CMS Alphabet Soup: MACRA, MIPS, APMs

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  • June 21, 2016
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CMS Alphabet Soup: MACRA, MIPS, APMs

In April 2015, Congress signed the Medicare Access and Chip Reauthorization Act, known as MACRA. That legislation did a number of things, including eliminating the sustainable growth rate (SGR) calculation for computing the physician fee schedule; allowing for a .05 percent increase in Medicare reimbursement until 2019; and finally and most importantly, laying the groundwork for a new system of value based reimbursement.
On April 27, 2016, CMS unveiled the proposed rule for a new quality-based payment program, named the Quality Payment Program. The program as proposed will have two tracks. One is the Merit-based Incentive Payment System (MIPS). The second is called Alternative Payment Model (APM). CMS has set the first participation year to be 2019, with the performance year to begin January 1, 2017. CMS further explained that in the first year of the program the majority of Eligible Clinicians (a new term replacing eligible provider)—as many as 90 percent—will qualify under MIPS. Only advanced entities, pre-approved by CMS taking downside, risk will be reporting as an Advanced Alternative Payment Model.
The objective of MIPS is to align three existing quality programs (PQRS, Meaningful Use, Value Based Payment Modifier) into one quality reporting program that meets CMS’s goals of better quality, healthier people, and reduced cost. To meet the goal eligible clinicians will be required to report measures from four domains:

  • Quality
  • Resource use
  • Clinical improvement activities
  • Advancing care information (EHR use)

Quality reporting will be much like PQRS reporting, except clinicians will be required to report six measures, only. One measure must be an outcome measure, and one must be a cross-cutting measure. There are over 300 measures to choose from, and with the help of several specialty societies recommendations for reporting measures, the decision on meaningful measures to report should be easier.
Resource use will not require any reporting from clinicians. CMS will take the resource use data from claims, and will use an algorithm similar to that used to assess the value modifier (which takes into account the attribution of patients and the total per capita cost), the Medicare spending per beneficiary (MSPB), and episode groups including chronic obstructive pulmonary disease (COPD), congestive heart failure, coronary artery disease, and diabetes mellitus.
Clinical improvement activities will include many items clinicians have been doing in their practices for years, such as improved access to care, or timely reporting of information to patients and others on the care team.
Finally, Advancing Care Information is a new term for using the electronic medical record as well as other technologies such as health information exchange, portals, and secure messaging. Clinicians will earn points on a base score for many of the processes included in meaningful use, and also points for a performance score which incorporates many of the measures from meaningful use two and three.
Each domain has its own set of reporting requirements that will result in a clinician’s ability to receive a maximum composite score of 100. For those clinicians who achieve the maximum composite score, a 4 percent increase in reimbursement is awarded in the first year, which increases over time. Because the program is designed to be budget neutral, the increase to successful reporters will come from those clinicians and groups who were unsuccessful reporters. An additional bonus payment could be earned by those clinicians or groups who are exceptional performers and achieve a score 25 percent above the performance threshold.
The second track outlined in the proposed rule is the Alternative Payment Model. An APM includes those that come under the CMS Innovation Center Model, Medicare Shared Savings Model, Patient Centered Medical Homes, and Other CMS models.
Only Advanced Alternative Payment Models will be eligible to receive the additional five percent reimbursement based on the prior year’s estimated aggregate expenditure if all reporting criteria are met. In the proposed rule, CMS mentions only a few entities deemed eligible for this enhanced reimbursement including Next Generation ACO’s, CMS Center for Innovation models, and track 2 and 3 Shared Savings ACO’s. An Advanced APM must use Certified EHR technology, base payment on quality measures comparable to those in MIPS, and either bear more than nominal risk for financial losses, or is a Medical Home Model expanded under the Centers for Medicare and Medicaid Innovation center.
All other Alternative payment models will report under MIPS. It is a long term goal of CMS, however, to promote greater participation in APM’s, over time.
For more details on these proposed rules go to:

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Tracy Bird
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Ms. Bird, CPC, CPMA, CPC-I, CEMC is Senior Practice Management Advisor for KaMMCO, a professional liability insurance company serving physicians and hospitals in Kansas. She has over 40 years of experience working in all aspects of practice management, billing, coding, and staff training.

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