Making $ense of MACRA

MAKING $ENSE OF MACRA

CMS….SGR… MACRA… MIPS… APMs… QCDRs… ACOs… Why does Washington D.C. love acronyms and complicated payment systems?  What the heck is going on here?

ACG Hopes to Keep This Simple
ACG has reviewed the law and continues to review the final rule that implements MACRA.  We compiled a detailed overview for you that seeks to make some sense out of this alphabet soup – but hopefully in a simplified fashion and in plain English.  In the upcoming days, ACG will focus on certain segments of this new payment system, delving more into the specifics but in piecemeal and in brief summaries.  This way, we hope the busy GI clinician is not overloaded with lengthy explanations, complicated charts, and more acronyms all at the same time.

Background

On April 27, 2016, the Centers for Medicare and Medicaid Services (CMS) released the much anticipated proposed rule, outlining details of how ACG members participating in Medicare will be reimbursed beginning 2019.  The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), enacted April 16, 2015, repealed the Medicare sustainable growth rate (SGR) formula and created a new reimbursement system beginning 2019.

CMS released the final rule on October 14, 2016.  This rule outlines the details of the Merit-Based Incentive Payment System (MIPS), a new program for certain Medicare-participating practitioners.  This proposed rule also establishes incentives for participation in certain alternative payment models (APMs), supporting the Administration’s goals of moving more fee-for-service payments into APMs.

MACRA: What Happens Now?
Congress repealed the SGR formula in 2015, along with the annual ritual of looming cuts that came with it, and the obligatory congressional intervention at the last minute for the temporary fix.

MACRA Update:

2017 – December 2019: A 0.5% annual update each year for Medicare fee for service providers

MACRA:  MIPS & APMs will drive your payment update 2019 and forward

Beginning in 2017, most physicians will be required to choose whether to be evaluated based on performance measures and activities under the Merit-based Incentive Payment System (MIPS) or to participate in an Advanced Alternative Payment Model (APM).

Beginning Jan 1, 2019- MIPS payment adjustment begins.

THIS IS BASED ON YOUR 2017 REPORTING YEAR DATA.

2017 is a “Transition Year”

Here is what you need to know for 2017:  CMS views CY 2017 as a transition year to ease Medicare providers into MIPS.  In September of 2016, CMS eased earlier reporting requirements, so that even if you make some sort of effort in quality reporting in CY 2017, you will not receive a cut in 2019.

Providers who submit 90 consecutive days of 2017 data may earn a neutral or small positive payment adjustment.

  1. If you don’t send in any 2017 data, then you receive a 4% payment cut in 2019.
  2. If you submit a minimum amount of 2017 data to Medicare, you can avoid a downward payment adjustment.  For example, one quality measure, or one improvement activity.
  3. If you submit a continuous 90-days’ worth of 2017 data to Medicare, you will avoid the payment cut and be potentially be eligible for a bonus payment.
  4. If you submit a full year of 2017 data to Medicare, then according to CMS, you may earn a moderate payment bonus.

The Important Dates:

  • January 1, 2017: MIPS begins
  • June 30, 2017: the deadline to register if you are reporting as a “Group Practice” and intend to use the CMS website to submit your practice’s 2017 data.
  • October 2, 2017: last day to begin submitting 90 continuous days’ worth of 2017 data.
  • December 31, 2017: last day for 2017 data.
  • March 31, 2018: deadline for submitting for CY 2017 MIPS data

You will also still receive annual 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

** However: Even APM clinicians must report through MIPS in 2017.  CMS will use this reporting data to determine whether you meet approved-APM requirements for 2018 and beyond.

