Making $ense of MACRA: Year 2

ACG Hopes to Keep This Simple.
ACG continues to provide membership with educational guidance in a simple, easy-to-understand fashion.

We compiled a detailed overview for you that seeks to make some sense out of this alphabet soup, including acronyms such as MACRA, QPP, MIPS, APMs, etc. – but hopefully in a simplified fashion and in plain English.

Please visit ACG’s MACRA Year 1 summary here.


MACRA Year 2: Background and Acronyms

On November 2, 2017, the Centers for Medicare and Medicaid Services (CMS) released the “Quality Payment Program Year 2” final rule, outlining the details of the Medicare reimbursement policy changes for the 2018 reporting year.  The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the Medicare sustainable growth rate (SGR) formula and created a new reimbursement system beginning in 2017 (impacting the 2019 reimbursement year).  In implementing MACRA, CMS calls this new program the “Quality Payment Program” (QPP).

CMS released the QPP Year 2 rule on November 2, 2017 and published the rule in the Federal Register on November 16, 2017.   This rule outlines the details of the Merit-Based Incentive Payment System (MIPS), the modified Medicare Part B fee-for-service program for certain participating practitioners.  This rule also establishes incentives for participation in certain alternative payment models (APMs) that allow providers to be excluded from participating in MIPS.

MACRA 2018: The 2 Year Lag (Reporting Year vs. Reimbursement Year)

What happens to your current reimbursement depends on what you completed 2 years ago. Thus, your CY 2018 quality reporting will impact your CY 2020 payment year, and what you did in CY 2016 will shape your CY 2018 Medicare fee-for-service payments.  If you successfully participated in a physician quality reporting system (PQRS), “Meaningful Use,” etc. back in 2016, you may be eligible for a payment bonus in CY 2018.

In CY 2018, you will receive an annual fee schedule update of .41% absent anything you may have done during the CY 2016 reporting year.  Under MACRA, providers receive an annual MACRA update of .5% through December 2019.  However, CMS is also obligated to implement budgetary and other policy changes.  Thus, in 2018, the Medicare fee-for-service 2018 update is .41% as opposed to .5%.

2018 is another “Transition Year”

As you may recall, CMS eased the transition into MACRA in 2017.  If you made some sort of effort in quality reporting in CY 2017, you would avoid a payment cut in CY 2019.  (More on 2017:  Making $ense of MACRA: 2017.)  CMS also provided a side-by-side comparison that summarizes the final changes to the requirements for MIPS and APMs for calendar year 2018 compared to 2017.

CMS estimates that there are 11,298 MIPS-eligible GI clinicians in CY 2018.  According to CMS estimates, 3% would receive a reimbursement cut in CY 2020, while 97% would be eligible for a bonus, or would at least avoid a payment cut.  The estimates for smaller practices are not as positive: CMS approximates that there are 116,626 MIPS-eligible clinicians in practice sizes of 1 to 15. Of these practices, 9% are expected to receive a payment cut.

Key take away: The maximum payment cut for the 2020 payment year is 5% for those who do not report MIPS measures in CY 2018. This is a deeper cut from the 4% payment adjustment for not participating in MIPS in 2017 (which impacts payment in CY 2019).

Do I have to participate in the QPP in 2018?

Who has to participate in MACRA? You do, if you are a:

  1. physician
  2. physician assistant
  3. nurse practitioner
  4. clinical nurse specialist; or
  5. a certified registered nurse anesthetist (CRNA)

**In the future (from CY 2021 and beyond) Medicare will also have the authority to add other providers to MIPS, such as:

  • Physical or occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians/nutritional professionals.

Those Not Subject to the QPP in 2018

You may be exempt from the QPP if you are:

  • a newly Medicare-enrolled eligible clinician during the reporting period, i.e. those in the FIRST year of Medicare Part B participation in CY 2018
  • a practice below the 2018 “low volume threshold” of Medicare Part B allowed charges that are less than or equal to $90,000 or see less than or equal 200 Medicare Part B patients in a year.

Impact on Smaller and Rural GI Practices- 15 or fewer eligible clinicians in your practice

This is where being a solo practitioner or practicing in a small practice (15 or fewer QPP-eligible clinicians) may help you.

You may be excluded from the QPP and not have to do anything.  According to CMS, many small practices did not have to participate in MIPS during the 2017 transition year due to this low-volume threshold. For the CY 2017 performance period, the agency set this threshold at less than or equal to $30,000 in Medicare fee-for-service allowed charges, or less than or equal to 100 Medicare fee-for-service patients.  CMS increases this threshold (thus excluding more providers) in CY 2018.

The low-volume threshold in 2018 is less than or equal to $90,000 in Medicare fee-for-service allowed charges, or less than or equal to 200 Medicare fee-for-service patients.

Your first step: Check eligibility

Visit the Medicare Quality Payment Program website to check your “eligibility” by entering your national provider identifier (NPI) number.

Your next step (if you must participate): Pick your payment track

Your next step requires you to decide what reimbursement system or “track” you want to participate in for your Medicare fee-for-services patients.

These 2 tracks include:

  1. A modified fee-for-service reimbursement system called the Merit-Based Incentive payment System (MIPS); or
  2. An alternative way to get paid, like participating in a bundled payment or accountable care organization (ACO) payment model. Certain CMS-approved payment mechanisms are call “advanced alterative payment models.”

Track 1 MIPS

What is the “Merit-Based Incentive Payment System (MIPS)”?

  • MIPS consolidates the former Medicare quality reporting programs: PQRS, the Value Modifier and the EHR Meaningful Use program (now called “Advancing Care Information”) into one composite program.
  • MIPS is broken down into 4 performance categories, with different weights for each category.
  • CMS will develop a “composite score,” or total performance score from each category, using a scoring scale of 0 to 100.  This target score will be based upon previous years’ actual composite score data or other quality reporting data if no prior year data exists (i.e. in 2019 and 2020).
  • This aggregate score from each performance category will be compared to the CMS “target score.”
  • The provider’s reimbursement will be adjusted (bonus, cut, or no update) on a sliding scale based on a comparison of all other providers’ scores (remember the 2 year lag).
  • The provider still submits Medicare fee-for-service claims, but reports other information as well.

What are the MIPS performance categories and weights for CY 2018?

Quality Reporting Cost Improvement Activities Advancing Care Information (“Meaningful Use”) Total Score
50% of total MIPS score 10% of total MIPS score 15% of total MIPS score 25% of total MIPS score 100%

Gets a little complicated here: Providers will have scores for each MIPS performance category.  The scores for each category have their own separate scoring system.  CMS will then take the scores from each category, multiply that score by the respective conversion weight, which will convert your score to a numerical 0-100 aggregate score.

