Making $ense of MACRA: Year 3

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. (impacting your CY 2019 Medicare Part B payments)

Please visit ACG’s MACRA Year 2 summary here. (impacting your CY 2020 Medicare Part B payments)


MACRA Year 3: Background and Acronyms

On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year 2019 Physician Fee Schedule (PFS) final rule, which included the finalized changes for Year 3 of the Quality Payment Program Year (QPP). This final rule outlines the details of the Medicare reimbursement policy changes for the 2019 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  The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the Medicare sustainable growth rate (SGR) formula and created a new reimbursement system – the QPP – beginning in 2017 (impacting the 2019 reimbursement year).

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 revises incentives for participation in certain alternative payment models (APMs) that allow providers to be excluded from participating in MIPS.

MACRA 2019: The 2 Year Lag (Reporting Year vs. Reimbursement Year)

Key take-away: what happens to your current reimbursement depends on what you did 2 years ago.

Your CY 2019 quality reporting will impact your CY 2021 payment year, and what you did in CY 2017 will shape your CY 2019 Medicare fee-for-service payments.  If you successfully participated in the QPP in 2017, you may be eligible for a payment bonus, or at least avoid a reimbursement cut, in CY 2019.

In CY 2019, you will receive an annual fee schedule update of .11%, absent anything you may have done during the CY 2017 reporting year.  Under MACRA, providers receive an annual MACRA update of .5% through December 2019.  However, Congress reduced this to .25% in 2018.  CMS is also obligated to implement budgetary and other policy changes.  Thus, in 2019, the Medicare fee-for-service 2018 update is .11%, or a conversion factor of $36.04.

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

2019: No Longer a “Transition Year”

As you may recall, CMS made efforts to ease the transition into MACRA in quality reporting years 2017 and 2018.  If you made some sort of effort in quality reporting in CYs 2017 and 2018, you likely avoided a payment cut in CYs 2018 and 2019.

Key take away

Do I have to participate in the QPP in 2019?

Who must participate in the QPP? You do, if you are a:

  1. physician
  2. physician assistant
  3. nurse practitioner
  4. clinical nurse specialist
  5. certified registered nurse anesthetist (CRNA)
  6. physical therapist
  7. occupational therapist
  8. clinical social worker
  9. clinical psychologist

Those Not Subject to the QPP in 2019

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 2019, or
  • a GI practice below the 2019 “low volume threshold”:
    •  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, or
    • Provide 200 or fewer covered professional services in a year.

In other words: you must meet all three categories the “low volume threshold” to be eligible for the QPP.

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, small practices did not have to participate in MIPS during the 2019 reporting year due to this low-volume threshold.   As mentioned above, a GI practice is below the 2019 “low volume threshold” if the individual’s Medicare Part B allowed charges are less than or equal to $90,000 or sees less than or equal 200 Medicare Part B patients or provides 200 or fewer covered professional services in a year.

In addition to the “low-volume” threshold, solo practitioners and groups of 15 or fewer clinicians automatically earn 6 bonus points in the MIPS Quality performance category.  Please note that this replaces the “small practice bonus” added to the total MIPS score in CY 2018 reporting year.  CMS also awards small practices 3 points for submitted quality measures that don’t meet the data completeness requirements.  Small practices can also continue to submit quality data for covered professional services through the Medicare Part B claims submission type for the Quality performance category.

Can I volunteer to participate in the QPP and “opt in”?

Yes.  If you meet one of the “low volume threshold” criteria, you may opt-in MIPS and submit your data.  Please note: if you decide to opt-in you could be eligible for a payment bonus, but you could also be subject to a payment cut.

ACG Member Checklist: What are the steps I need to take?

Your first step: Check eligibility

First you need to find out whether you must participate in the QPP.  Visit the Medicare Quality Payment Program website to check your participation status by entering your national provider identifier (NPI) number.

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

Your next step requires you to decide what reimbursement system or “track” you can participate in for your Medicare fee-for-services patients.  This participation look-up will help you. The options:

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

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 “Meaningful Use” program 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.
  • 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 2019?

Quality
Cost Improvement Activities Promoting Interoperability
Total MIPS Score
45% of MIPS score 15% of MIPS score 15% of MIPS score 25% of MIPS score 100% of MIPS score

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 Scoring System

How do I participate in MIPS?

