CMS Releases Final Rule on MACRA, MIPS & APMs

  • 0
  • October 26, 2016

On October 14, 2016, CMS issued the Final Rule that implements the Medicare Access and CHIP Reauthorization Act (MACRA). The final rule, Medicare Program; Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, provides details on the first year implementation of the new Quality Payment Program (QPP) and the two paths eligible clinicians will choose from: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS).

In response to commenters concerns and suggestions, the final rule, released on October 14, includes some significant changes from the proposed rule.

The first payment year for MIPS is 2019 and will be based on the 2017 MIPS performance. Acknowledging commenters concerns that eligible clinicians will not be ready by January 1, 2017 to report under MIPS, CMS has developed 3 options for participation in the MIPS path of the QPP program for the transition year 2017:

  1. Test: Eligible clinicians who submit a minimum amount of 2017 data to Medicare (at least 1 quality measure, 1 improvement activity or report the required measures of the advancing care information performance category), can avoid a downward payment adjustment but will not be eligible for any bonus in 2019.
  2. Partial: Eligible clinicians who submit 2017 data for a full 90-day period at a minimum and report more than 1 quality measure, more than 1 improvement activity, or more than the required measures in the advancing care information performance category may avoid a negative MIPS payment adjustment and may qualify for positive payment adjustment in 2019.
  3. Full: Eligible clinicians, who submit a full year of 2017 data to Medicare, may qualify for a positive payment adjustment and those who are shown to be exceptional performers are eligible for an additional positive adjustment in 2019.

Due to these new options for transition year 2017, only eligible clinicians that do not send in any 2017 data will receive a negative 4% payment adjustment in 2019.

In the final rule, CMS increased the low volume threshold for exclusion from MIPS. As finalized, in the first year, eligible clinicians who will not be subject to MIPS include:

  • Providers in their first year of Medicare Part B participation,
  • Medicare providers with $30,000 or less in billed Medicare Part B allowed charges or 100 or fewer Medicare Part B patients in one year, or
  • Providers significantly participating in Advanced APMs.

MIPS Composite Performance Score

MIPS will measure Medicare Part B providers to develop an annual MIPS Composite Performance Score) based on performance in four weighted performance categories:

  1. Quality – based on PQRS
  2. Cost – based on the VM
  3. Improvement Activity – new category
  4. Advancing Care Information – based on EHR


Below is a summary of the four MIPS performance categories and the requirements for full participation in these categories for transition year 2017:

Quality Performance Category

  • Clinicians will report on 6 quality measures, including at least 1 outcome measure, or another high-priority measure if outcome is unavailable, or
  • One specialty-specific or subspecialty-specific measure set
  • Year 1 weight: 60%

Cost Performance Category      

  • Assessment under all available resource use measures, as applicable to the clinician
  • CMS calculates scores based on claims so there are no reporting requirements for clinicians
  • Year 1 weight: 0%

Improvement Activity Performance Category

  • To not receive a zero score, EPs must report on at least 1 CPIA activity (from 90+ proposed activities) with additional credit for more activities.
    • Full credit for participation in patient-centered medical home
    • Minimum of half credit for APM participation, with opportunity to select additional activities for full credit
  • CPIA activities are categorized as high or medium weight, earning 20 or 10 points, respectively, with full credit achievement of 40 points.
  • Year 1 weight: 15%

Advancing Care Information (ACI) Performance Category

  • Eligible clinicians will report key measures of health IT interoperability and information exchange.
  • The overall ACI score will be made up of a base score and a performance score for a maximum score of 100 percentage points.
    • For the base score eligible clinicians must report on 5 measures
  • In 2017, non-physician practitioners may elect not to submit data under the ACI component, in which case CMS will assign a weight of 0% for these non-physician practitioners.
  • Year 1 weight: 25%

Table 60 in the final rule estimates the net impact of MIPS payment adjustments as a percentage of allowed charges by specialty. As reported, the net impact on oncology/hematology would be 0.6% with 95.3% of oncologists/hematologists receiving a positive or neutral MIPS payment adjustment and 4.7% receiving a negative payment adjustment.

The estimated impact of the MIPS payment adjustment by practice size shows a considerably better outlook for small practices than was first reported in the proposed rule. Table 64 of the proposed rule (based on 2014 PQRS data) showed an estimated 87% of solo practitioners and 69.9% of practices with 2-9 eligible clinicians would receive a negative payment adjustment under MIPS. The final report uses updated 2015 data and the estimated percentage of small practices that would receive a negative MIPS adjustment is greatly improved with an estimated 10% of practices with 1-9 clinicians receiving the negative payment adjustment.

This is just a very brief summary of some of the significant changes of the QPP and its associated MIPS and APM programs. Watch your email inbox for a forthcoming detailed summary on the MACRA, MIPS and APM Final Rule.