MIPS Aggregate Scoring System

Quality Performance category score x quality performance category weight

+

Cost Performance category score x cost performance category weight

+

Improvement Activities performance category score x improvement activities performance category weight

+

Advancing Care Information performance category score x advancing care information performance category weight

= Your final MIPS score

How do I participate in MIPS?

You have the option of participating in MIPS:

  • As an “Individual” (using your national provider identifier (NPI) and each tax identification number (TIN) you are assigned to)
  • As part of your “Group Practice” (defined as 2 or more clinicians under the single TIN)
  • As a “Virtual Group” (can be compromised of solo practitioners and groups of 10 or fewer eligible clinicians to collectively participate in MIPS as if they were part of the same group practice)

MIPS Scoring- Target is at least 15 points

As mentioned above, CMS set quite a low bar to meet the MIPS target score in 2017.  For 2017 MIPS, the “target score” threshold was 3 points.  Any effort to participate would be sufficient to avoid a payment cut in 2019.

In CY 2018, CMS increased this threshold to 15 points.  This means that you must score at least 15 points to avoid a payment cut in CY 2020.  The size of your cut will depend on the amount of data you submit for CY 2018, with up to a maximum cut of 5% of Medicare Part B allowable charges.

Clinicians who achieved a final score of 70 or higher may have been eligible for the “exceptional performance adjustment,” funded from a pool of $500 million (more on this below).

The bare minimum: How I can avoid the cut and achieve 15 points?

Examples of how to do this include:

  • Meeting the Improvement Activities performance category
  • Meeting the Quality performance category
  • Meeting the Advancing Care Information performance category’s base score, and then submitting 1 measure in the Quality performance category
  • Meeting the Advancing Care Information performance category’s base score, and then submitting 1 medium-weighted measure in the Improvement Activities performance category

MIPS Payment Formula

The BAD: The Cuts… sliding scale from less than 15 points to maximum percent of 5% of your Medicare Part B allowable charges.  The maximum cuts from failing to participate in MIPS are defined in MACRA:

  • 2020       -5% (based on CY 2018 reporting year)
  • 2021       -7% (based on CY 2019 reporting year)
  • 2022+    -9% (based on CY 2020 reporting year)

The GOOD: The Bonuses… Scaling Factor up to 3x the maximum cut to determine the positive adjustment.

However, MACRA is subject to budget neutrality.

Year Maximum Cut Bonus
2020 -5% 5% up to 15%
2021 -7% 7% up to 21%
2022+ -9% 9% up to 27%
MipsGraphic

Important note: Does that mean in 2020, the maximum penalty is 5%…  but a 5-15% bonus is included for successfully participating in MIPS? 

  • Language from MACRA: “The Secretary may adjust the positive payment percentage by a scaling factor to maintain budget neutrality but may not exceed 3X.”
  • A provider could be eligible for up to a 15% bonus in 2020, but this depends on the actual maximum reimbursement cut to other providers in that particular year.  It does not mean the successful MIPS scoring providers are assured a 4-12% bonus.

Umm… Huh?

  • “Budget Neutrality”: Bonuses are to be proportional to cuts.  The total amount paid out must be equal to the total amount of penalties assessed for budget neutrality that year.

KEY TAKEAWAY: IN ORDER FOR THE POOL OF BONUS MONEY TO EXIST, THERE MUST FIRST BE CUTS.

  • This suggests that as the cuts get higher, and the requirements gets fully implemented, the funds will become available in order to provide MIPS bonuses. This also suggests that as CMS “transitions” clinicians into MIPS and helps clinicians with avoiding reimbursement penalties, there is also limited funds for MIPS bonuses.

CMS estimates that there are 11,298 MIPS-eligible GI clinicians. According to CMS estimates, 3% would receive a reimbursement cut in CY 2020, while 97% would be eligible for a bonus, or would at least avoid a payment cut.  Thus, there must be a higher ratio of low scoring providers in other specialties.

“Exceptional Performance Bonus”

MACRA provides that the 25th percentile of all aggregate scores receive additional bonus that is NOT subject to budget neutrality rules (2019 – 2025).  For example, in 2018, the target threshold score is 70.

Though MACRA allows CMS some leeway in determining the exceptional performance category, the following general rules are set:

  • Payments are comprised of $500 million distributed evenly each year for 6 years.
  • Bonus capped at 10% per eligible provider.
  • Not subject to budget neutrality rules.

For the 2019 and 2020 payment years, CMS set this “exceptional performance category” score at 70.
Here’s how the sliding scale looks for 2018:

2020 Payment Year (2018 reporting year)
Final MIPS Score Payment Adjustment
0-3.75 You receive the maximum 5% payment cut.
3.76-14.99 You receive a payment cut that is less than 5%, depending on how your score falls in a linear sliding scale.
15 You receive no payment cut and are not eligible for a payment bonus.
15.01-69.99 You are eligible for a payment bonus, depending on how your score falls in a linear upwards scale, and if there are providers receiving a payment cut in order to pay for the payment bonuses.
70-100 You are eligible for a payment bonus, depending on how your score falls in a linear upwards scale, and if there are providers receiving a payment cut in order to pay for the payment bonuses.

AND

You are eligible for the “exceptional performance” payment bonus.  This is not subject to budget neutrality rules.  The amount of the $500 million depends on how many providers are scoring 70+ points (capped at 10% for each provider).

Bonuses and Points for Small Practices and Complex Patients

CMS defines a “small practice” as practices consisting of 15 or fewer MACRA-eligible clinicians.  For the reporting year 2018, CMS will add 5 additional points to the total MIPS score to small practices (groups or individuals).  In order to receive this bonus, however, the provider or group must submit data on at least 1 MIPS performance category.

Providers and groups can also earn a 5% bonus to their MIPS score in 2018 for treating complex patients.  “Complexity” is based on medical complexity, as measured by the Hierarchical Condition Category (HCC) risk score, and a score based on the percentage of dual-eligible (Medicare and Medicaid) beneficiaries.  Clinicians or groups must submit data on at least 1 performance category in an applicable performance period to earn the bonus.

The Important Dates:

  • January 1, 2018: MIPS performance year begins
  • October 2, 2018: last day to begin submitting 90 continuous days’ worth of 2018 data.
  • December 31, 2018: MIPS performance year ends
  • March 31, 2019: deadline for submitting for CY 2018 MIPS data

Peeling Back the Onion: More on the MIPS Performance Categories & Weights

The MIPS Categories

The MIPS Quality Performance Category

What do you need to know for 2018?

The Quality Category represents 50% of your MIPS score for the CY 2018 reporting year.  This performance category is similar to old PQRS, where you choose from a list of CMS-approved quality measures and choose the way you can submit your data.

