Overview of MACRA- Presented by: Dixon Davis
Senior Consultant
Provide high level understanding of the Medicare Access and the CHIP Reauthorization
Act of 2015 (MACRA)
Understand how MACRA will impact practices and their approach to patient care
Objectives
MACRA Review
Creates the Merit-Based
Incentive Payment System
(MIPS).
Repealed the
Sustainable Growth Rate
(SGR) formula and prevented
the 21% reimbursement cut.
Combines and replaces
existing Medicare quality
reporting programs beginning
in 2019 (based on 2017
reporting period).
Promotes development of
Alternative Payment Models
(APMs) through
incentive payments.
Signed into law in April 2015
Sets Medicare fee schedule moving forward
MACRA Timeline
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Timeline.PDF
What is MIPS?
How will practices get paid for Medicare services?
Two Payment Tracks
Merit-Based Inventive
Payment System (MIPS)
Beginning in 2019, practices will be reimbursed from
CMS under one of two payment tracks:
How is an APM different from MIPS?
How will practices get paid?
Alternative Payment
Models (APMs)
Merit Based Incentive Payment System
(MIPS)
MIPS Overview
MIPS replaces
the old SGR formula
and will provide
updates to the
physician
payment system,
moving forward.
MIPS introduces a
fourth program:
Clinical Practice
Improvement
Activities
MIPS sunsets and
consolidates the
following programs:
Quality: Physician
Quality Reporting
System (PQRS)
Advancing Care
Information:
Meaningful Use
Resource Use: Value
Based Payment Modifier (VBPM)
Existing program penalties sunset at the end of 2018
Quality Category
• Practices will report on 6 measures (as opposed to 9 in current PQRS model) with at least one
cross-cutting measure.
• Additional reporting options to accommodate differences in practice size and specialty.
• Focus on decreasing reporting burden.• Accounts for 50% of the MIPS score in 2019, but
will decrease in subsequent years.
Replaces the Physician Quality
Reporting System (PQRS)
Advancing Care Information Category
• Very similar to Meaningful Use, but with more reporting flexibility.
• Increased emphasis on interoperability and
secure information exchange • Score made up of two components: Base Score
and Performance Score• Accounts for 25% of the MIPS score in 2019.
Replaces Meaningful Use
Cost Category
• Based on Medicare claims, so no additional reporting is required.
• Category uses 40 episode-specific measures to
account for specialty differences.• Accounts for 10% of the MIPS score in 2019, but
will increase in subsequent years.
Replaces the Value Based
Payment Modifier Program
(VBPM)
Focused on practice improvement in the
areas of care coordination, patient
engagement, and patient safety.
Practices will choose from more than 90
CPIAs in 9 categories.
Some activities will have a higher weight than
others.
Accounts for 15% of MIPS score in 2019.
Clinic Practice Improvement Activities (CPIA)
Expanding
patient access
Patient
engagement
Achieving
health quality
Population
management
Patient safety and
practice assessment
Emergency
preparedness and
response
Care
coordination
Participating in
an APM
Integrated behavioral
and mental health
9 CPIA Categories
How will practices get paid under MIPS?
Eligible professionals (EPs) will receive a composite score of
0-100 based on the 4 categories.
Score will be compared to a performance threshold based on
the mean or median composite score.
EPs that meet the threshold will see no change in
reimbursement.
EPs that fall below/above certain threshold will receive
payment adjustment (+/-).
Beginning in 2026, MIPS participants will receive annual
payment updates of 0.25%.
MIPS scores to be publicly accessible.
2019 MIPS Weighted Categories
Clinic Practice Improvement
Activities15%
Quality (PQRS)50%
Resource (VBPM)10%
Advancing Care Information
(Meaningful Use)25%
Based on 2017 Reporting Period
Future Changes to MIPS Categories
2019 20202021 (and
beyond)
Quality (PQRS) 50% 45% 30%
Advancing Care Information (Meaningful Use) 25% 25% 25%
Resource Use 10% 15% 30%
Clinical Practice Improvement Activities 15% 15% 15%
Alternative Payment Models (APMs)
Alternative Payment Models (APMs)
In addition to the clinic practice improvement activities under MIPS, CMS continues to promote the concept of Alternative Payment Models.
Current examples of APMs include Medicare Shared Savings Program ACOs, all CMS Innovation Center initiatives, and other demonstration programs.
In future years of the program, practices can possibly earn incentive payments through non-Medicare payers, now referred to “Other Payer Advanced APMs.”
CMS to annually review new payment models that would qualify as Advanced APMs.
Must use certified EHR
technology
Provide payment based on quality
measures (comparable to
MIPS)
Bear financial risk for monetary
losses
APM Entity Requirements
How will practices get paid under an APM?
Incentive payments will apply for those eligible
professionals that receive a certain % of revenue or
see a certain % of patients through their APM.
From 2019 – 2024 providers qualifying for the APM
track will receive a 5% annual lump-sum bonus on
their Medicare fee-for-service payments.
Providers must meet increasing revenue and
patient thresholds in future years.
How will practices get paid under an APM?
Participants who fail to meet the required will be
paid under the MIPS system.
Participants who are close to the percentage can
partially qualify.
Starting in 2026, APM participants will receive
annual payment updates of 0.75% compared to
0.25% for MIPS participants.
Advanced APM Requirements
Requirements for Incentive Payments for Significant Participation in
Advanced APMs
(Clinicians must meet payment or patient requirements)
2019 2020 2021 2022 2023 2024 or
later
Percentage of
Payments
through an
Advanced
APM
25% 25% 50% 50% 75% 75%
Percentage of
Patients
through an
Advanced
APM
20% 20% 35% 35% 50% 50%
Local Market Activity
Pay attention to market changes with payers and health systems
Trade Associations
Pay attention to resources and programs offered by trade associations
How can practices stay up-to-date on these changes?
Final MIPS/APM Rule
• Look for educational resources to be
provided by CMS
• Determine CPIAs that will be applicable
• APM criteria to be updated annually
Current Reporting
Requirements
2019 MIPS score to be based on
2017 reporting
Where do we start?
Focus on Quality measurements
– 50% of MIPS and focus of commercial payers
Review technology for proper tracking
Develop long term plan
– Resource use
– Advancing care information
– Clinical practice improvement activities
Focus on patient-reported outcomes and satisfaction.
Explore new ways to track and
report data on patient/disease
populations.
Reviewing CPT utilization in their groups.
Explore ways to proactively
collaborate with commercial
payers.
Be open to changing
business models.
What can practices focus on internally at this
time?
Continue to meet Meaningful Use
and PQRS Requirements
Summary
Traditional fee for service is not going away, but does change with MIPS.
Practices must be open in adapting to new payment models.
Change is coming, but there are a lot of details still to be worked out.
Practices who are proactive now will be in better position with CMS and commercial payers in the future.