MIPS

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

  • Consolidates current Medicare quality reporting programs: PQRS, the Value Modifier and the EHR Meaningful Use program (now called “advancing care information”) into one composite program.  Adds “Clinical Practice Improvement Activities” as another category.
  • Medicare will develop a “composite score” or total performance score 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).
    • Gets a little complicated here: MIPS providers will have scores for each performance category.  The scores for each category have their own separate scoring system.  For example, the Advancing Care Information scoring system can have more than 100 percentage points.  Each category is separately weighted so CMS will then take the scores from each category, multiply that score by a conversion weight, which will calculate your 0-100 aggregate score.
  • This aggregate score 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 this targeted score vs. actual score comparison relative to all other providers.
  • Please note: Providers can participate in MIPS as an individual or as a part of a group practice.

2017 is a “Transition Year”

Here is what you need to know for 2017.  CMS views CY 2017 as a transition year to ease Medicare providers into MIPS.  In September of 2016, CMS eased earlier reporting requirements, so that even if you make some sort of effort in quality reporting in CY 2017, you will not receive a cut in 2019.

Providers who submit 90 consecutive days of 2017 data may earn a neutral or small positive payment adjustment. CMS explains that these adjustments will be made in a budget neutral manner.

  1. If you don’t send in any 2017 data, then you receive a 4% payment cut in 2019.
  2. If you submit a minimum amount of 2017 data to Medicare, you can avoid a downward payment adjustment.  For example, one quality measure, or one improvement activity.
  3. If you submit a continuous 90-days’ worth of 2017 data to Medicare, you will avoid the payment cut and be potentially be eligible for a bonus payment.
  4. If you submit a full year of 2017 data to Medicare, then according to CMS you may earn a moderate payment bonus.

For 2017 MIPS, the “target score” threshold will be lowered to 3 points.

Clinicians who achieve a final score of 70 or higher will be eligible for the exceptional performance adjustment, funded from a pool of $500 million (more on this below).

Eligibility for Merit-based Incentive Payment System (MIPS): Are all GI providers participating in Medicare assigned to this new MIPS program?

Who has to participate in MACRA? If you bill more than $30,000 to Medicare, and provide care to more than 100 Medicare patients per year, and you are a:

  1. physician
  2. physician assistant
  3. nurse practitioner
  4. clinical nurse specialist
  5. CRNA

For GI, CMS estimates that there are roughly 12,168 MIPS-eligible clinicians in 2017 that would be subject to MIPS.

From 2021 on… Medicare has 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 MIPS

If 2017 is your first year participating in Medicare, then you are not required to participate in MIPS in 2017.

If you bill less than $30,000 to Medicare OR provide care to less than 100 Medicare patients per year.

CMS estimates that there will be 2,579 (up from 1,849) GI clinicians excluded from MIPS in 2017.  Who is also considered ineligible?

  • Newly Medicare-enrolled eligible clinicians
    • Those in the FIRST year of Medicare Part B participation (440 GI clinicians)
  • **Qualifying alternative payment model (APM) Participants (QPs) (224 GI clinicians)
  • **Certain Partial Qualifying APM Participants (Partial QPs)
    • A slightly reduced threshold (% of patients or payments in an Advanced APM), you are considered a “Partial Qualifying APM Participant” (Partial QP) and can opt out of MIPS to avoid a cut, or participate in MIPS to potentially receive a bonus

** However: Even APM clinicians must report through MIPS in the first year

Noteworthy:

  • MIPS does not apply to hospital reimbursement or impact ASC facility fees
  • Eligible Clinicians can fulfill MIPS requirements as an individual or as part of a group (assigned by group’s TIN)
  • “Virtual groups” will not be implemented in Year 1 of MIPS

You can choose to participate in MIPS as an individual or as a group practice

Individuals: An individual is defined as a single National Provider Identifier (NPI) that is tied to a single Tax Identification Number (TIN).  Individual may submit their MIPS data through certified EHRs, a registry, or a qualified clinical data registry (i.e. GIQuIC).  Individuals can also submit their quality data your Medicare claims forms (only quality data though).