Performance Category Requirements Ways to submit data (individual) Ways to submit data (groups)
Quality

(50% of MIPS score)

You select 6 measures from a list of 270+ measures. If fewer than 6 measures apply, the GI clinician would be required to report on each measure that is applicable.  The reporting period is the entire CY 2018.

1 measure must be labeled an “outcome” measure or “high priority.”

CMS also provided a suggested list of common quality measures reported by GI providers.  This is known as the “gastroenterology specialty measure set.”  It is not required that ACG members select measures from this list.

You must include at least 60% of Medicare Part B patients who are applicable for each measure you select, over the course of the entire year (reporting period is full calendar year).

On your Medicare reimbursement claims form.

Via a registry or an organization’s “quality clinical database registry.” CHECK OUT GIQUIC TO LEARN HOW TO GIQUIC DO THIS FOR YOU!!

Via a CMS-certified electronic health record.

 

 

Via a registry or an organization’s “quality clinical database registry.” CHECK OUT GIQUIC TO LEARN HOW TO GIQUIC DO THIS FOR YOU!!

CMS website (for groups of 25 or more).

Via a CMS-certified electronic health record.

 

 

Please note: Participation in these “qualified clinical database registries” such as GIQUIC can also earn you credit for other categories.  The registry compiles and submit your data to CMS for you.

Where do I go to select a measure and find measure requirements?

Go to the ACG website or Medicare Quality Payment Program resource library to find the list of measures for 2018, as well as the measure specifications for each measure.

This is important: KNOW THE NUMERATOR AND DENOMINATOR FOR EACH MEASURE.  ACG IS HERE TO HELP.

MIPS-approved Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey

CMS will continue to allow registered groups of two or more MIPS-eligible clinicians to voluntarily elect to participate in an approved CAHPS for MIPS survey.

For the applicable 12-month performance period, the group must have the CAHPS for MIPS survey reported on its behalf by a CMS-approved survey vendor.  CMS requires that the survey administration period span at least 8 weeks and end no later than February 28, 2019.

CAHPS surveys would count as your required “high priority measure.”  The survey, however, would only count as 1 quality measure.  You need to submit the 5 other measures through another data submission mechanism.  Although, MIPS-eligible clinicians may be awarded points under the “clinical improvement activities.”

Quality Category: Scoring

Remember: Each MIPS performance category has its own scoring system.  Scores from each performance category will be converted into an aggregate MIPS score (scale of 0-100).

For CY 2018, CMS states that the maximum quality performance score will continue to be 60 points for solo practitioners and groups of 15 or fewer clinicians (6 submitted measures x 10 points =60)  and 70 points for groups of 16 or more reporting the population measure (6 submitted measures x 10 points + ACR measure x 10 points). The methodology:

  • 10 points for each of the 6 measures reported and 10 points for 1 population measure for groups of 16 or more.
  • Clinicians and groups reporting a measure set of more than 6 measures would be credited for their performance on their best 6 measures.
  • Clinicians and groups who do not satisfy the 60% data completeness standard for a quality measure would receive 1 point.  However, CMS will continue to award small practices 3 points for measure that don’t meet data completeness requirements.
  • Clinicians and groups who satisfy the 60% data completeness standard for a quality measure receive 3 points at minimum.  (Thus, you would earn above the 15 total MIPS points threshold and avoid a payment cut).
  • 2 bonus points for each outcome and patient experience measure reported.
  • 1 bonus point for other high priority measure reported in addition to the one high priority measure required (10 possible points).
  • Bonus also provided for use of certified electronic health record technology (CEHRT) (up to 10 possible bonus points).

Quality: Performance Requirements – Population-Based Measures

MACRA provides that the Secretary may use global measures, such as global outcome measures, and population-based measures for purposes of the quality performance category—CMS is choosing to use this authority for group practices of 16 or more.  This will be included in the providers’ overall Quality score.  Practices do not actually report data.  Instead, CMS will calculate an “all cause hospital readmissions” population-based measure for them based on Medicare claims data (minimum of 200 cases).

Quality Category: Improvement Score

For 2018, CMS will begin to include an “improvement component” to the Quality performance category.  Quality improvement scoring is calculated at the category level (not for each measure) for up to 10 points toward the total score.  CMS will do this by comparing your quality score to your quality scores in previous years.  The methodology is captured by the following equation:

Quality Improvement Score = (Absolute Improvement/Previous Year Quality Performance Category Percent Score Prior to Bonus Points) / 10

An Example of Quality Scoring: Solo Practitioner

If a MIPS-eligible solo practitioner submitted 5 quality measures, and scored 9 out of 10 on each measure, but reported another measure that was below the required data completeness standard, the clinician would receive 40 points for the Quality performance category, which would then be weighted to 50% of the total MIPS score.

(5 measures X 9 points) + (1 measure X 3 point small practice threshold) or 48 out of 60 possible points, 48/60 X 50 (weight of quality performance category) = 40 points toward the total MIPS score.

This performance alone already exceeds the 15 point floor for the transition year, which would avoid a payment reduction in 2020.  The solo practitioner would also be eligible for a “small practice” bonus for the final MIPS score.

An Example of Quality Scoring: Group Practice of 20

If a group of 20 MIPS-eligible physicians reported on only 2 measures, but failed to meet the data completeness standard of 60% for one, the group would receive the minimum floor of 1 point for one measure and up to 10 points for the other. Additionally, the group will be automatically scored on the population-based measure.  Assume the group was awarded 10 points for high performance.  The group would receive 15 points for the Quality performance category, which would then be weighted to 50% of the total MIPS score.

(1 measures X 1 point) + (1 measure x 10 points) + (1 population measure X 10 points) or 21 out of 70 possible points, 21/70 x 50 (weight of quality performance category) = 15 points toward the total MIPS score.

The MIPS Advancing Care Information performance category

What do you need to know for 2018?

This category is similar to the “Meaningful Use” Program.  However, CMS is attempting to reduce practice management burdens by focusing more on health IT functionality (what the EHR can do) and interoperability (who the EHR can communicate with).

This category makes up 25% of total MIPS score in 2018.

Remember: each MIPS performance category has its own scoring system. You need to fulfill the requirements of all the “Base Score” measures. If these requirements are not met, you will get a 0 in the overall Advancing Care Information performance category score.

…. this category is still related to Meaningful Use, so it has to be a bit more complicated, right?

Of course.

Here’s how it works:

In the Advancing Care Information performance category, you may score above 100% for this specific category, but will be capped at 100%.  This structure was deliberately created by CMS to “ensure that clinicians have flexibility to focus on measures that are the most relevant to them and their practices.”

