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Volume 11, Issue 3 Download for iPad

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 this newsletter we will briefly review the path that led us to MACRA and summarize the final rule. Please take some time to review the final rule, as the performance period for QPP opens on January 1, 2017.

 

PHYSICIAN PAYMENT REFORM 1,2

The Balanced Budget Act (BBA) of 1997 reformed the Medicare program and Medicare payments to physicians. In particular, the BBA established the Sustainable Growth Rate (SGR) formula as a mechanism to slow the growth in Medicare spending for physician services. Under the SGR formula, Congress established an annual target for Medicare physician spending. If physician spending exceeded the annual target for the year, the SGR formula automatically triggered a proportional cut in physician reimbursements the following year.

However, it soon became evident that the SGR formula was flawed and would result in unintended large cuts to physician payments. In response, each year since 2002, Congress acted to temporarily halt the cuts to physician payments.

Finally, in 2015 Congress passed a bipartisan bill to repeal the SGR. The Medicare Access and CHIP Reauthorization Act (MACRA), signed into law on April 16, 2015, provides a permanent fix to the physician payment formula by doing away with the SGR formula and further shifting Medicare payment towards value-based payments.

The MACRA mandates that the base physician payment rate will be increased annually by 0.5% from 2015 through 2019. From 2020 through 2025 the base physician rate will be frozen, but eligible providers (EPs) will have the opportunity to receive additional payment adjustments through the new Merit-Based Incentive Payment System (MIPS).

VALUE-BASED PAYMENTS AND MACRA 3,4,5,6

The move from the traditional Medicare Fee-for-Service (FFS) model to a Value-Based Payment (VBP) methodology was mandated by the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 and furthered through passage of the Affordable Care Act (ACA), which was signed into law on March 23, 2010.

The Physician Feedback reporting was mandated through the MIPPA and expanded upon by the ACA when the Centers for Medicare & Medicaid Services (CMS) was directed to provide information to physicians and group practices about the resources used and quality of care provided to their Medicare Fee-for-Service patients, including measurement and comparisons of patterns of resource use and cost among physicians and medical practice groups.

MACRA accelerates the pace and depth of the transition from a FFS payment methodology that pays based on the quantity of services performed to a VBP methodology that bases payment on the quality and cost of those services.

In addition to repealing the Medicare SGR formula, Section 101 of MACRA also establishes the new MIPS for EPs, and sunsets payment adjustments under the current Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VM), and the Medicare Electronic Health Records (EHR) Incentive Program. Aspects of each of these quality programs will be streamlined and consolidated into the new MIPS. Section 101 of the MACRA also mandates the development of Alternative Payment Models (APMs) providing incentive payments for EPs who participate in certain APMs. MACRA left the details of the new MIPS and APMs to be developed in separate rule making.

MACRA PROPOSED AND FINAL RULES 7,8,9

On April 27, 2016, CMS issued a notice of proposed rule making to implement key provisions of the MACRA including those related to MIPS and APMs. The proposed rule was published in the Federal Register on May 9, 2016, and CMS received 3,918 comments by the end of the comment period on June 27, 2016.

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

The framework for the changes to physician payment under MACRA is called the Quality Payment Program (QPP) and consists of two paths: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Eligible clinicians will choose between participation in MIPS or an Advanced APM.

CMS initially proposed that the first performance period for the QPP would run from January 1, 2017, through December 31, 2017. However, after receiving numerous requests that the performance period be delayed, CMS is designating 2017 as a "transition" year and will allow eligible clinicians to begin reporting in the QPP program anytime between January 1 and October 2, 2017. For the 2017 reporting period, all performance data must be sent in by March 31, 2018.

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:

  • 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.
  • 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 a positive payment adjustment in 2019.
  • 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.

Alternatively, MIPS eligible clinicians may choose to participate in an Advanced APM. Eligible clinicians who see a sufficient number of Medicare patients or receive a sufficient portion of their Medicare payments through the Advanced APM may be exempt from MIPS and qualify for a 5% bonus incentive payment in 2019.