The options:

MIPS Scoring- Target is at least 30 points

As mentioned above, CMS set quite a low bar to meet the MIPS target scores in 2017 and 2018.  For 2017 and 2018 MIPS, the “target score” thresholds were 3 and 15 points.

In CY 2019, CMS increased this threshold to 30 points.  This means that you must score at least 30 points to avoid a payment cut in CY 2021.  The size of your cut will depend on the amount of data you submit for CY 2019, with up to a maximum cut of -7% of Medicare Part B allowable charges.

Clinicians who achieved a final score of 75 or higher may have been eligible for the “exceptional performance adjustment,” funded from a pool of $500 million (more on this below).

MIPS Payment Formula

The BAD: The Cuts… sliding scale from less than 30 points to maximum percent of -7% of your Medicare Part B allowable charges.  The maximum cuts from failing to participate in MIPS are defined in MACRA:

  • 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
2021 -7% 7% up to 21%
2022+ -9% 9% – 27%
MipsGraphic

Important note: Does that mean in 2021, the maximum penalty is -7%…  but a 7-21% 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 21% bonus in 2021, but this depends on the actual maximum reimbursement cut to other providers in that year.  It does not mean the successful MIPS scoring providers are assured a 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, more funds will become available 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.

Example: Lessons Learned from 2017

CMS recently provided performance data from 2017, which highlights this the “budget neutrality” dilemma.  According to CMS, there were roughly 1.1 million providers qualifying for MIPS in 2017, with roughly 1 million qualifying for a neutral or positive adjustment.

Roughly 5% received a payment cut, meaning that those roughly 1 million providers were left with a meager positive payment adjustment bonuses in payment year 2019, or +.28% – 1.88%.

“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).  In 2019, the target threshold score is 75.

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 2021 payment year (CY 2019 reporting year), CMS set this “exceptional performance category” score at 75.

Here’s how the sliding scale looks for 2019:

2020 Payment Year (2018 reporting year)
Final MIPS Score Payment Adjustment
0-7.5 You receive the maximum -7% payment cut.
7.51-29.99 You receive a payment cut that is less than -7%, depending on how your score falls in a linear sliding scale.
30 You receive no payment cut and are not eligible for a payment bonus.
30.01-74.99 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 to pay for the payment bonuses.
75-100 You are eligible for a payment bonus above 0%.

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 75+ points (capped at 10% for each provider), with a minimum of .5% bonus.

Bonuses Points for Complex Patients

Providers and groups can also earn a 5 bonus points to their MIPS score in 2019 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, 2019: MIPS performance year begins
  • October 2, 2019: last day to begin submitting 90 continuous days’ worth of 2019 data.
  • December 31, 2019: MIPS performance year ends
  • January 1, 2020: Medicare payment year based on your CY 2018 MIPS performance/reporting year
  • March 31, 2020: deadline for submitting for CY 2019 MIPS data

The MIPS Quality Performance Category

What do you need to know for 2019?

The Quality Category represents 45% of your MIPS score for the CY 2019 reporting year.  This performance category is like 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

(45% of MIPS score)

You select 6 measures from a list of 250+ 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 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 HERE!

Via a CMS-certified electronic health record.

Via a registry or an organization’s “quality clinical database registry.” CHECK OUT GIQUIC HERE!

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 submits your data to CMS for you.

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

Go to the ACG website or CMS’ Quality Payment Program website to find the list of quality measures for 2019, as well as the measure specifications for each measure.

This is important: KNOW THE NUMERATOR AND DENOMINATOR FOR EACH MEASURE.  CMS reviews your “data completeness” for each measure, or the percentage of each eligible case/service relevant to that specific measure (requirement is 60% for most GI practices).

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, 2020.

CAHPS surveys would count as your required “high priority measure.”  The survey, however, would only count as 1 quality measure.  You would need to submit the 5 other measures through another data submission mechanism.