Also, the measures you report depend on the type of CEHRT you have.

Don’t know what year your CEHRT is certified?  Click here.

Performance Category Requirements Ways to submit data (individual) Ways to submit data (groups)
Advancing Care Information

(25% of MIPS score)

 

Providers use 2014 or 2015 CMS-certified electronic health record technology (CEHRT), and submit patient data for 90 continuous days in the 2018 reporting year.

Report the required measures of the “base score” (50% total score)

Not required but:

Report on additional measures for a “performance score” (up to 90%)

Earn bonus points for measures (up to 15-25%)

Attestation (CMS web portal)

Via a registry or an organization’s “quality clinical database registry.”

Via a CMS-certified electronic health record

 

Attestation (CMS web portal)

Via a registry or an organization’s “quality clinical database registry.”

Via a CMS-certified electronic health record

CMS website (for groups of 25 or more)

 

 

 

2014 vs. 2015 CEHRT: Different CEHRT Means Different Advancing Care Information Measure Sets  

Now you have a fork in the road.  You use 1 of 2 measure sets, depending on the year in which your EHR system was certified by CMS.

MIPS-eligible clinicians can report the “Advancing Care Information objectives and measures” if you have:

  • EHR Technology that CMS has certified in the 2015 Edition of CEHRT; or
  • A combination of technologies from the 2014 and 2015 Editions of CEHRTs.

MIPS-eligible clinicians can alternatively report the “Advancing Care Information transition objectives and measures” if you have:

  • Technology certified to the 2015 Edition; or
  • Technology certified to the 2014 Edition; or
  • A combination of technologies certified to the 2014 and 2015 Editions

The 2018 “Advancing Care Information Objectives and Measures” Set

2018 ACI Measure Is this measure required for Base Score? (50%) How much is the measure worth for the Performance Score? (90%) What do I report?
Security Risk Analysis

 

Yes 0 A “yes” or “no” statement
e-Prescribing

 

Yes 0 The numerator/denominator
Provide Patient Access

 

Yes Up to 10% The numerator/denominator
Send Summary of Care

 

Yes Up to 10% The numerator/denominator
Request/Accept Summary of Care Yes Up to 10% The numerator/denominator
The Performance Score. “Building off of base score.” You can also earn a higher percentage score from better performance in the following required measures:
Patient-Specific Education No Up to 10% The numerator/denominator
View, Download, and Transmit No Up to 10% The numerator/denominator
Secure Massaging No Up to 10% The numerator/denominator
Patient-Generated Health Data No Up to 10% The numerator/denominator
Clinical Information Reconciliation No Up to 10% The numerator/denominator
Additional Performances Score Measures where you can earn a maximum of 10% (combined)
Immunization Registry Reporting No 10% A “yes” or “no” statement
Syndromic Surveillance No 10% A “yes” or “no” statement
Electronic Case Reporting No 10% A “yes” or “no” statement
Public Health Registry Reporting No 10% A “yes” or “no” statement
Clinical Data Registry Reporting No 10% A “yes” or “no” statement

 The 2018 “Advancing Care Information Transition Objectives and Measures” Set

2018 ACI Measure Is this measure required for Base Score? (50%) How much is the measure worth for the Performance Score? (90%) What do I report?
Security Risk Analysis

 

Yes 0 A “yes” or “no” statement
e-Prescribing

 

Yes 0 The numerator/denominator
Provide Patient Access

 

Yes Up to 20% The numerator/denominator
Health Information Exchange Yes Up to 20% The numerator/denominator
The Performance Score. “Building off of base score.” You can also earn a higher percentage score from better performance in the following required measures:
Patient-Specific Education No Up to 10% The numerator/denominator
View, Download, and Transmit No Up to 10% The numerator/denominator
Secure Massaging No Up to 10% The numerator/denominator
Medication Reconciliation No Up to 10% The numerator/denominator
Additional Performances Score Measures where you can earn a maximum of 10% (combined)
Immunization Registry Reporting No 10% A “yes” or “no” statement
Syndromic Surveillance No 10% A “yes” or “no” statement
Specialized Registry Reporting No 10% A “yes” or “no” statement

 Please Note New Measure/Objective Exclusions: There are exclusions for e-Prescribing and Health Information Exchange measures. A clinician writing fewer than 100 prescriptions may be exempted from the e-Prescribing measure, but is required to attest to qualifying for the exclusion in order to satisfy the base score and earn points toward the performance category. Similarly, a clinician who refers or transfers a patient to another setting fewer than 100 times during the performance period may be exempted from the Health Information Exchange measure if the clinician attests to qualifying for the exclusion.

The 2018 “Advancing Care Information Objectives and Measures” Set Bonuses

2018 ACI Measure How much is this worth? What do I report?
Report to one or more additional public health agencies or clinical data registries  beyond the one used for the Performance Score 5% bonus A “yes” or “no” statement
Report MIPS’ Improvement Activities performance using CEHRT 10% bonus A “yes” or “no” statement
Report measures only using 2015 edition of CMS-certified CEHRT 10% bonus A “yes” or “no” statement

 The 2018 “Advancing Care Information Transition Objectives and Measures” Set Bonuses

2018 ACI Measure How much is this worth? What do I report?
Report to one or more additional public health agencies or clinical data registries  beyond the one used for the Performance Score 5% bonus A “yes” or “no” statement
Report MIPS’ Improvement Activities performance using CEHRT 10% bonus A “yes” or “no” statement

 Advancing Care Information Scoring (Base Score + Performance Score + Bonuses)

How is the Base Score Calculated?

MIPS-eligible clinicians need to fulfill the requirements of all the “base score” measures in order to receive the 50% base score. The base score is necessary– If these requirements are not met, you will get a 0 in the overall Advancing Care Information performance category score.

In order to receive the 50% base score, MIPS-eligible clinicians must submit a “yes” for the security risk analysis measure, and at least 1 patient in the numerator for the numerator/denominator of the remaining measures.  The “good news” is that some of the base score measures can also contribute towards your Performance Score.

Important note: All you need is 1 patient to get the full credit for a required measure.

How is the Performance Score Calculated?

The “Performance Score” is calculated by looking at the numerators and denominators submitted for each measure.  Think of “performance” as the number of patients you report that are applicable to that measure.  Do not confuse with health outcomes or reporting performance.

The potential total performance score is 90%. For each measure with a numerator/denominator, the percentage score is determined by the “performance rate.”