Group Practices:  If you choose to participate in MIPS as a group practice, the entire group will get the payment adjustment (cut, no cut, or bonus).  A group is defined as a set of clicnians sharing the same TIN.  Groups can submit their MIPS data through certified EHRs, a registry, or a qualified clinical data registry (i.e GIQuIC).  Groups can also submit data via a CMS website (must register by June 30, 2017).  Groups cannot submit their quality data via your Medicare claims forms.

MIPS Payment Formula

For GI, CMS estimates that roughly 93-96% would be eligible for a bonus, or at least no payment cut, and 4-7% would be subject to a payment cut.  Thus, there must be a higher ratio of low scoring providers in other specialties.

  • The BAD: The Cuts… sliding scale to maximum percent of cuts defined in MACRA:
    • 2019       -4%
    • 2020       -5%
    • 2021       -7%
    • 2022+    -9%
  • The GOOD: The Bonuses… Scaling Factor up to 3x the maximum cut to determine the positive adjustment.
    • “Highest bonus cannot exceed 3x maximum penalty”
    • Subject to budget rules
Year Maximum Cut Bonus
2019 -4% 4% up to 12%
2020 -5% 5% up to 15%
2021 -7% 7% up to 21%
2022+ -9% 9% up to 27%
MipsGraphic

“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, if the target threshold is 60, then the range of possible final scores above the performance threshold would be 61-100. The 25th percentile of those possible values is 70.

  • $500 million distributed evenly each year for 6 years for these payments.
  • Bonus capped at 10% per eligible provider
  • Not subject to budget rules

MACRA also allows CMS some leeway in determining the exceptional performance category.  So for the 2019 payment year, CMS sets this “exceptional performance category” score at 70.
For the 2019 payment year, CMS chose not to establish the exceptional performance threshold at the 25th percentile of the range of possible final scores above the target. “With a performance threshold set at 3 points, the range of total possible points above the performance threshold is 4 to 100 points. The 25th percentile of that range is 27.3 points, which is less than one third of the possible 100 points in the MIPS final score. We do not believe it would be appropriate to lower the additional performance threshold to 27.3 points, as we do not believe a final score of 27.3 points demonstrates exceptional performance by a MIPS eligible clinician.”

Important note: Does that mean in 2019, the maximum penalty is 4%, but also a mean of 4-12% bonus? 

  • 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 12% bonus in 2019, 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 that year for budget neutrality.

KEY TAKEAWAY: THERE MUST FIRST BE CUTS IN ORDER FOR THE POOL OF BONUS MONEY (does not include “exceptional performance” awardees).

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

WeightsbyPerformance

MIPS Aggregate Scoring System

Your final MIPS score = 100 x

[(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)]

What do you need to know for 2017?

For 2017 MIPS, the “target score” threshold will be 3 points.

Clinicians who achieve a final score of 70 or higher will be eligible for the exceptional performance adjustment, funded from a pool of $500 million.

Here’s how the sliding scale looks for 2017:

MIPSAdjustment

The MIPS Categories

Quality

What do you need to know for 2017?

The Quality Category represents 60% of your MIPS score for 2019.  This is similar to PQRS, and you will choose from various reporting options and various CMS approved quality measures.  You would first select quality measure(s), then submit the measures via a reporting mechanism of your choosing (i.e. on your Medicare claims, or potentially via GIQuIC).

In 2019, ACG members can be eligible for a bonus if you: submit data for at least 90 continuous days’ worth of 2017 data (or you can choose the full calendar year), and report more than one measure in the Quality Performance category, more than one Clinical Improvement Activity, or more than the required measures in the Advancing Care Information performance category.

ACG members can avoid a payment cut in 2019, if you report one measure in the Quality Performance Category; one Clinical Improvement Activity performance category; or report the required measures in the Advancing Care Information performance category.

ACG members who choose to submit no 2017 data will receive the full negative 4% payment cut in 2019.

