With 2017 just around the corner, that means data collection for the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) implementation program – the Quality Payment Program – is about to begin.
MACRA will eliminate the sustainable growth formula and replace it with a .5% annual rate increase through 2019, after which physicians are encouraged to shift to one of two Quality Payment Programs: 1) Merit-Based Incentive Payment System (MIPS) or 2): Alternative Payment Model (APM). MIPS streamlines reporting programs by combining the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VPM), and the Meaningful Use (MU) EHR Incentive program.
Following the release of the final rule in October, CMS noted it could expand opportunities in the Advanced APM space but what should the 592,119-642,119 clinicians on the hook to participate in MIPS during the first year expect from the new reporting program?
MIPS timeline and eligible providers
In 2017 and 2018, MIPS reporting requirements will apply to physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse anesthetists participating in Medicare Part B. CMS estimates about 70,000 clinicians will be excluded from MIPS and receive the 5% Advanced APM bonus in the first year. For small practices, CMS expects 51.6% of eligible clinicians with one to nine providers will be excluded from MIPS in the first year.
Providers can report individually or as a group with a shared taxpayer identification number. Some providers are exempt from MIPS in the first year. These include providers in their first year participating in Medicare Part B, providers that receive more than 25% of Medicare payments or see more than 20% of Medicare patients through an advanced APM, and providers with less than $30,001 in Medicare Part B billings or less than 101 Medicare patients.
Eligible reporters are required to begin recording MIPS-related data in 2017 and must submit that data by March 31, 2018 which will influence payment adjustments for 2019. In 2019, the maximum payment adjustment will be 4% in either direction. In following years, the maximum payment adjustments will progress to 5% in 2020, 7% in 2021, and 9% in 2022 and beyond.
CMS will allow varying participation options in 2017. One allows providers to test MIPS in 2017 to avoid a negative payment adjustment. This requires reporting at least one improvement activity, one quality measure, or four or five advancing care information measures. A second option allows providers to submit at least 90 days worth of required measures to experience a neutral or positive payment adjustments. Providers can opt to report for the full year with the potential for the maximum payment adjustment in either direction in 2019. If non-exempt providers do not submit any 2017 data, they will receive a negative 4% payment adjustment in 2019.
MIPS performance categories and reporting measures
In the first year, MIPS payment adjustments will be calculated according to performance across three categories: Quality, advancing care information and improvement activities.
Based on their performance in each of the weighted categories, providers will receive a total composite performance score from 0 to 100. Scoring 70 points or more will earn providers a positive adjustment and make them eligible for an additional bonus of at least 0.5%. Scoring 4 to 69 points will earn providers a positive adjustment without eligibility for a bonus. A neutral payment adjustment will be applied to providers scoring 3 points.
Cost will be added as a fourth category in 2018 to replace the VPM. This category will be calculated using claims and will not require reporting any additional measures.
Quality (60% of total score)
The MIPS quality category replaces the PQRS and the quality component of VPM. Most participating providers are required to track at least six of approximately 300 quality measures, one of which must be an outcome measure. Many of the measures included in the category are specialty specific. Physicians reporting quality measures through an APM are not required to also report quality measures through MIPS
Providers can score three to 10 points per quality measure based on performance against benchmarks. There is potential to score bonus points for reporting additional outcome and patient experience measures related to high priority measures and those reported using certified EHR technology (CEHRT).
Advancing care information (25% of total score)
The advancing care information category replaces the MU EHR Incentive Program. There are a total of 15 measures in the category. MIPS requires participating providers to report on five of these: Security risk analysis, e-prescribing, providing patient access, sending summaries of care, and receiving summary of care. Providers can report data on up to nine measures for bonus points.
Providers can earn up to a 155% maximum score in this category, capping at 100%. Providers earn 50% for reporting required measures. If any required measures are not reported, providers will earn 0 points in the category. Providers can earn an additional 90% based on performance against benchmarks and an additional 15% for reporting measures beyond those that are required.
Providers who face significant hardship reporting on measures in this category can apply to have it weighted to zero and offset in other performance categories.
Improvement activities (15% of total score)
Whereas the quality category and advancing care information category represent legacy reporting programs, improvement activities is a new category. There are more than 90 measures in the improvement activities category and most providers will be required to select four measures to report. Providers in groups of less than 15 and those in rural or health professional shortage areas are only required to report on two measures for a minimum of 90 days.
Providers can score 10 points for medium-activity improvement measures and 20 points for high-activity measures. Values are doubled for providers in small, rural, and underserved practices or with non-patient facing providers.
Time to prepare
Reporting into a single program could hopefully prove less burdensome for administration than the current system. The option to test MIPS, participate partially or fully should allow many providers to avoid significant negative payment adjustments with proper preparation.
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