CMS anticipates that most Medicare eligible clinicians will initially participate in the QPP through MIPS. CMS states that in the first year, the majority of clinicians in APMs will be in non-advanced APMs, which do not qualify for exemption from MIPS, and some clinicians who are participating in an Advanced APM will not meet the threshold for payments or number of patients to be deemed a Qualified Provider (QP) and thus will not be exempt from MIPS. 10

MIPS Criteria

The MIPS combines requirements of the three current Medicare quality - and value - reporting programs: the Electronic Health Records (EHR) Incentive Program, the Value-Based Payment Modifier (VM), and the Physician Quality Reporting System (PQRS). Penalties for these programs sunset at the end of 2018, and the requirements will be rolled into the MIPS.

In the first two years of the program, MIPS will apply to physicians, nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs), and certified RN anesthetists (CRNAs). The Health and Human Services (HHS) Secretary may expand the eligible clinicians group to include other clinicians in subsequent years.

MIPS does not apply to hospitals or facilities, but it will directly affect hospitals that employ physicians  and bill for their services under the Medicare Physician Fee Schedule.

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:

  • Quality - based on PQRS
  • Cost - based on the VM
  • Improvement Activity - new category
  • Advancing Care Information - based on EHR

In an effort to ease the transition to MIPS, CMS announced in the final rule that eligible clinicians will not be evaluated on cost during the first year of MIPS. Therefore, in 2017 (the first performance year), the cost (resource use) category will be weighted at 0% of the final score. As shown in Figure 1-3, in subsequent years, the cost performance category will gradually increase from 0% to the 30% level required by MACRA by the MIPS payment year of 2021.

MIPS PERFORMANCE CATEGORY WEIGHTS

Figure 1 Source: 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; Final Rule.

Figure 2 Source: 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; Final Rule.

Figure 3 Source: 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; Final Rule.

Scores in all four categories will be combined into a Composite Performance Score (CPS) from 0-100 using the weights for the categories. A Performance Threshold will be established based on how all eligible clinicians performed in the prior year on the CPS. The threshold for payment adjustments will be the mean or median composite score for all MIPS-eligible professionals during the previous performance period.

For the 2017 transition year, CMS has lowered the performance threshold to a threshold of 3 points. This lower performance threshold was implemented to increase provider participation in the first year of MIPS and will be increased in subsequent years.

The additional performance threshold remains at 70 points, and eligible clinicians who achieve or exceed this final score threshold will be eligible for the exceptional performance adjustment which is to be funded from a pool of $500 million.

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, eligible clinicians must report on at least 1 improvement 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 an opportunity to select additional activities for full credit
  • Improvement 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%

MIPS Reporting Options

MIPS eligible clinicians and groups will be required to submit data on measures and activities for the Quality, Improvement Activity and ACI performance categories. CMS is not proposing any data submission requirements for the Cost performance category as this would be calculated by CMS using administrative claims data.

Table 3 in the final rule outlines the data submission mechanisms for each of the performance categories for eligible clinicians reporting individually and Table 4 provides the data submission mechanisms for group practice reporting.

MIPS eligible clinicians and groups may also choose to submit data via multiple mechanisms; however, they must use the same identifier for all performance categories and are limited to one data submission mechanism per performance category.

Table 3: Data Submission Mechanisms for MIPS Eligible Clinicians Reporting Individually as Tax Identification Number (TIN)/National Provider Identifier (NPI)

Performance Category
Individual Reporting Data Submission Mechanisms
Quality Claims
Quality Clinical Data Registry (QCDR)
Qualified Registry
EHR
Cost Administrative claims (no submission required)
Advancing Care Information (ACI) Attestation
Quality Clinical Data Registry (QCDR)
Qualified Registry
EHR
Improvement Activities Attestation
Quality Clinical Data Registry (QCDR)
Qualified Registry
EHR

Source: 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.