Quality: Performance Requirements

ACG members would select 6 measures to report, at least one must be an “outcome measure” (if available).  Otherwise, the clinician would be required to report one other “high-priority measure” (i.e. what CMS labels “appropriate use,” “patient safety,” “efficiency,” “patient experience,” and “care coordination” measures) in place of an outcome measure.  CMS publishes an annual list of acceptable measures, along with the measure’s designation.    You also have the option of reporting quality measures that are not on this list of measures if you participate in a CMS-approved clinical quality data registry (QCDR).  GIQuIC intends to be a QCDR for 2017, pending CMS approval.

  • Those relying on Medicare claims-based submissions to report quality data would report at least 50% of their Medicare Part B patients.
  • If fewer than 6 measures apply, the GI clinician would be required to report on each measure that is applicable.
  • 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.

CMS finalizing the policy that certain MIPS-approved Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey would count as a “high priority measure.”  The survey, however, would only count as one quality measure.  In order for groups to elect participation via CAHPS for MIPS survey, groups must register by June 30 of the applicable performance period (that is, June 30, 2017, for performance periods occurring in 2017).

  • Please note 1 nuance for CAHPS: CMS is now allowing a full MIPS reporting period of 90 continuous days.  You can also report a full year, too.  HOWEVER—the CAHPS are structured for a full year.  Groups electing CAHPS would participate in CAHPS for a full year.
  • The group would be required to submit at least five other measures through another data submission mechanism.
  • In addition, a MIPS eligible clinician may be awarded points under the “clinical improvement activities” performance category, as the CAHPS is included in the Patient Safety and Practice Assessment subcategory.

Quality Scoring System

Remember, each category has its own scoring system.  Scores from each performance category will be converted into an aggregate MIPS score (scale of 0-100).
For the Quality category: Maximum of 70 points, or 60 points for solo practitioners and groups of 15 or fewer clinicians.

  • 10 points for each of the six measures reported and 10 points for each of the three population measures derived through claims data for groups of 16 or more clinicians (scoring will vary for CMS Web Interface option)
  • 2 bonus points for each outcome and patient experience measure reported
  • 1 bonus point for other high priority measures reported in addition to the one high priority measure required (10 possible points)
  • Bonus for using HHS-certified electronic information technology (bonus point per measure, up to 10 possible points)

Other Notes:

  • This is a very important category to achieve a MIPS bonus, especially in the early years of MIPS (2019 and 2020).
  • Please note: to report your quality measures via an approved registry, which may include GIQuIC.  Participation in these “qualified clinical database registries” can also earn credit for other categories (more on this below).

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 15 or more.  This will be included in the providers’ overall Quality score.  CMS will calculate an “all cause hospital readmissions” measure.  (Minimum of 200 cases)

Advancing Care Information (aka the new Meaningful Use)

This category is similar to the current 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 will make up 25% of total composite score from 2019+.

  • Weighting can be decreased and shifted to other categories if the Sec. of HHS estimates that the proportion of physicians who are meaningful EHR users is 75% or greater. There is a statutory minimum floor of 15%.
  • No more duplicative quality reporting like providers were previously forced to do for both PQRS and Meaningful Use.
  • No more “Clinical Decision Support” or “Computerized Provider Order Entry” objectives currently required in Meaningful Use.

What do you need to know for 2017?

CMS eased the reporting period for CY 2017 to 90 days as opposed to a full year.

ACG members can be eligible for a bonus in 2019 if you submit 90 continuous days of 2017 data, and at a minimum and report more than one Quality measure, more than one Clinical Improvement Activity, or more than the required measures in the Advancing Care Information performance category.

ACG members can avoid a payment cut in 2019 if you report one measure in the Quality Performance Category; one Clinical Improvement Activity performance category; or report the required measures in the Advancing Care Information performance category. (Note: need to report more than one Advancing Care Information measure)

ACG members who choose to submit no 2017 data will receive the full negative 4% payment cut in 2019.

…. 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 2017, there are two measure set options for reporting. The option you use to submit your data is based on your electronic health record edition (when your EHR was last certified by HHS).