Quality Category: Scoring

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

For 2019, 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 + hospital readmission measure x 10 points). The methodology:

  • Up to 10 points for each of the 6 measures reported and 10 points for 1 population measure (all-cause readmission measure) for groups of 16 or more.
  • Clinicians and groups reporting a measure set of more than 6 measures will 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 will 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 at least 15 total MIPS points for exceeding the completeness threshold for all measures).
  • 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 required.
  • Bonus also provided for use of certified electronic health record technology (CEHRT) (up to 6 possible bonus points).
  • In addition to the up to 6 bonus points for reporting these measures, solo practitioners and groups of 15 or fewer clinicians automatically earn 6 bonus points (replacing the “small practice bonus” added to the total MIPS score last year).

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 continuing to use this authority for group practices of 16 or more.  Practices do not actually report data.  Instead, CMS calculates an “all cause hospital readmissions” population-based measure for them based on Medicare claims data (minimum of 200 cases).

Quality Category: Improvement Score

For 2019, CMS will continue 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 calculates the improvement score by comparing your quality score to your quality scores in the prior year (i.e. 2018).  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, including one required outcome measure, 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 53 points for the Quality performance category, which would then be weighted to 45% of the total MIPS score.

(5 measures X 9 points) + (1 measure X 3 point small practice threshold) + (6 points for small practice bonus, awarded automatically) or 53 out of 60 possible points, 53/60 X 45 (weight of quality performance category) = 39.75 points toward the total MIPS score.

This performance alone already exceeds the 30-point performance threshold for 2019, which would avoid a payment reduction in 2021.

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 (ACR) measure.  Assume the group was awarded 10 points for high performance.  The group would receive 21 points for the Quality performance category, which would then be weighted to 45% of the total MIPS score.

(1 measure X 1 point) + (1 measure x 10 points) + (1 population measure X 10 points) or 21 out of 70 possible points, 21/70 x 45 (weight of quality performance category) = 13.5 points toward the total MIPS score.

The MIPS Promoting Interoperability (formerly Advancing Care Information) performance category

What do you need to know for 2019?

This category is like the “Meaningful Use” Program.

This category makes up 25% of total MIPS score each year.

Remember: each MIPS performance category has its own scoring system. You need to fulfill the requirements for each EHR measure to earn a score toward the Promoting Interoperability category. If you fail to report any measure without an exemption, you will get a 0 in the overall Promoting Interoperability performance category score.

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

Of course.

Here’s how it works:

In the Promoting Interoperability performance category, you are now required to have EHR certified to the 2015 Edition.

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

Performance Category Requirements Ways to submit data (individual) Ways to submit data (groups)
Promoting Interoperability

(25% of MIPS score)

Providers use 2015 CEHRT and submit patient data for 90 continuous days in the 2019 reporting year.

Report all five required measures and perform a Security Risk Analysis

Attestation (CMS web portal)

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

Via CEHRT

Attestation (CMS web portal)

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

Via CEHRT

CMS website (for groups of 25 or more)

The 2019 Promoting Interoperability Measures Set

2019 PI Measure Is this measure required? How much is the measure worth? What do I report?
Security Risk Analysis Yes 0 A “yes” or “no” statement
e-Prescribing Yes 10 The numerator/denominator
PDMP Query No 5 bonus points The numerator/denominator
Verify Opioid Treatment Agreement No 5 bonus points The numerator/denominator
Provide Patients Electronic Access Yes 40 points The numerator/denominator
Information Exchange: Send Health Information Yes 20 points The numerator/denominator
Information Exchange: Receive Health Information Yes 20 points The numerator/denominator
Public Health/Clinical Data Exchange Yes 10 points A “yes” or “no” statement (for two registries)

Measure 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 to earn any points toward the performance category. Similarly, a clinician who refers or transfers patients 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.

Important note: Previously, all you needed was to satisfy the measure for a single patient to get the full credit for a required measure. In 2019, measure points are “performance based” meaning they are calculated based on the number of patients for whom the measure is successfully completed out of the total possible.

Promoting Interoperability Scoring: Two Examples

Example 1:

A solo practitioner reports all objectives and measures but did not perform a Security Risk Analysis in 2019.  The clinician would receive 0 points for the Promoting Interoperability performance category, which would then be weighted 0% out of 25% of the total MIPS score. Reminder: Clinicians must complete each measure and perform an annual Security Risk Analysis to earn any points toward the category.