Table 4: Data Submission Mechanisms for Groups

Performance Category
Group Practice Reporting Data Submission Mechanisms
Quality Quality Clinical Data Registry (QCDR)
Qualified Registry
EHR
CMS Web Interface (groups of 25 or more)
CMS-approved survey vendor for Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS (must be reported in conjunction with another data submission mechanism)
and
Administrative claims (For all-cause hospital readmission measure no submission required)
Cost Administrative claims (no submission required)
Advancing Care Information (ACI) Attestation
Quality Clinical Data Registry (QCDR)
Qualified Registry
EHR
CMS Web Interface (groups of 25 or more)
Improvement Activities Attestation
Quality Clinical Data Registry (QCDR)
Qualified Registry
EHR
CMS Web Interface (groups of 25 or more)

Source: 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.

The final deadline for data submission for all reporting methods across all MIPS performance categories for the 2017 reporting year will be March 31, 2018.

MIPS Payment Adjustments

Beginning in 2019 (based on 2017 performance), clinicians participating in MIPS will be eligible for neutral, positive, or negative Medicare payment adjustments. The statutory amount for payment adjustments start at 4% in 2019 and gradually increase to 9% for 2022, with a potential 3x that amount in the upward adjustment.

The bonuses and penalties must be budget neutral, so the dollar amount of the upward adjustments (or bonuses) will be equal to the dollar amount of negative adjustments (or penalties). The size of the bonus payments depends on the amount of penalties collected and how many practices qualified for the bonuses. If for instance, many practices receive large penalties and few practices qualify for bonuses, then the bonuses per practice will be larger. However, MACRA limits the bonus to 3 times the statutory amount. In 2019, the statutory amount is 4%, so the upper limit for bonuses would be 12% (3 x 4%).

However, CMS estimates that in the first performance year, approximately half of all MIPS eligible clinicians will earn an incentive and half will be accessed a penalty. Under such a scenario the x factor would be approximately 1.0, resulting in a maximum base bonus of 4% (4% x 1.0 = 4%).

In addition, for the first five payment years, there is $500 million in an additional performance bonus that is exempt from budget neutrality for eligible clinicians with exceptional performance. The exceptional performance bonus is capped at an additional 10%.

Payment adjustments will be based on a sliding-scale bell-shaped curve, eligible clinicians who score at the threshold will receive no payment adjustment, those whose composite score is above the mean will receive a positive payment adjustment on each Medicare Part B claim for the following year, and those  whose composite score is below the mean will receive a negative payment adjustment on each Medicare Part B claim for the following year.

Based on MIPS Performance Score, clinicians will receive positive, negative, or neutral adjustments.

Source: CMS, The Medicare Access & Chip Reauthorization Act of 2015 Quality Payment Program Webinar.

Advanced APM Criteria 5,7,8,9

CMS has made no secret of their goal to move the majority of Medicare payments to alternative payment models that tie payments to quality or value. And providers may elect to enroll in an Advanced APM in order to be excluded from MIPS payment adjustments. In addition, providers that are deemed to be a qualified participant (QP) in an Advanced APM will receive a 5% upward adjustment for Medicare payments between 2019 and 2024 and higher fee schedule updates starting in 2026.

Advanced APMs are those care models where providers accept both risk and reward for providing coordinated, high-quality, efficient care. Qualified Advanced APMs must meet certain criteria including:

  • Require participants to use certified EHR technology
  • Report comparable quality measures to MIPS
  • Have financial risk above a nominal amount, or be a Medical Home Model expanded under Center for Medicare & Medicaid Innovation (CMMI) authority

In the proposed rule, CMS identified the following models that they felt might be considered Advanced APMs in 2017, these APMs were also included in the final rule:

  • Comprehensive End-Stage Renal Disease (ESRD) care model
  • Comprehensive primary care plus (CPC+)
  • Medicare Shared Savings Program-tracks 2 and 3
  • Next-generation Accountable Care Organization (ACO) model

However, CMS did not provide a definitive list of 2017 Advanced APMs in the final rule, but instead said they would release the 2017 list of Advanced APMs as soon as possible but no later than January 1, 2017.

Qualifying and Partial Qualifying APM Participant

In order to be exempted from MIPS and qualify for incentive payments, providers would have to significantly participate in an Advanced APM and meet certain payment or patient thresholds to be deemed to be a Qualifying APM Participant (QP). 