Option 1: “Advancing Care Information Objectives and Measures”

Option 2: “2017 Advancing Care Information Transition Objectives and Measures”

CMS recognizes that in 2017, some MIPS eligible clinicians will not yet have access to EHR technology certified to the 2015 Edition. Therefore, you will be allowed to report for the 2017 performance period using EHR technology certified to the 2014 Edition, or a combination of both 2014 and 2015 Editions.

In 2017, a MIPS eligible clinician who has technology certified to a combination of 2015 Edition and 2014 Edition may choose to report on either the “Advancing Care Information Objectives and Measures” set, or the “2017 Advancing Care Information Transition Objectives and Measures” set.

The Scoring System:

MIPS eligible clinicians have the ability to earn an overall score of up to 155 percentage points when the base score (50%), performance score (90%), and bonuses score (15%) are all added together.  This will determine the overall advancing care information performance category score.

Please note MIPS eligible clinicians must report all required measures of the base score to earn any base score, and thus, to earn any score in the advancing care information performance category.

The Required Measures for the Advancing Care Information Measures Set: (the Base Score)

  • Security Risk Analysis:  Conduct or review a security risk analysis, including addressing the security (to include encryption) of data created or maintained by certified EHR technology, implementing security updates as necessary, and correcting identified security deficiencies as part of the MIPS eligible clinician’s risk management process.
  • e-Prescribing:  At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology.
  • Provide Patient Access: For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) the MIPS eligible clinician ensures the patient’s health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programing Interface (API) in the MIPS eligible clinician’s certified EHR technology.
  • Send Summary of Care: For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider: (1) creates a summary of care record using certified EHR technology; and (2) electronically exchanges the summary of care record.
  • Request/Accept Summary of Care: For at least one transition of care or referral received or patient encounter in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician receives or retrieves and incorporates into the patient’s record an electronic summary of care document.

The Performance Score. “Building off of base score.” You can also earn a higher percentage score from better performance in the following required measures: Provide Patient Access, Send Summary of Care, Request/Accept Summary of Care.

The optional measures: (performance score)

  • Patient-Specific Education
  • View, Download, Transmit
  • Secure Messaging
  • Patient-Generated Health Data
  • Clinical Information Reconciliation
  • Immunization Registry Reporting

Bonus Measures (performance score)

  • Syndromic Surveillance Reporting
  • Electronic Case Reporting
  • Public Health Registry Reporting
  • Clinical Data Registry Reporting

Additional Bonuses:

  • Report to 1 or more additional public health and clinical data registries beyond the Immunization Registry Reporting measure
  • Reporting MIPS Category “improvement activities” using certified EHRs

The performance score builds upon the base score (calculated using the numerator/denominator). A performance rate of 1-10 percent would earn 1 percentage point, a performance rate of 11-20 percent would earn 2 percentage points, 21-30 would earn 3 points, 31-40 would earn 4 points, 41-50 would earn 5 point, 51-60 would earn 6 points, 61-70 would earn 7 points, 71-80 would earn 8 points, 81-90 would earn 9 points, and 91-100 would earn 10 points.

For example, if an ACG member reports a numerator/denominator of 85/100 for the “Prove Patient Access” measure, their performance rate would be 85%, and they would earn 9 percentage points toward their performance score for the advancing care information performance category. With nine measures included in the performance score, a MIPS eligible clinician has the ability to earn up to 90 percentage points if they report all measures in the performance score.

Hardship Exemptions

CMS is keeping the old Meaningful Use hardship exclusions for MIPS eligible clinicians who lack sufficient internet connectivity, face extreme and uncontrollable circumstances, lack control over the availability of certified health IT, or do not have face-to-face interactions with patients. For those MIPS eligible clinicians, CMS will reweight the advancing care information performance category to 0%.

Improvement Activities

This category is new and 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 2019+.