Example 2:

A group’s EHR technology was certified to the 2015 Edition.  They report all required measures and perform a Security Risk Analysis.  The group does all prescribing electronically, provides all its patients with access to electronic access to their medical records, and supports feedback loops by sending a receiving data for half of their patents.  The group also attests to using a clinical registry such as Gauci and reporting data to a relevant public health registry.  The group would earn 80 percentage points toward the Promoting Interoperability performance category, which would equate to 20 points toward the total MIPS score.

(e-prescribing measures X 10) + (provide patient access measures X 40) + (feedback look measure (send) 20 x 0.5 = 10) + (feedback look measure (receive) 20 x 0.5 = 10) + (clinical data exchange measure x 10) = 80 out of 100 possible points, or 80/100 X 25 (weight of performance category) = 20 points toward the total MIPS score.

Promoting Interoperability: 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 2019, CMS also maintains 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
  • Other non-physicians (e.g., therapists and dieticians)
  • Non-patient facing clinicians

CMS will reweight the Promoting Interoperability 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 70% of the total MIPS score for these individuals.

The MIPS Improvement Activities Performance Category

What do you need to know for 2019?

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 scores each year.  To earn full credit in this performance category, participants must submit one of the following combinations of activities (each activity must be performed for 90 continuous days or more during 2019): 2 high-weighted activities, 1 high-weighted activity and 2 medium-weighted activities, or 4 medium-weighted activities.

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 117 Improvement Activities and attest to incorporating these activities into daily practice for at least 90 continuous days during the 2019 reporting year.

Each activity is weighted as either medium (10 points) or high (20 points) 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 HERE!

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 HERE!

 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 118 differently weighted “Improvement Activities.”  Check out the ACG MACRA website for more information.  You can review and select activities that best fit your practice.  Some examples:

  • You can earn credit for various improvement activities by participating and using a qualified clinical data registry (QCDR), such as GIQuIC, in various ways.
  • You can earn for other activities such as: implementation of documentation improvements for practice/process improvements (medium), implementation of formal quality improvement methods, practice changes, or other practice improvement processes (medium), implementation of specialist reports back to referring clinician or group to close referral loop (medium), use evidence-based decision aids to support shared decision-making (medium), implementing of condition-specific chronic disease self-management support programs (medium weight).

Important: a simple attestation or “yes” is all that is required to report 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.  There are several ways to earn full credit:

  • Reporting of four medium-weighted activities would result in 40 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 a different weighted system for small practice (groups of 15 and under) as well as those in rural areas whereby the point values of measures are doubled, and thus:

  • Reporting of two medium-weighted activities would result in 40 points.
  • Reporting of one high-weighted activity would result in 40 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 would result in 40 points, full credit in the performance category, which is weighted 15% of the total composite MIPS score. This category’s score alone would result in one-half the total MIPS score needed to avoid a negative payment adjustment in 2021.

(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.

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 falls short of the 30-point performance threshold for 2019 and could result in a payment reduction in 2021 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 2019?

The Cost performance category is like 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 2019, CMS will use two of the same measures from the Value-Based Payment Modifier program (Total Per Capital Cost for All Attributed Beneficiaries [TPCC] and Medicare Spending Per Beneficiary [MSPB]) along with eight new episode-based cost measures, including one on screening/surveillance colonoscopy.

The Cost performance category is 15% of your total MIPS score in 2019.  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

(15% of total MIPS score)

CMS calculates this data from a provider’s Medicare claims data over the course of CY 2019 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 all the measures attributed to that clinician or group in 2019

CMS will weigh the cost measures equally if more than one measure is attributed. If only 1 measure can be scored, CMS will use 1 measure for the performance category. If 3 measures can be scored, CMS will average the scores of those 3 measures equally. If none of the measures can be scored, then the Quality performance category will be reweighted to 60%.

The MSPB measure will have a 35-patient case minimum.  CMS intends to use the minimum of 20 cases for the TPCC measure. Procedural episode-based measures have a 10-patient case minimum, while acute inpatient medical condition episode-based measures are a minimum of 20.  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 TPCC measure.

You report nothing for this performance category. You report nothing for this performance category.