The final rule also includes a mechanism that allows providers in Advanced APMs, that fall short of the APM participation requirement, to report MIPS measures and to decline to participate in MIPS. These APM providers would need to meet a slightly reduced payment and patient count threshold to be considered a Partial Qualifying AMP Participant (Partial QP). CMS calls this option an intermediate track as it allows providers to move between MIPS and APM payment models, depending on their changing circumstances.

In 2019 and 2020, the participation thresholds may only be met through Medicare patients or Medicare payments. However, starting in 2021 (performance year 2019), the participation thresholds may include non-Medicare payers and patients. In the final rule, in Tables 32-35, CMS provides the payment and patient amount thresholds for the Medicare and All-Payer combination options. As illustrated, the participation requirements will increase over time. 

Table 32: QP Payment Amount Thresholds - Medicare Option

Medicare Option - Payment Amount Method
Payment Year 2019 2020 2021 2022 2023 2024 and later
QP Payment Amount Threshold

25%

25%

50%

50%

75%

75%

Partial QP Payment Amount Threshold

20%

20%

40%

40%

50%

50%

Source: 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.

Table 33: QP Payment Amount Thresholds - All-Payer Combination Option 

All-Payer Combination Option - Payment Amount Method
Payment Year 2019 2020 2021

2022 2023 2024
and later
QP Payment Amount Threshold N/A N/A 50% 25% 50% 25% 75% 25% 75% 25%
Partial QP Payment Amount Threshold N/A N/A 40% 20% 40% 20% 50% 20% 50% 20%
    Total Medicare Total Medicare Total Medicare Total Medicare

Source: 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. 

Table 34: QP Patient Count Thresholds - Medicare Option

Medicare Option - Patient Count Method
Payment Year

2019

2020

2021

2022

2023

2024 and later

QP Patient Count Threshold

20%

20%

35%

35%

50%

50%

Partial QP Patient Count Threshold

10%

10%

25%

25%

35%

35%

Source: 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. 

Table 35: QP Patient Count Thresholds - All-Payer Combination Option

All-Payer Combination Option - Patient Count Method
Payment Year 2019 2020

2021

2022

2023

2024
and later

QP Patient Count Threshold N/A N/A 35% 20% 35% 20% 50% 20% 50% 20%
Partial QP Patient Count Threshold N/A N/A 25% 10% 25% 10% 35% 10% 35% 10%
Total Medicare Total Medicare Total Medicare Total Medicare

Source: 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.

In the proposed rule, CMS stated their intention to inform APMs of their QP status after the MIPS performance period has closed. Commenters expressed concern that they would not know their QP status until after the end of the MIPS submission period and thus would be unable to proactively report MIPS in case they do not reach the QP thresholds. CMS agreed with the commenters that earlier notification of QP status would be optimal. In the final rule, CMS states their intention to incorporate QP determinations during the calendar year based on data from less than the full QP Performance Period. CMS will also provide preliminary information to eligible clinicians participating in an Advanced APM early in the QP Performance Period so they may assess their likelihood of becoming a QP for a year.

APM Scoring Standard

Eligible clinicians who are participating in an Advanced APM but do not meet the participation thresholds to be excluded from MIPS will be subject to APM scoring standards for MIPS reporting requirements and the MIPS payment adjustment. The final rule incorporates changes to the scoring standard for MIPS eligible clinicians participating in certain types of APMs. CMS acknowledged comments received and incorporated several changes that they say will reduce the reporting burden for eligible clinicians participating in these APMs.

CMS proposes that the APM scoring standard would only be applicable to certain eligible clinicians participating in MIPS APMs, which would be defined as APMs that meet the following criteria:

  • APM Entities participate in the APM under an agreement with CMS or by law or regulation;
  • APM Entities include one or more MIPS eligible clinicians on a Participation List; and
  • The APM bases payment incentives on performance (either at the APM Entity or eligible clinician level), on cost/utilization, and quality measures.

The MIPS APM scoring standard varies from the regular MIPS reporting. Under the MIPS APM scoring standard, CMS is proposing not to calculate a Resource Use performance score for MIPS APMs as they are already being measured on cost in their respective APMs.