Providers would select from a list of 93 Improvement Activities PIAs in certain areas of care, such as “Expanded Practice Access,” “Population Management,” “Care Coordination,” “Beneficiary Engagement,” “Patient Safety and Practice Assessment,” “Participation in an APM or Medical Home,” “Achieving Health Equity,” “Emergency Preparedness and Response,” and “Integrated Behavioral and Mental Health.”  Each activity is individually weighted to determine a score within this category.

What do you need to know for 2017?

The Improvement Activities represents 15% of your MIPS score for 2019.

ACG members can be eligible for a bonus in 2019 if you submit 90 continuous days of 2017 data, and at a minimum and report more than one measure in the Quality Performance category, more than one clinical Improvement Activity, or more than the required measures in the Advancing Care Information performance category.

ACG members can avoid a payment cut in 2019 if you report one measure in the Quality Performance Category; one clinical Improvement Activity performance category; or report the required measures in the Advancing Care Information performance category.

ACG members who choose to do nothing in 2017 will receive the full negative 4% payment cut in 2019.

What are the individual “Improvement Activities”?

CMS has a list of 93 differently weighted “improvement activities.”  Participation in a clinical data registry (i.e. potentially GIQuIC) can earn credit in this category.

What are the MIPS requirements for full credit?

ACG members will review and select activities that best fit your practice.

  • Attest that you completed up to 4 “medium-weighted” improvement activities or 2 “high-weighted” improvement activities for a minimum of 90 days.
  • Groups with fewer than 15 participants or those in a rural or health professional shortage area: Attest that you completed up to 2 “medium weighted” activities or 1 “high-weighted” activity for a minimum of 90 days.

For those ACG members participating in MIPS in order to qualify for an APM, or participating or other APM  (more on APMs below):

  • 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 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 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.

What is the Improvement Activities scoring system?

CMS requires a total of 40 points to receive the highest score for the improvement activities performance category.  How would thins look?

  • Reporting of one medium-weighted activity would result in 10 points, or one-fourth of the highest score.
  • Reporting of two medium-weighted activities would result in 20 points, or one-half of the highest score.
  • Reporting of three medium-weighted activities would result in 30 points, or three-fourths of the highest score.
  • Reporting of four medium-weighted activities would result in 40 points, or the highest score.
  • Reporting of one high-weighted activity would result in 20 points, or one-half of the highest score.
  • Reporting of two high-weighted activities would result in 40 points, or the highest score.
  • 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).

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, or one-half of the highest score.
  • Reporting of two medium-weighted activities would result in 40 points, or the highest score.
  • Reporting of one high-weighted activity would result in 40 points, or the highest score.
  • Reporting of one medium-weighted activity would result in 20 points, or one-half of the highest score.

Cost/Resource Use (cost of providing care)

This category is somewhat similar to the current value-based payment modifier, where CMS looks at claims data at the practice level to determine whether group practices are cost-efficient compared to other practices submitting similar claims to Medicare.  CMS would now review the individual provider’s claims.

What do you need to know for 2017?

To address public comments on the cost performance category, this will not be part of your MIPS score in 2017.

The Resource Use category will commence 2018.  Stayed tunes for more information on this category.

APMs

What is an “Alternative Payment Model” (APM)?

MACRA does not create new alternative payment models, but rather authorizes incentives to encourage participation.  CMS and Congress view the APM and transition away from fee-for-service and move towards the path of not only reducing programmatic costs, but also improving the quality of care for the patients.

ACG shares this goal of improved quality, but also realizes that the goal of APMs is to save money for the system or the payor of the health care services (insurers, Medicare); not so much to adequately reward the payee for providing these quality services (you).  You are also held accountable for the actions of others in the APM.  However, there are a few positive aspects about the APM structure, including bonus payments, potentially more referrals to your practice, and a structure fostering more coordinated care.

Some other perks:

  • 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 MPFS versus non-QPs (0.25%).