Performance Rates for Each Measure When Worth up to 10%
Performance Rate 1-10 = 1% Performance Rate 51-60 = 6%
Performance Rate 11-20 = 2% Performance Rate 61-70 = 7%
Performance Rate 21-30 = 3% Performance Rate 71-80 = 8%
Performance Rate 31-40 = 4% Performance Rate 81-90 = 9%
Performance Rate 41-50 = 5% Performance Rate 91 – 100 = 10%

There are 2 measures with a Performance Score worth up to 20%.  You would use the same chart above, but multiply by 2.

Example: If you submit a numerator and denominator of 85/100, your performance rate would be 85%, and they would earn 9 percentage points for that specific measure.

Advancing Care Information Scoring: Two Examples

Example 1:

A solo practitioner reports all objectives and measures of the base score, but did not report any measures toward the performance score.  The clinician would receive 50 points for the Advancing Care Information performance category, which would then be weighted 25% of the total MIPS score.

(5 measures X 10%) + (0 measure X 10%) or 50 out of 100 possible points, or 50/100 X 25 (weight of MIPS performance category) = 12.5 points toward the total MIPS score.

Example 2:

A group’s EHR technology was certified to the 2015 Edition.  They report all objectives and measures of the Base Score.  They also report 6 measures in the Performance Score with a 100% performance rate.  They also attest to using a clinical or specialized registry such as GIQuIC.  The group would earn 125 percentage points toward the Advancing Care Information performance category.  Because a clinician or group cannot exceed 100 percentage points, the score would be reduced to 100%, which would then be weighted at 25% of the total score.

(5 measures X 10%) + (6 measures X 10%) + (15% bonus) or 125 out of 100 possible points, or 100/100 X 25 (weight of performance category) = 25 points toward the total MIPS score.

Advancing Care Information: Hardship Exemptions and Exclusions

You can still claim a hardship exemption for this performance category like you could under the old Meaningful Use program.  A MIPS-eligible clinician or group may submit a “Quality Payment Program Hardship Exception Application,” citing one of the following specified reasons:

  • Insufficient Internet Connectivity
  • Extreme and Uncontrollable Circumstances
  • Lack of Control over the availability of CEHRT

In 2018, CMS also expanded hardship exemption categories to:

  • Solo practitioners and small groups (15 or fewer)
  • Ambulatory Surgical Center (ASC) based clinicians— however, you must have 75% or more of all services and billings in the ASC setting (POS 24).
  • MIPS-eligible clinicians whose EHR was decertified.

Important: Know the status of clinicians in your practice! “Special Status Clinicians”

There are some MIPS-eligible clinicians that are considered “Special Status,” who will be automatically reweighted and do not need to submit a Quality Payment Program Hardship Exception Application.  Special Status clinicians include the following:

  • Hospital-based MIPS-eligible clinicians
  • Physician Assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Non-patient facing clinicians

CMS will reweight the Advancing Care Information performance category to 0% of the final score and reallocate this performance category weight of 25% to the MIPS Quality performance category.  Thus, the new Quality performance category would be 75% of the total MIPS score for these individuals.

The MIPS Improvement Activities Performance Category

What do you need to know for 2018?

This category was established in MACRA.  MACRA defines a “clinical improvement activity” as “an activity that relevant eligible clinician organizations and other relevant stakeholders identify as improving clinical practice or care delivery, and that the Secretary determines, when effectively executed, is likely to result in improved outcomes.”

CMS now calls this category “Improvement Activities.”  This category is 15% of the total composite MIPS score in 2020+.

Performance Category Requirements Ways to submit/attest to improvement activities (individual) Ways to submit/attest to improvement activities (group)
Improvement Activities

 

(15% of total MIPS score)

Providers select from a list of 112 differently weighted Improvement Activities and attest to incorporating these activities into daily practice over 90 continuous days during the 2018 reporting year.

Each activity is individually weighted to determine a score within this category.

Attestation on CMS website

Via a registry or an organization’s “quality clinical database registry.” CHECK OUT GIQUIC TO LEARN HOW TO GIQUIC DO THIS FOR YOU!

Via a CMS-certified electronic health record

 

Attestation on CMS website

Via a registry or an organization’s “quality clinical database registry.” CHECK OUT GIQUIC TO LEARN HOW TO GIQUIC DO THIS FOR YOU!

 Via a CMS-certified electronic health record

CMS website (groups of 25 of more)

What are the individual “Improvement Activities”?

CMS has a list of 112 differently weighted “improvement activities.”  Check out the ACG MACRA website as well.  You can review and select activities that best fit your practice.  Some examples:

  • You can earn credit for ACG CME courses: “Medical Education (CME) programs as eligible to receive improvement activity credit and allow other improvement activities in the inventory to count towards CME” (medium weight).
  • You can earn credit for participating in qualified clinical data registry, such as GIQuIC.
  • You can earn for other activities such as: MIPS-Eligible Clinician Leadership in Clinical Trials or CBPR (medium weight); Provide Education Opportunities for New Clinicians (high weight); Participation in Population Health Research (medium weight); Improved Practices that Engage Patients Pre-Visit (medium weight); Measurement and Improvement at the Practice and Panel Level (medium weight); Implementation of formal quality improvement methods, practice changes, or other practice improvement processes (medium weight).

Important: a simple attestation or “yes” is all that is required to completing an Improvement Activity.

Important for Groups/Virtual Groups: only one clinician in each TIN must attest to performing an Improvement Activity for the TIN to get credit.

What is the Improvement Activities scoring system?
Remember: Each MIPS performance category has its own scoring system.

You can earn a maximum of 40 points to receive the highest score for the improvement activities performance category.  Some examples:

  • Reporting of one medium-weighted activity would result in 10 points.
  • Reporting of two medium-weighted activities would result in 20 points.
  • Reporting of three medium-weighted activities would result in 30 points.
  • Reporting of four medium-weighted activities would result in 40 points.
  • Reporting of one high-weighted activity would result in 20 points.
  • Reporting of two high-weighted activities would result in 40 points.
  • Reporting of a combination of medium-weighted and high-weighted activities where the total number of points achieved are calculated based on the number of activities selected, and the weighting assigned to that activity (number of medium-weighted activities selected x 10 points + number of high-weighted activities selected x 20 points).

Small Practices: CMS has finalized a different weighted system for small practice (groups of 15 and under) as well as those in rural areas:

  • Reporting of one medium-weighted activity would result in 20 points.
  • Reporting of two medium-weighted activities would result in 40 points.
  • Reporting of one high-weighted activity would result in 40 points.
  • Reporting of one medium-weighted activity would result in 20 points.

Those ACG members participating in certain APMs (more on APMs below) would get credit in this MIPS performance category.

  • Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: you will automatically earn full credit.
  • Participants in certain APMs under the APM scoring standard, such as an accountable care organization or “ACO” Shared Savings Program Track 1 or the Oncology Care Model: you will automatically be scored based on the requirements of participating in the APM.
  • For all current APMs under the APM scoring standard, this assigned score will be the full credit.
  • For all future APMs under the APM scoring standard, the assigned score will be at least half credit.
  • Participants in any other APM: You will automatically earn half credit and may report additional activities to increase your score.

Improvement Activities performance category: Scoring Examples

Example 1:

A solo practitioner attests to 2 medium-weighted Improvement Activities. This performance already meets the 15 point “performance threshold” for 2018 to avoid a payment reduction in 2020.

(2 medium-weighted activities x 20 points) or 40 out of 40 possible points.  The weight of the Improvement Activity performance category is 15%.  Thus 40/40 x 15 = 15 points toward the total MIPS score.

**Combined with the 5 point bonus for small practices and/or performance in other categories, the solo practitioner could earn points toward a MIPS payment bonus**

Example 2:

If a group of 26 MIPS-eligible physicians attests to two activities: 1 medium-weighted activity and 1 high-weighted activity, the group would receive 30 points for the Improvement Activities performance category, which is weighted 15% of the total MIPS composite score. This performance alone does not meet the 15 point performance threshold for 2018, and could result in a payment reduction in 2020 without submitting additional performance data in other MIPS performance categories.

(1 medium-weighted activity X 10 points) + (1 high-weight activity X 20 points) or 30 out of 40 possible points.  The weight of the Improvement Activity performance category is 15%.  Thus 30/40 x 15 = 11.25 points toward the total MIPS score.

 The MIPS Cost Performance Category

What do I need to know for 2018?
The Cost performance category is similar to Medicare’s program formerly known as the Value-Based Payment Modifier, where CMS looks at your submitted Medicare claims and groups them together to determine whether you are a “high cost” provider when compared to other providers submitting similar billing codes.  This performance category is designed to measure and compare the costs of your services versus other providers performing the same services.  For 2018, CMS will use two measures from the Value-Based Payment Modifier program in 2018.

The Cost performance category is 10% of your total MIPS score in 2018.  Unlike the other MIPS performance categories, you do not have to report anything to CMS.  CMS calculates the data for you.

Performance Category Requirements Ways to submit/attest to improvement activities (individual) Ways to submit/attest to improvement activities (group)
Cost

 (10% of total MIPS score)

CMS calculates this data from a provider’s Medicare claims data over the course of CY 2018 reporting year.

Performance is compared against performance of other clinicians/groups during the performance year (it is not based on a previous year).

The performance score is the average of 2 measures: Medicare Spending per Beneficiary (MSPB); and total per capita cost.

CMS will weigh the two cost measures equally. If only 1 measure can be scored, CMS will use 1 measure for the performance category.

The MSPB measure will have a 35 patient case minimum.  CMS intends to use the minimum of 20 cases for the total per capita cost measure.  All cost measures will continue to be adjusted for geographic payment rate adjustments and beneficiary risk factors. In addition, a specialty adjustment will be applied to the total per capita cost measure.

 

You report nothing for this performance category.

 

You report nothing for this performance category.

Overview of the 2 measures included in MIPS’ Cost performance category (2018)

Medicare Spending per Beneficiary (MSPB)
Goal of measure To assess the cost to Medicare of services performed by TIN/NPIs during an MSPB episode. The episode comprises of the period immediately prior to, during, and following a patient’s hospital stay.
Numerator The TIN/NPI’s average MSPB Amount.  MSPB amount is defined as the sum of standardized, risk-adjusted spending across all of a TIN/NPI’s eligible episodes divided by the number of episodes for that TIN/NPI.
Denominator The MSPB expected cost based on the national expected cost of all eligible TIN/NPIs.
Exclusions The following episodes are excluded:

  • Those with episodes where at any time 93 days before admission through 30 days post-discharge, the beneficiary is enrolled in a Medicare Advantage plan, or Medicare is the secondary payer.
  • Episodes where the beneficiary dies.
  • Regarding beneficiaries whose primary insurance becomes Medicaid during an episode due to exhaustion of Medicare Part A benefits, Medicaid payments made for services rendered to these beneficiaries are excluded. However, all Medicare Part A payments made before benefits are exhausted and all Medicare Part B payments made during the episode are included.
  • Episodes where the index admission inpatient claim has $0 actual or standardized payment.
  • Acute-to-acute transfers are not considered to be index admissions.
  • Admissions to hospitals that are not reimbursed by Medicare through the IPSS system are not considered to be index admissions.
  • Note: if an acute-to-acute transfer or hospitalization in a PPS-exempt hospital occurs during the post-discharge timeframe, those costs will be included.
Risk adjustment The measure is adjusted to account for differences in patient populations and case mix using the diagnosis-related group (DRG).
How the episode is defined? An MSPB episode includes all Medicare Part A and Part B claims with a start date falling between 3 days prior to an IPPS hospital admission (index admission) through 30 days post-hospital discharge.  CMS’ rationale for the 30-day post-discharge inclusion is that an episode includes the 30 days after a hospital discharge in order to emphasize the importance of care transitions and care coordination in improving patient care. Only discharges occurring at least 30 days before the end of the performance period are counted as index admissions. Admissions that occur within 30 days of discharge from another index admission are not considered to be index admissions.
What costs are included? All Medicare Parts A and B claims during the performance period that include inpatient hospital; outpatient; skilled nursing facility; home health; hospice; durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); and Medicare Part B carrier (non-institutional physician) claims.

(Part D-covered prescription drug costs are not included.)

How is the measure calculated? CMS uses the observed-to-expected cost ratio for each MSPB episode assigned to the MIPS-eligible clinician or group and takes the average of the assigned ratios. Then CMS takes the average ratio for the MIPS-eligible clinician or group and multiplies it by the average of observed costs across all episodes nationally, in order to convert a ratio to a dollar amount.
How are costs attributed? The measure is attributed to the TIN/NPI or NPI that has the plurality of claims for both individuals and groups. Plurality is determined by TIN/NPI, but for individuals, the measure is attributed to the specific TIN/NPI being evaluated, and for groups, it would be attributed to any TIN/NPI billing under the TIN. Plurality is based on the Part B services performed by eligible professionals (EPs) during the index hospitalization. These services are those physician services that are billed on non-institutional claims and from the time of the admission date and discharge date.

Each physician or group must have a minimum of 35 cases in order for this measure to apply.

