The ABCs of MACRA: Understanding MIPS vs. APM

As you prepare for the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program (QPP), you have probably heard about the basics of the program, and know that your practice will participate if you bill Medicare more than $30,000 per year and provide care for more than 100 Medicare patients a year.

You probably have also heard that there are 2 tracks to follow for the QPP: MIPS (Merit Based Incentive Payment System) and the Alternative Payment Model (APM). For the calendar year 2017, most providers will participate through MIPS, unless they are in their first year participating in Medicare, have very low Medicare volume, or participate in APMs.

It is expected that APM will be the desired option long term, but how can your practice determine what is the best choice beyond 2017?

Distinguishing the 2 tracks

When it comes to MIPS, 4 performance areas will determine a clinician’s score: quality measure performance (replaces the Physician Quality Reporting System), advancing care information (replaces Meaningful Use), resource use (replaces the Value-Based Modifier), and clinical practice improvement activities (new category). Clinicians can choose the activities and measures that are most meaningful for their practice. Each category has a different weight and relative weighting will change over time. Together, these determine the MIPS Composite Performance Score (CPS), and based on this score clinicians will receive positive, negative, or neutral adjustments to the provider’s base rate of Medicare Part B payment. The cost category will be calculated in 2017, but will not be used to determine your payment adjustment. In 2018, the cost category will start to be used to determine payment adjustment.MIPS 2017

For APMs, payment structure is linked to value to provide added incentives to clinicians for providing high-quality and cost-effective care. To be considered as participating in an eligible APM, the APM must meet the following criteria: be CMS Innovation Center models, be on Shared Savings Program tracks, or be part of certain federal demonstration programs; base payment on quality measures comparable to those in MIPS; require participants to use certified EHR technology; and either bear more than nominal financial risk for monetary losses or be a Medical Home Model expanded under Innovation Center authority. Initially approved Advanced APM models include: Next Generation ACO Model, Comprehensive Primary Care Plus (CPC+), Medicare Shared Savings Program (MSSP) Tracks 2 and 3, and Comprehensive ESRD Care (CED). A final list will be published before January 1, 2017.

Financial impact

There are two types of financial impacts for those who participate in MIPS. One is a small, annual inflationary adjustment to the Part B fee schedule. The other one consists of payment adjustments (incentives or penalties) that are based on the aforementioned 100-point CPS.

The inflationary adjustment is an annual +0.5% increase for the payment years 2016 to 2019. The inflationary adjustment resumes in 2026 and thereafter, when MIPS-eligible clinicians will receive a +0.25% annual adjustment.

The payment adjustments offer the biggest incentives and penalties. Clinicians that fall 1 point above the threshold will receive a bonus, and those 1 point below the threshold will receive a penalty. The further a provider’s CPS is above or below the threshold, the larger the reward or penalty, up to a 4% max in 2019. The potential maximum adjustment percentage will increase each year from 2019 to 2022 (5% in 2020, 7% in 2021, and 9% in 2022 and beyond). Exceptional performers have the potential to achieve additional incentives from 2019 to 2024. By 2020, clinicians’ MIPS scores can impact their Medicare reimbursement from +9 to +37%.

APM 2017

When it comes to the APM track, clinicians are exempt from MIPS requirements and will be rewarded annual lump-sum incentive payments of up to 5% in 2019 for Advanced APM participation in 2017. From 2026 and beyond there will be a 0.75% annual baseline payment update. To qualify for these incentives, clinicians must receive 25% of their revenue from Medicare or see 20% of Medicare patients through eligible APMs in 2017. The minimum must increase through 2021 up to 75%.

For more information on payment, visit the CMS website.

You can prepare now by talking to your EHR provider about the kinds of reports you will need to meet these requirements. Learn more about these quality-measure summaries by contacting a Quest Diagnostics representative at 1.888.835.3409.

See a Quanum EHR demo for iPad.

References: AAFP, CMS.

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