MACRA-approved alternative payment models are called an “Advanced APMs.”  The APM entity must meet certain requirements outlined in MACRA and the final rule.  ACG members and others may become a “qualified participant” or QP, by joining these Advanced APMs.  QPs are excluded from the MIPS.  CMS also allows for “Partial QPs,” who can choose whether they wish to be subject to a MIPS payment adjustment.

What do you need to Know for 2017?
In short, if you want to qualify for an APM, then you need to participate in MIPS.  In 2017, whether you want participate in MIPS or an Advanced APM, the cycle of the program works like this:

  • 2017 is the year when you first start reporting.
  • The first performance period opens January 1, 2017 and closes December 31, 2017.  During 2017, you will record quality data and how you used technology to support your practice.
  • If you wish to participate in an Advanced APM that fits your practice needs, then you strive to meet the Medicare patient count and payment requirements during this reporting year.  Thus, you participate in MIPS.
  • In order to earn the 5% incentive payment for participating in a CMS-approved Advanced APM, you send your quality data through your Advanced APM administrators.
  • If you are deemed successfully participating in an Advanced APM in 2017, then you could earn 5% bonus payment in 2019.  The bonus payment is based on your 2018 Medicare fee for service claims.

What is an example of an Advanced APM?

In 2017, the list of payment models that would be considered an “Advanced APM” include (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

For the 2018 performance year, CMS anticipates that the following models would be Advanced APMs (in addition to the list above).

  • ACO Track 1+
  • New voluntary bundled payment model
  • Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT)

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 targets.

What are the requirements for an APM entity to be considered an “Advanced APM”?

An Advanced APM Entity must be an entity that participates in an APM that:

  • Requires the use of HHS 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.”

The first requirement: 50% of the APM’s participants must be using certified health IT beginning 2017.

The second requirement: 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 (i.e. NQF);
  • Quality measures developed under the PQRS;
  • Quality measures submitted in response to the MIPS Call for Quality Measures; or
  • Any other quality measures that CMS determines to have an evidence-based focus and be reliable and valid.

The third requirement:  The Advanced APM can meet this “nominal amount standard” during the first two QP Performance Periods (2017-2018) by 1 of 2 ways:

  • A “revenue-based standard”: 8% of the average estimated total Medicare Parts A and B revenues of participating APM entity; or
  • A “benchmark-based standard”: 3% of expected expenditures for which an APM Entity is responsible under the APM (costs exceed targets)

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.

How do I become an Advanced APM qualifying participant or QP?

CMS will look at your Medicare Part B professional services that are furnished through an Advanced APM Entity during 2017 (patients treated by the APM, or eligible to be treated by APM).  Your “patient count” or “payment count” must meet certain thresholds.

  • If you do not meet one of these thresholds, you may meet the “Partial QP Threshold.”  While this status does not allow you to receive the 5% bonus, it does allow you to choose whether or not you want to participate in MIPS.  For example, if you participate in MIPS and believe you could be eligible for a bonus, then, as a Partial QP, you have the option to be included in MIPS.   If you think you may not score well under MIPS, you can choose to opt out.

The determination of whether an ACG member has met the QP Thresholds for 2019 payment incentives will be based on your Payment Amount Counts and Patient Counts in 2017. A QP performance period is the full year, e.g. the 2017 QP Performance Period will be the entire 2017 calendar year.

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

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

2019 2020 2021 2022 2023+
QP 20% 20% 35% 35% 50%
Partial QP 10% 10% 25% 25% 35%

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

2019 2020 2021 2022 2023+
QP 25% 25% 50% 50% 75%
Partial QP 20% 20% 40% 40% 50%

CMS will identify the eligible clinician group for each Advanced APM Entity by taking snapshots of the APM participation or affiliated practitioner list on March 31, June 30, and August 31 of the performance year. CMS will then provide notice to clinicians of QP determinations during the summer of the following year.

 

APM

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 scores 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.

Next Steps

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