 

Per Capita Costs for All Attributed Beneficiaries
Goal of measure Evaluates the overall efficiency of care provided to beneficiaries attributed to solo practitioners and groups, as identified by their Medicare Taxpayer Identification Number (TIN).
Numerator The sum of Medicare Part A and Part B costs for each beneficiary. Costs are payment standardized, annualized, risk adjusted, and specialty adjusted.
Denominator All Medicare beneficiaries who received Medicare-covered services and are attributed to a TIN during the performance period.
Exclusions Beneficiaries are excluded if they meet any of the following:

  • Were not enrolled in both Medicare Part A and Part B for every month during the performance period, unless partial year enrollment was the result of new enrollment or death.
  • Were enrolled in a private Medicare health plan (for example, a Medicare Advantage HMO/PPO or a Medicare private FFS plan) for any month during the performance period.
  • Resided outside the United States, its territories, and its possessions during any month of the performance period
Risk and specialty adjustment The measure is adjusted to account for differences in demographic and clinical factors.  It also has a specialty adjustment applied after the measure is calculated to address differences in specialty mix within a practice.
What costs are included? All Medicare Parts A and B final action claims during the performance period that inpatient hospital; outpatient hospital; skilled nursing facility; home health; hospice; durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); and Medicare carrier (non-institutional physician/supplier) claims.

(Part D-covered prescription drug costs are not included.)

How is the measure calculated? CMS uses the following three steps to calculate measure:

(1) Medicare Part A and Part B costs for services provided to beneficiaries are payment standardized and annualized,

(2) The annualized payment-standardized per capita costs are risk adjusted,

(3) The (annualized payment-standardized) risk-adjusted costs are then specialty adjusted.

How are costs attributed? CMS uses a 2-step attribution process for this measure.

Step 1: A beneficiary is attributed to a TIN if the TIN’s primary care physicians (PCPs)—defined as family practice, internal medicine, geriatric medicine, or general practice physicians—accounted for a larger share of allowed charges for primary care services for the beneficiary than PCPs of any other TIN. Primary care services include evaluation and management services provided in office and other non-inpatient and non–emergency-room settings, as well as initial Medicare visits and annual wellness visits. CMS also expanded this definition to include the transitional care management and chronic care management codes and excluded skilled nursing facility codes in the 2017 MACRA final rule. If two TINs tie for the largest share of a beneficiary’s primary care services, then the beneficiary is assigned to the TIN that provided primary care services most recently.

Step 2: Beneficiaries who are not assigned to a TIN after the first step (because they did not receive any eligible primary care services from a PCP) may be assigned to the TIN whose Step 2 Professionals [i.e., physician specialists, nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs)] accounted for more Medicare allowed charges for primary care services than any other TIN. However, in order to be attributed to a TIN in the second step, a physician at the TIN (regardless of specialty) must have provided a primary care service to the beneficiary. If the beneficiary did not receive a primary care service from a physician at the TIN whose Step 2 Professionals provided more primary care services to the beneficiary than any other TIN, then the beneficiary will not be attributed to any TIN.

Beneficiaries who do not receive any primary care service from a physician during the performance period are not attributed.

Each physician or group must have a minimum of 35 cases in order for this measure to apply.

Cost performance category: Improvement Score

When there is sufficient data to calculate year-over-year improvement (i.e., consecutive years of performance of the same cost measure), the cost performance score will include an improvement component.  Unlike the Quality improvement score – which is calculated at the category level – cost improvement scoring will be calculated at the measure level (up to 1 point). When there is not sufficient data to calculate a cost improvement score, the score will be set at 0.

Coming Down the Pike: “Episodes of Care” in GI for this performance category

MACRA requires CMS to develop an “episode of care” to include in the MIPS’ Cost performance category.  An “episode of care” is a defined group of health services, over a specific period of time.  The goal is to attribute medical costs to the corresponding medical provider.  How does CMS do this?  What do you do?

CMS looks at your reimbursement claims and other providers’ Medicare claims for the same patient and attempts to assign — or attribute — the cost of those patient’s services to a certain provider, the theory being that one provider has primary control over the costs of those services for that patient.  This is where it gets tricky, because we all know that in reality, this may not be true.  Providers still submit Medicare fee-for-services claims as you normally would.  This is all “behind the scenes” work at Medicare.

CMS then looks at the claims and checks for a “trigger” service.  This will trigger a review of all services provided to a patient over that defined period of time.  CMS then includes and/or excludes certain services over that time-period, and produces a cost figure.  CMS then compares this cost to other providers falling into the same episode.  From there, CMS will assign a MIPS performance category to you.

CMS is currently developing a “Screening/Surveillance Colonoscopy” episode of care for gastroenterologists.  Stay tuned.


Track 2 Alternative Payment Models

What’s the difference between an “Advanced Alternative Payment Model” vs. an “Alternative Payment Model”?

MACRA does not create new alternative payment models, such as accountable care organizations or bundled payments.  MACRA does, however, authorize incentives to encourage participation.

Unlike MIPS, participants of any APM submit data to the APM entity, and not CMS.  The APM entity then aggregates this data and submits to CMS.

In short, Advanced APMs are a subset of APMs.  They are approved APMs that CMS has labeled “Advanced APMs.”  Advanced APM entities must meet certain requirements outlined in MACRA and subsequent QPP regulations in order to be eligible for financial incentives.  Participants in Advanced APMs become a “qualified participant,” or a “QP,” by joining these Advanced APM entities and meeting certain requirements.  The biggest difference is that you are also excluded from the MIPS if you are in an Advanced APM.  Some other perks:

  • From 2020 through 2024, QPs receive a lump sum incentive payment equal to 5% of their prior year’s payments for Medicare Part B covered professional services.
  • For 2026 and future years, QPs receive a higher Medicare fee schedule annual update (0.75%) under the Medicare physician fee schedule versus non-QPs (0.25%).

You do have the opportunity to participate in an APM that is not considered an “Advanced APM.”  If so, you would be required to participate in MIPS.  There is a different scoring standard (more on this below)

Also, CMS also allows for “Partial QPs,” who can choose whether or not they wish to be subject to a MIPS payment adjustment.

Advanced Alternative Payment Models

As mentioned above, Advanced APMs are a “MACRA-approved” subset of APMs that are approved by CMS.  MACRA provides the blueprint for CMS to determine whether an APM can become an “Advanced APM.”  Under MACRA, in order to be an Advanced APM, the payment model must meet 3 requirements:

  • Requires the use of Certified EHR Technology (CEHRT); and
  • Provides payment based on quality measures comparable to MIPS quality measures; and
  • The entity must bear financial risk for monetary losses “in excess of a nominal amount.”

** CMS also considers primary care “medical homes” to be an Advanced APM.  Medical home models are subject to different requirements.  Since these models are largely primary care-based, this summary does not get into the details of medical home models.

The first requirement: Requires the use of Certified EHR Technology (CEHRT)

50% of the APM’s participants must be using certified health IT.