The APM scoring standard will apply to APMs that are identified by CMS as MIPS APMs.

Table 11: APM Scoring Standard for the Shared Savings Program - 2017 Performance Period for the 2019 Payment Adjustment

MIPS Performance
Category
APM Entity Submission Requirement Performance Score Performance Category Weight
Quality Shared Savings Program ACOs submit to the CMS Web Interface on behalf of their MIPS eligible clinicians. The MIPS quality performance category requirements and benchmarks will be used at the ACO level. 50%
Cost MIPS eligible clinicians will not be assessed on cost. N/A 0%
Improvement Activities ACOs only need to report if the CMS-assigned improvement activities scores is below the maximum improvement activities score. CMS will assign the same improvement activities score to each APM Entity group based on the activities required of participants in the Shared Savings Program. The minimum score is one half of the total possible points. If the assigned score does not represent the maximum improvement activities score, ACOs will have the opportunity to report additional improvement activities to add points to the APM Entity group score. 20%
Advancing Care Information All ACO participant TINs in the ACO submit under this category according to the MIPS group reporting requirements. All of the ACO participant TIN scores will be aggregated as a weighted average based on the number of MIPS eligible clinicians in each TIN to yield one APM Entity group score. 30%

Source: 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.

Table 12: APM Scoring Standard for the Next-Generation ACO Model - 2017 Performance Period for the 2019 Payment Adjustment

MIPS
Performance Category
APM Entity Submission Requirement Performance Score

Performance Category Weight

Quality ACOs submit quality measures to the CMS Web Interface on behalf of their participating MIPS eligible clinicians. The MIPS quality performance category requirements and benchmarks will be used to determine the MIPS quality performance category score at the ACO level. 50%
Cost MIPS eligible clinicians will not be assessed on cost. N/A 0%
Improvement Activities ACOs only need to report improvement activities data if the CMS-assigned improvement activities score is below the maximum improvement activities score. CMS will assign the same improvement activities score to each APM Entity group based on the activities required of participants in the Next Generation ACO Model.
This minimum score is one half of the total possible points. If the assigned score does not represent the maximum improvement activities score, ACOs will have the opportunity to report additional improvement activities to add points to the APM Entity group score.
20%
Advancing Care Information Each MIPS eligible clinician in the APM Entity group reports advancing care information to MIPS through either group reporting at the TIN level or individual reporting. CMS will attribute one score to each MIPS eligible clinician in the APM Entity group. This score will be the highest score attributable to the TIN/NPI combination of each MIPS eligible clinician, which may be derived from either group or individual reporting. The scores attributed to each MIPS eligible clinician will be averaged to yield a single APM Entity group score. 30%

Source: 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.

Table 13: APMs Scoring Standard for MIPS APMs other than the Shared Savings Program and Next Generation ACO Model - 2017 Performance Period for the 2019 Payment Adjustment

Performance
Category
Reporting Requirement Performance Score Weight
Quality The APM Entity group will not be assessed on quality under MIPS in the first performance period. The APM Entity will submit quality measures to CMS as required by the APM. N/A 0%
Cost MIPS eligible clinicians will not be assessed on cost. N/A 0%
Improvement Activities APM Entities only need to report improvement activities data if the CMS-assigned improvement activities score is below the maximum improvement activities score. CMS will assign the same improvement activities score to each APM Entity group based on the activities required of participants in the MIPS APM.

The minimum score is one half of the total possible points. If the assigned score does not represent the maximum improvement activities score, APM Entities will have the opportunity to report additional improvement activities to add points to the APM Entity group score.
25%
Advancing Care Information Each MIPS eligible clinician in the APM Entity group reports advancing care information to MIPS through either group reporting at the TIN level or individual reporting. CMS will attribute one score to each MIPS eligible clinician in the APM Entity group. This score will be the highest score attributable to the TIN/NPI combination of each MIPS eligible clinician, which may be derived from either group or individual reporting. The scores attributed to each MIPS eligible clinician will be averaged to yield a single APM Entity group score. 75%

Source: 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.

