The Medicare Access & CHIP Reauthorization Act (MACRA) repealed the Medicare Sustainable Growth Rate (SGR) and replaces it with a new Quality Payment Program (QPP). Participating clinicians will be subject to payment adjustments based on their performance. Clinicians will follow either the Merit-based Incentive Payment System (MIPS) or Alternative Payment Model (APM) track depending on current reimbursement.
CMS has stated that they expect about 90% of MACRA clinicians to participate in MIPS. Eligible clinicians will follow the MIPS path unless they are in an Alternative Payment Model (APM).
Alternative Payment Model (APM)
Participating in a qualifying APM can award the clinician a 5% bonus payment from 2019-2024. Clinicians are part of an APM when either of the following conditions are met:
- 25% of Medicare payments are through an APM in 2017
- 20% of Medicare patients are through an APM in 2017
Clinicians are considered APM MIPS when they are not part of an Advanced APM.
Merit-based Incentive Payment System (MIPS)
The MIPS track combines three current Medicare programs (Meaningful Use, PQRS, & VBM) and adds an additional category. By 2020, clinicians will see payment adjustments from -9% to +27% based on a composite MIPS score from the four performance categories. Scores for each of the four categories are weighted based on a 1 to 100-point scale.
- Advanced Care Information (ACI) formerly Meaningful Use (MU)
- Quality Measures formerly known as Physician Quality Report System (PQRS)
- Resource Use (Cost) formerly known as Value Based Modifier (VBM)
- Clinical Practice Improvement Activities (CPIA)
MIPS PaymentsYour MIPS Composite Performance Score will be based on the following:
- Quality Reporting - 60%
- Advancing Care Information (ACI) - 15%
- Improvement Activities - 15%
- Resource Use (Cost) - 0%
The maximum negative and positive adjustments increase each reporting year:
Maximum Negative Adjustment
Maximum Positive Adjustment
Successful MACRA MIPS reporting requires the following:
- NextGen Regulatory Release (version 5.9/KBM 8.4) recommended upgrade in early 2018 (required by October 1, 2018). The application and KBM upgrade are performed at the same time. *
- NextGen Patient Portal or a patient portal solution
- NextGen Share
- NextGen HQM
- NextGen Care, NextGen Population Health, or another population health solution is recommended
*Pending release of MACRA 2018 Final Rule from CMS
The following clinicians are eligible for 2017 and 2018 reporting:
- Physicians (MD/DO and DMD/DDS)
- Physician Assistants
- Nurse Practitioners
- Clinical Nurse Specialists
- Certified Registered Nurse Anesthetists
Select clinicians and facilities are exempt from the MIPS program:
- First year Medicare participants
- Below low volume threshold
- Less than $30k in allowed Medicare charges
- Less than 100 Medicare patients seen in a year
- Participating in Medicaid Meaningful Use
- They will still need to upgrade by January 1, 2018 to participate in Meaningful Use Stage 3 and includes FQHCs, CHCs, and Planned Parenthood.
- Exempt but may be eligible after 2019:
- Physical Therapists
- Occupational Therapists
- Speech Language Pathologists
- Certified Nurse Midwives
- Clinical Social Workers
- Clinical Psychologists
- Dietitians/Nutritional Professionals
2017 MIPS Reporting Options
Clinicians are offered the following four MIPS reporting options for 2017:
- Don't Participate - The clinician will receive a negative 4% payment adjustment if no data is submitted for 2017.
- Submit Something - The clinician will avoid a negative payment adjustment if some data is submitted (ex: one QM and one ACI).
- Submit a Partial Year - The clinician will earn a neutral or small positive payment adjustment if 90 days of data is submitted.
- Submit a Full Year - The clinician will earn a positive payment adjustment if a full year of 2017 data is submitted.
Group vs Individual Reporting
MIPS participants must decide to report either as a group or an individual.
- When reporting as a group, all encounters are reported based on the tax ID number. Therefore, all encounters are reported together, regardless of the clinician.
- When reporting as an individual, encounters are reported based on the clinician’s NPI
MIPS Deep Dive
- Choose 6 measures out of about 300 for a minimum of 90 days for positive adjustment
- One measure must be an Outcome measure OR High Priority measure
- Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks
- Controlling High Blood Pressure
- Documentation of Current Medication
- Fall Risk Assessment
- Use of High Risk Medications in the Elderly
Advancing Care Information (ACI)In 2017 there are 2 measure sets available for reporting Advancing Care Information Objectives and Measures or 2017 Advancing Care Information Transition Objective and Measures:
- The measure sets are dependent on the participant's Certified EHR version.
- Fulfill the required base measures for a minimum of 90 days. Select from additional performance and bonus scores for additional credit.
- Security Risk Analysis
- Provide Patient Access
- Send Summary of Care
- Request/Accept Summary of Care
- A clinician must obtain 40 points total from available activities under 9 sub-categories:
- Expanded Practice Access
- Population Management
- Care Coordination
- Beneficiary Engagement
- Patient Safety and Practice Assessment
- Participation in an APM
- Achieving Health Equity
- Integrating Behavioral and Mental Health
- Emergency Preparedness and Response
- Attest for a minimum of 90 days for a positive adjustment.
- Anticoagulation Management Improvements
- Engagement of Community for Health Status Improvement
- Implementation of Medication Management Practice Improvements
- Participation in Population Health Research
Resource Use (Cost)
- CMS will collect cost data for informational purposes via Medicare claims submission.
- This will not have any impact on the overall composite score.
- Feedback will still be provided on this category in 2017 but will not affect 2019 payments.
Here are your first steps to planning your transition to MACRA:
- Determine your MACRA path: MIPS, APM MIPS, or Advanced APM
- Develop a MACRA road map and timeline for the next two years
- Work on getting organizational buy-in
- Create an upgrade budget and allocate resources
- Decide whether to report as a group or individual clinician
- Review the TempDev MIPS Toolkit
- Contact us to plan your successful MACRA transition
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