The second requirement: Provides payment based on quality measures comparable to MIPS quality measures

Your payment through the APM will be based on quality measures that meet the following requirements:

  • Any of the quality measures included on the proposed annual list of MIPS quality measures;
  • Quality measures that are endorsed by a consensus-based entity;
  • Quality measures developed under the old PQRS;
  • Quality measures submitted in response to the annual CMS “Call for MIPS’ Quality Measures;” or
  • Any other quality measure that CMS determines to have an evidence-based focus and be reliable and valid.

The third requirement: The entity must bear financial risk for monetary losses “in excess of a nominal amount”

The Advanced APM can meet this “nominal amount standard” commitment by 1 of 2 ways:

  • A “revenue-based standard”: The APM is willing to risk 8% of the average estimated total Medicare Parts A and B revenues of a participating APM entity for CYs 2018, 2019, and 2020; or
  • A “benchmark-based standard”: The APM is willing to risk 3% of expected expenditures for which an APM entity is responsible for all performance years.

If actual APM expenditures exceed APM expected/targeted expenditures during the performance period, CMS can:

  • withhold payment for services to the APM entity and/or the APM entity’s eligible clinicians;
  • reduce payment rates to the APM entity and/or the APM entity’s eligible clinicians; or
  • require the APM entity to owe payment(s) to CMS.

What is an example of an Advanced APM?

In 2018, the list of payment models that would be considered an “Advanced APM” is the same as 2017 (list tailored for GI; there are others):

  • Comprehensive Primary Care Plus (CPC+)
  • Medicare Shared Savings Program/ACOs – Track 2
  • Medicare Shared Savings Program/ACOs – Track 3
  • Next Generation ACO Model
  • Medical Home

Each of these models have different rules, but share the same basic theme: the participants share both the responsibility and risk in providing care to meet certain quality and financial benchmark targets.

Learn about specific Advanced APMs and how to apply.

What are the “rules of participation” for each APM and Advanced APM? How are the benefits split up for each participating provider?

While MACRA and CMS have requirements for APMs and Advanced APMs, each APM entity will have their own rules, requirements, and contract agreements.  There are different rules of “engagement” or participation for each APM entity.  This is one of the reasons why practical guidance is difficult—outside of the rules outlined by CMS and MACRA, each APM entity’s leadership sets their own rules and requirements regarding services and how payments are allocated.  ACG is here to help.

How do I become an Advanced APM qualifying participant or QP?
If you want to be part of an Advanced APM model and receive potential financial incentives, you need to be considered a “qualifying participant” or “QP.” If you are considered a QP, you’ll earn the 5% incentive payment in 2020 if:

  • You receive 25% of your Medicare Part B payments through an Advanced APM; or
  • See 20% of your Medicare Part B patients through an Advanced APM

You can use a CMS look-up tool to see whether you meet these Medicare patient volume and revenue thresholds:  Qualifying APM Participant (QP) Look-up Tool

CMS will look at your Medicare Part B professional services that are furnished through the APM Entity during 2018 (patients treated by the APM, or eligible to be treated by APM).  Your “patient count” or “payment count” must meet certain thresholds.

The determination of whether an ACG member has met the QP Thresholds for 2020 payment incentives will be based on your Payment Amount Counts and Patient Counts in 2018. A QP performance period is the full year, e.g. the 2018 QP Performance Period will be the entire 2018 calendar year.

After CMS looks at your patient and payment counts, CMS will use whichever threshold method is more favorable to you.

Medicare Part B Patient Count Threshold (remember the 2 year lag)

2020 2021 2022 2023+
QP 20% 35% 35% 50%
Partial QP 10% 25% 25% 35%

 

Medicare Part B Payment Count Threshold (remember the 2 year lag)

2020 2021 2022 2023+
QP 25% 50% 50% 75%
Partial QP 20% 40% 40% 50%

 

CMS Takes “Snaps Shot” of APM Participation throughout the Year

CMS will identify the QPs for each Advanced APM Entity by taking snapshots of the APM participation or affiliated practitioner list on March 31, June 30, and August 31, 2018.  CMS will then provide notice to clinicians of QP determinations during the summer of the following year.  For Advanced APMs that start or end during the QP performance period, QP Threshold Scores are calculated using only the dates that APM Entities were able to participate in the Advanced APM, as long as they were able to participate for at least 60 continuous days during the QP performance period.

QP Determinations at the Group Level

QP determinations will be made at the clinician group level, rather than an individual level. If that eligible clinician group’s collective score meets the relevant QP threshold, all eligible clinicians in that group will receive the same QP determination.

However, CMS will assess the eligible clinician individually when the provider participates in multiple APMs, using combined information for services associated with that individual’s NPI and furnished through all such eligible clinician’s Advanced APM Entities during the QP Performance Period.

What is a MIPS APM?

There may be APM entities and APM participants that do not meet the Advanced APM requirements, or the participants might not meet the requirements to become a “QP.”  CMS has also allowed MIPS APMs, and has developed a scoring standard that is similar to MIPS, but a bit different.  This scoring standard applies to APM entities that:

  • Have an agreement with CMS;
  • include 1 or more MIPS-eligible clinicians as participants; and
  • agree to a payment incentive tied to cost and quality

The MIPS APM scoring standard:

Quality 50%
Cost 0%
Improvement Activities 20%
Advancing Care Information 30%

CMS Takes “Snaps Shot” of MIPS APM Participation throughout the Year

As mentioned above, CMS takes a snapshot of your APM participation throughout the year to determine whether you meet the requirements to become a QP.  The last snapshot is August 31st.  CMS also takes a 4th snapshot to determine MIPS APM participation.  CMS does this to allow participants who joined APMs between September 1 and December 31 of the performance year in order to be under the MIPS APM scoring standard.

All Payor APMs- Starting in 2019

CMS announced that it will begin accepting Advanced APM models not only for Medicare, but also for payment models that include all payors.  This means that you could achieve “QP status” (and be eligible to receive incentive payments) based upon your participation in APMs in Medicare and with other payors, such as commercial insurers.

Please note that this will begin in the CY 2019. Stay tuned for more information on this option.

MACRA: Further Down the Road

Annual Physician Fee Schedule Updates

MIPS:

2020 – 2025: 0.0% update for fee-for-service

2026+: 0.25% update for fee-for-service

Also Subject to Individual Provider’s MIPS Score (cut, neutral payment, bonus)

APMs:

2019 – 2024: 5% annual update

2025: 0% APM update

2026+: 0.75% APM annual update

Not subject to MIPS (after 2019) but subject to APM Rules on Risk-Sharing

Next Steps

Stay tuned, as ACG will continue to provide you with simple and easy-to-understand information on how MACRA impacts GI.