Impact by Specialty and Practice Size

Using data from the three APMs that were in effect in 2015, Table 58 in the final rule provides an estimate, by specialty, of the eligible clinicians that would be excluded from MIPS for the 2017 transition year. The percent excluded ranges from a low of 16.8% in gastroenterology to a high of 90.2% for chiropractors. CMS estimates that in the 2017 reporting year, a total of 18.6% of oncology/hematology clinicians would be excluded; 3.5% because of new enrollment in the Medicare program, 1.5% that are Qualifying APM Participants and 13.6% due to the low-volume threshold.

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.

On June 20, 2016, in response to concerns about the impact of MIPS on small practices, HHS announced their plan for a major initiative to help small practices prepare for the QPP. As required by MACRA, HHS will provide $20 million, each year for the next 5 years, to fund training and education for Medicare clinicians in individual or small group practices of 15 or fewer clinicians.

In addition, small practices will be allowed to collectively report metrics as virtual groups, although the final rule states that virtual groups will not be implemented in the 2017 transition year.

This final rule is complex and will require providers to carefully review their options and the program details. For more information, resources and tools visit the CMS QPP website often: https://qpp.cms.gov.

 

2 The Heritage Foundation. Medicare's Sustainable Growth Rate: Principles for Reform.
http://www.heritage.org/research/reports/2013/07/medicares-sustainable-growth-rate-principles-for-reform. Accessed August 25, 2016.

3 U.S. Government Publishing Office. Medicare Improvements for Patients and Providers Act of 2008. https://www.gpo.gov/fdsys/pkg/PLAW-110publ275/pdf/PLAW-110publ275.pdf. Accessed August 1, 2016.

4 U.S. Department of Health & Human Services. The Affordable Care Act, Section by Section. http://www.hhs.gov/healthcare/about-the-law/. Accessed August 1, 2016.

5 Notice of Proposed Rulemaking Medicare Access and CHIP Reauthorization Act of 2015: Quality Payment Program Fact Sheet. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf. Accessed August 2, 2016.

6 CMS.gov. H.R.2 Medicare Access and CHIP Reauthorization Act of 2015. https://www.congress.gov/bill/114th-congress/house-bill/2/text. Accessed August 1, 2016.

7 Federal Register Vol.81, No.89. Monday, May 9, 2016. Proposed Rules. 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; Proposed Rule. https://www.gpo.gov/fdsys/pkg/FR-2016-05-09/pdf/2016-10032.pdf. Accessed August 1, 2016.

9 QPP.CMS.gov. 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. https://qpp.cms.gov/docs/CMS-5517-FC.pdf. Accessed October 17, 2016.

10 CMS.gov. CMS Consumer Week Listening Session. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Consumer-Week-Listening-Session-Slides-for-QPP-Proposed-Rule.pdf. Accessed August 1, 2016.

Published by Rise Marie Cleland.Sponsored by Lilly Oncology

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Volume 5, Issue 3
Volume 5, Issue 2
Volume 5, Issue 1

PAST ISSUES
Access all of our previous newsletters.

ABOUT THE EDITOR
Risë Marie Cleland is the Founder and CEO of Oplinc, Inc., a national organization of oncology professionals. Through Oplinc, Inc., Ms. Cleland publishes the weekly Oplinc Fast Facts focusing on the timely dissemination of information pertaining to billing, reimbursement and practice management in the oncology office and Oplinc’s Best Practices Review, which provides a more in-depth look at the issues and challenges facing oncology practices. Ms. Cleland also works as a consultant and advisor for physician practices, pharmaceutical companies and distributors.

IMPORTANT NOTICES
Please note that this newsletter is presented for informational purposes only. It is not intended to provide coding, billing or legal advice. Regulations and policies concerning Medicare reimbursement are a rapidly changing area of the law. While we have made every effort to be current as of the issue date, the information may not be as current or comprehensive when you review it. Please consult with your legal counsel for any specific reimbursement information. For Medicare regulations visit: www.cms.gov.

CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2016 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

Copyright ©2016 Oplinc, Inc.

Oplinc, Inc., grants permission to distribute this newsletter without prior permission provided it is forwarded unedited and in its entirety.

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