Overview of the measures included in MIPS’ Cost performance category (2019)

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 the ratio of payment-standardized observed to expected MSPB episode costs for all a TIN/NPI’s eligible episodes.
Denominator The total number of MSPB episodes for the TIN/NPI or TIN.
Exclusions The following episodes are excluded where the beneficiary:

  • Is not continuously enrolled in both Medicare Parts A & B in the 93 days prior to admission through 30 days after discharge
  • Dies during the episode
  • Is enrolled in Medicare Advantage or Medicare was the secondary payer during the episode window and 90-day look back period
  • Has an index admission that did not occur in a “subsection (d) hospital” paid under IPPS or an acute hospital in Maryland
  • Was discharged for the index admission in the last 30 days of the performance period
  • Has an index admission that involved an acute-to-acute hospital transfer
  • Has an index admission occur within the 30-day post discharge period of another MSPB episode
  • Has an index admission inpatient claim indicates a $0 actual payment or a $0 standardized payment

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 the patient’s age and illness severity, using the CMS-Hierarchal Condition Category (CMS-HCC) indicators, recent long-term care status, ESRD status, and the MS-DRG code of the index admission.
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 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, 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 during the index admission. 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 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/National Provider Identifier (TIN/NPI). The TPCC measure can be reported at the TIN or the TIN/NPI level.
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/NPI, within a TIN or TIN/NPI (depending on the level of reporting) during the performance period.
Exclusion 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 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 once it is attributed to a TIN/NPI:(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/NPI 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/NPI or CMS Certification Number (CCN). 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 TIN/NPIs tie for the largest share of a beneficiary’s primary care services, then the beneficiary is assigned to the TIN/NPI that provided primary care services most recently.

Step 2: Beneficiaries who are not assigned to a TIN/NPI after the first step (because they did not receive any eligible primary care services from a PCP) may be assigned to the TIN/NPI if the beneficiary received more primary care services from non-primary care physicians within the TIN-NPI than in any other TIN-NPI or CCN. However, to be attributed to a TIN/NPI in the second step, a physician at the TIN (regardless of specialty) must have provided a primary care service to the beneficiary. If two TIN-NPIs tie for the largest share of a beneficiary’s primary care services, the beneficiary will be attributed to the non-primary care 
TIN- NPI that provided primary care services most recently. If the beneficiary received more PCS from non-primary care physicians from a CCN than any TIN-NPI, this beneficiary would be attributed to the CCN, would not be attributed to any TIN-NPIs, and would be excluded from risk adjustment.

If the beneficiary did not receive any primary care service via PCP, NP, PA, CNS or non-primary care physician, then the beneficiary would not be attributed

Each physician or group must have a minimum of 20 cases for this measure to apply.

New in 2019: “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.  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.  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 finalized a “Screening/Surveillance Colonoscopy” episode of care for gastroenterologists for implementation in 2019.

Screening/Surveillance Colonoscopy
Goal of measure Evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a screening or surveillance colonoscopy procedure during the performance period.
Numerator The ratio of observed to expected payment-standardized cost to Medicare for all Screening/Surveillance Colonoscopy episodes attributed to a clinician. This sum is then multiplied by the national average observed episode cost to generate a dollar figure.
Denominator Total number of episodes from the Screening/Surveillance Colonoscopy episode group attributed to a clinician during the performance period.
Exclusions Beneficiaries are excluded if they meet any of the following:

  • Has a primary payer other than Medicare for any time overlapping the episode window or 120-day lookback period prior to the trigger day.
  • Was not enrolled in Medicare Parts A and B for the entirety of the lookback period plus episode window or was enrolled in Part C for any part of the lookback plus episode window.
  • No main clinician is attributed to the episode.
  • The beneficiary’s date of birth is missing.
  • The beneficiary’s death date occurred before the episode ended.

The episode trigger claim was not performed in an ambulatory/office-based care, outpatient hospital, or ambulatory surgical center setting based on its place of service.

Risk and specialty adjustment The measure is adjusted to account for differences in clinical factors.
What costs are included? For the Screening/Surveillance Colonoscopy episode group, services performed in the following service categories are considered:

  • Emergency Department
  • Outpatient Facility and Clinician Services
  • Long Term Care Hospital (LTCH) – Medical
  • LTCH – Surgical
  • Inpatient (IP) – Medical
  • IP – Surgical
  • Inpatient Rehabilitation Facility – Medical

Additional criteria based on the presence of other diagnoses, procedures or billing codes or the specific timing of the service are also applied to determine whether specific costs should be included or excluded.

