Making Sense of MACRA, MIPS and APMs

Posted by Sandra Stork – Netgain’s Clinical IT Specialist on Nov 22, 2016 10:23:12 AM

MACRA.png2017 is sure to be a year full of changes, new policies and updated regulations in the healthcare industry - even more so than previous years. As practices strive to stay on top of these business changes, the consumer healthcare market is focusing on value-based care and building healthier communities.

Some of the upcoming changes have already been released and practices are deciphering what it means to their providers and their business.

As Netgain’s Clinical IT Specialist, I want to share my interpretation of the new regulations and what it means to our clients and practices nationwide.

MACRA – In a Nutshell

Just as soon as the healthcare community was beginning to understand Meaningful Use, the Centers for Medicare & Medicaid Services (CMS) released the final regulations for implementation of the Medicare Access and CHIP Reauthorization Act of 2015, known as MACRA.

MACRA is a new framework that rewards physicians for providing higher quality care by establishing two tracks for payment, essentially replacing and expounding on Meaningful Use. The two payment categories that practices will fit into are:

Merit-based Incentive Payment System (MIPS)
CMS predicts that 600,000 Part B clinicians will qualify for MIPS.  MIPS is effectively the “new default.”

MIPS combines three existing reporting programs: Physician Quality Reporting Program (PQRS), Value-based Payment Modifier and Meaningful Use.  It also adds a new performance program to form four base categories:

  • Quality—Replaces current Physician Quality Reporting System (PQRS) program
  • Resource use—Replaces current value-based modifier (VBM) program
  • Advancing Care Information—Replaces Meaningful Use program
  • Clinical practice improvement activities (new component)

CMS will set performance benchmark scores based on the CPS for all MIPS-eligible clinicians for a previous performance period.

Physicians will be measured on the four categories and payment adjustments will be determined by comparing the practice’s composite performance score (0-100) against the thresholds.  

There are several factors that would exempt a provider from MIPS, including:

  • Providers in their first-year billing Medicare
  • Providers whose volume of Medicare payments or patients fall below the proposed threshold (< 100 patients/year OR  < $30,000 in Medicare Part B charges)
  • Providers who qualify for payment under APMs with the associated bonuses are exempt from MIPS.

It is anticipated that providers practicing in rural health clinics or Federally Qualified Health Clinics (FQHCs) will be exempt from MIPS.

Alternative Payment Models (APMs)
Physicians that are exempt from MIPS can participate in an advanced alternative payment model and will receive a lump sum payment from Medicare, equal to 5 percent of last year’s fee for service payments.

To qualify as an alternative payment model under the MACRA statute, a practice must use Certified EHR Technology, report quality measures comparable to measures under MIPS and bear financial risk greater than a nominal amount.

How does this affect my practice?

It is a popular consensus that if you have been successfully reporting under the current programs and receiving bonuses, then you will quite likely receive bonuses under this new program. For physicians who have already been successfully reporting MIPS, this will not be a big change, however many practices do not have the tools in place to report the measures. 

In the first year of the MIPS program CMS is allowing a Pick Your Pace which gives you three options to avoid a payment adjustment. Depending on the data you submit by March 31, 2018, your 2019 Medicare payments will be adjusted up, down, or not at all. The Pick Your Pace is relevant for the 2017 reporting year (2019 payment year) only. CMS will provide additional information on payment adjustments for 2020 and beyond beginning next year. If you don’t send in any 2017 data then you receive a negative 4 percent payment adjustment. However if you submit a minimum amount of data, for example just one quality measure or one improvement activity for any point, you can avoid a payment adjustment. Submit a partial year or a full year and you may earn a positive payment. I would recommend using 2017 as a practice year and report on as much as possible rather than meeting just the minimum, using this first year as an opportunity to get up to speed.

MIPS does not impact the Medicaid Meaningful Use (MU) nor eligible hospital MU programs. MIPS changes Meaningful Use (renamed to ACI) from an all-or-nothing compliance program to a continuous scoring system where MU measure rates are compared to benchmarks in much the same way as described for the MIPS Quality category.

It is notable that providers who have done well under the all-or-nothing MU will not automatically have good ACI scores, because of the difference in scoring protocol. It is important to understand how each category is scored for maximum performance.

Although there are fewer measures to report in some categories, there is a new category that has to be measured. Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA), shared that “there will be a higher bar for data submission” with MIPS.  For example, he said, “there will be multiple levels to earn points for data submission rather than a yes/no level, and to get the full amount of points, you have to score very high.”

To support a single data submission method for multiple performance categories, MIPS expands existing PQRS quality reporting methods, such as registry, EHR, and QCDR. This allows for reporting measure across the MIPS categories of Quality, ACI, and CPIA. The Resource Use category is claims-based and thereby does not require clinicians to separately report cost information.

For a MIPS eligible clinicians also participating in an APM and meeting certain additional requirements (a MIPS APM clinician), there are special rules governing MIPS data submission. For example, for a MIPS APM clinician, the MIPS Quality category may not require a separate data submission if the APM is already collecting quality data for CMS to analyze.

MACRA may be able to help your practice by providing technical assistance. HHS has allocated $20 million a year to provide technical assistance to practices with 15 or fewer eligible clinicians participating in MIPS. This assistance is intended to assist practices in a successful transition into the MIPS program. Priority for this financial assistance will be given to practices in rural areas, health professional shortage areas (HPSAs) and medically-underserved areas.

If you do not qualify for the MACRA technical assistance, you may qualify for the Transforming Clinical Practice Initiative (TCPI). This program positions practices for participation in APMs. Practice Transformation Networks (PTNs) are available across the country to provide coaching, resources and tools to help practices prepare for value-based payment models. Call (800) 274-2237 or contact the AAFP to connect with a PTN near you.

How can I prepare?

Based on what we’ve experienced with the practices we work with, here are five of the most effective ways to prepare your providers and your practice for the January 2017 MACRA transition.

  • Educate your organization on the new payment tracks and what they mean for reimbursement
  • Estimate your MIPS score using your current MU, PQRS and VBM scores
  • Optimize MU and PQRS/VBM Quality to maximize the MIPS score (comprise 85 percent of the CY2017 MIPS score)
  • Evaluate staff, resources and organizational structure. For instance, consider combining MU and PQRS efforts under a single leader.
  • Identify CY2017 deadlines impacting CY2018 APM and/or MIPS participation. For example, Medicare Shared Savings Program Track 2/3 ACO or NCQA PCMH application deadlines to help gain MIPS exemptions or points.

There’s plenty to know about MACRA and, like Meaningful Use, there is plenty that has yet to be defined. Keeping current on the regulations and how they affect your providers will best position your practice for preparedness and success.


If you’re looking for more information on MACRA, MIPS or APMs, check out these resources:

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Topics: APM, Meaninguful Use, MACRA, MIPS

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We do this by proactively bringing ideas, expertise, and solutions to your attention, which enables you to communicate the related technology, security or compliance best practices to your employees.



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