the other three performance categories, MIPS data may be submitted through a qualified registry, a Qualified Clinical Data Registry, a health IT vendor that obtains data from the EC’s certified EHR technology (CEHRT) or a CMS-approved survey vendor.
The MIPS Composite Performance Score methodology is complicated. Suffice it to say, after the transition year of 2017, payment may be adjusted (positively or negatively) based on whether an EC scores above or below a performance threshold. CMS will use a sensitivity analysis to determine where the performance threshold is set annually, with approximately 50 percent of ECs above that threshold and 50 percent below. For payment years 2019 through 2024, an additional positive adjustment of $500 million will be distributed each year to those ECs who meet the “exceptional performance” threshold.
Composite scores and performance scores will be published on the Physician Compare website, as well as aggregate information on the range of MIPS composite scores and range of performance by category.
Alternative Payment Models
Between 2019 and 2025, qualifying participants who participate in the Advanced APMs described above will be excluded from the MIPS program and will be eligible to receive an annual lump sum incentive payment equal to five percent of their prior year’s payments for Part B-covered professional services. Starting in 2026, qualified participants will receive a higher annual fee schedule update than ECs participating in the MIPS program – a .75 percent increase rather than the standard .25 percent increase. CMS has established criteria for APMs and then a threshold amount to be an Advanced APM.
CAFP is developing additional, action-oriented resources to help you get ready for data submission in 2017. Coming soon:
- QPP for Small and Rural Family Physicians. Small and rural practices face unique challenges with QPP, but will have unique opportunities in terms of technical assistance and anticipated accommodations in the regulations. CAFP will develop outreach and educational materials to assist these members.
- QPP 201. Following publication of the final regulations, CAFP will offer programming to help family physicians develop a strategy for their practices. Learn how to select and report on measures that benefit your practice, patients and bottom line.
Any questions? Contact CAFP’s Director of Health Policy, Conrad Amenta.