How is the measure calculated? CMS uses the following three steps to calculate measure once it is attributed to a TIN/NPI or TIN:

(1) Calculate the ratio of observed to expected episode cost for each episode attributed to the TIN/NPI or TIN,

(2) Calculate the average ratio of observed to expected episode cost across the total number of episodes attributed to the TIN/NPI or TIN,

(3) Multiple the average ratio of observed to expected episode cost by the national average observed episode cost to generate a dollar figure representing risk-adjusted average episode cost.

How are costs attributed? Episodes are defined by billing codes that open, or “trigger,” an episode. The episode window starts on the day of the trigger and ends 14 days after the trigger. Clinicians are attributed when he/she bills a trigger code for the episode group on the day of the procedure.

Each physician or group must have a minimum of 10 cases for this measure to apply.

Cost performance category: Improvement Score

In early 2018, Congress retroactively delayed this through reporting year 2021.


Track 2 Alternative Payment Models (APMs)

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 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:

  • For payment years from 2019 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%).
  • For payment years 2021 and later, eligible clinicians may become QPs through a combination of participation in Advanced APMs and Other Payer Advanced APMs (i.e., the “All-Payer Combination Option”).

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; however, there is a different scoring standard (more on this below).

Also, CMS also allows for “Partial QPs,” who can choose whether 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, 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)

75% 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.

Note that at least one of the quality measures and at least one of the outcome measures must be finalized on the MIPS final list, endorsed by a consensus-based entity, or determined by CMS to be evidence-based, 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?

Below is the list of payment models that would be considered an “Advanced APM” in 2019 (list tailored for GI; there are others):

  • Bundled Payments for Care Improvement (BPCI) Advanced)
  • Comprehensive Primary Care Plus (CPC+)
  • Medicare Shared Savings Program/ACOs – Track 2
  • Medicare Shared Savings Program/ACOs – Track 3
  • Next Generation ACO Model

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 2021 if:

  • You receive 50% of your Medicare Part B payments through an Advanced APM; or
  • See 35% of your Medicare Part B patients through an Advanced APM at one of the determination periods

You can use a CMS look-up tool to see whether you meet these Medicare patient volume and revenue thresholds: QPP Participation Status

CMS will look at your Medicare Part B professional services that are furnished through the APM Entity during 2019 (patients treated by the APM, or eligible to be treated by APM).  Your “patient count” or “payment count” must meet certain thresholds to be eligible as either a QP or Partial QP.

The determination of whether an ACG member has met the QP Thresholds for 2021 payment incentives will be based on your Payment Amounts and Patient Counts in 2019 (based on the specific determination period). A QP performance period is the full year, e.g. the 2019 QP Performance Period will be the entire 2019 calendar year.

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

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

2021 2022 2023+
QP 35% 35% 50%
Partial QP 25% 25% 35%

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

2021 2022 2023+
QP 50% 50% 75%
Partial QP 40% 40% 50%

CMS Takes “Snapshot” 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, 2019.  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, if 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 like 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 to be under the MIPS APM scoring standard.

All-Payer APMs- Starting in 2019

CMS will begin accepting Advanced APMs not only for Medicare, but also for payment models that include all payers (e.g., Medicaid, commercial, private).  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 payers, such as commercial insurers.

Beginning in 2019, the eligible clinicians who do not meet the Advanced APM QP threshold under Medicare only may request a QP determination under the All-Payer option, which includes Other-Payer Advanced APM arrangements.

To be an Other-Payer Advanced APM, the payment arrangement must meet the following criteria:

  • CEHRT use of at least 50% (to increase to 75% in 2020)
  • Payments must be based on quality measures comparable to those in the MIPS quality performance category with at least one outcome measure (if available) on the MIPS measure list
  • Participants must bear a certain amount of financial risk or be a Medicaid Medical Home Model (comparable to Medical Home Models)

Other-Payer Advanced APM determinations are based on information submitted by payers. Clinicians may submit, for approval, to CMS that they are part of an Other-Payer Advanced APM.

Next Steps

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