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MACRA 101: What you need to know about MIPS

Editor’s note: MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015, and is Medicare payment reform that goes into effect Jan. 1, 2017. The associated Quality Payment Program (QPP) is the regulation that will shift the reimbursement model from straight fee for service to a more comprehensive value-based framework. In this MACRA 101 blog series, Jim Brulé dives into the details of the two tracks within the QPP, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).

The Centers for Medicaid and Medicare (CMS) estimates that of the 712,000 Medicare Eligible Clinicians (ECs) that will participate in the QPP, about 87% will default to the MIPS track in the initial years. It has lower risk but also lower incentives, as it was crafted by Congress to ultimately be the less attractive option.

Calculating a MIPS score

Providers that choose the MIPS track will earn a composite performance score based on four categories:

1) Quality of outcomes (ultimately 30%) – These are familiar clinical quality measures, many the same as Physician Quality Reporting System (PQRS) and Value-Based Modifiers (VM). Participants must choose six measure to report. This is weighted at 60% in 2017.

2) Cost of outcomes (ultimately 30%) – CMS will automatically calculate these 11 measures, solely based on claims. Participants don’t have to do anything and won’t really know about their performance until after the year is finished. This category is given no weight in 2017, but CMS will still report scores to help ECs assess their performance.

3) Process Improvement Activities (IA) (15%) – This is a brand new category focused on better processes in nine categories, and it is very similar to patient-centered medical home (PCMH). Each activity has “all or nothing” scale for scoring, and participants simply report whether they did them or not. Forty points must be achieved through a combination of 2-4 measures, or by participating in a PCMH or MIPS Alternative Payment Model.

4) Advancing Care Information (ACI)/Use of Health IT (25%) – This is the most complicated category, because there are three types of scores in this category: a Base Score (five measures = 50 points), Performance Score (nine Meaningful Use measures in 2017 = 90 points), Bonus points (15 points). Though these subcategories add up to 155 potential points, participants can only earn up to 100 points in this category.

Scores in these four categories will translate into a 100-point scale MIPS score. CMS will calculate a performance threshold to keep the program “budget neutral,” which means that the total incentives must equal the total penalties. As a result, if only a small number of participants do poorly, then there will be a smaller incentive pool to distribute among those who do well. Likewise, the more people who do well and are entitled to rewards, the smaller the incentives will be. For these reasons, we expect that most MIPS incentives will be well below the maximum outlined for each payment year.

Reporting periods for 2017

For the performance year in 2017, participants have some flexibility on how they chose to report:

Path 1 –  Submit “test” data to CMS for any period of time within 2017. Providers report on only one element of MIPS with no minimum timeframe. Choosing this option will eliminate any penalties (and rewards) from the MIPS program for payment year 2019.

Path 2 – Submit complete data for a portion of program year 2017. Providers must report on all three categories, for any length of time 90 days or greater. Choosing this option will provide the opportunity for a partial incentive payment, if any is earned.

Path 3 –  Submit complete data for all of program year 2017. Providers report a full year of ACI and a full year of quality, and 90 days or more for IA. Choosing this option provides the opportunity for a full incentive payment, if any is earned.

Participants in paths 2 and 3 will score higher the more measures they report. They don’t have to declare a path or which measures they have chosen until they report. Note that these rules are specific only to performance year 2017.

The CMS website is an excellent resource to stay informed. Allscripts has also prepared educational webinars to help navigate MACRA’s QPP and its final rule, which you can download here.

Editor’s Note: Though the Trump administration will ultimately put forward policies related to health IT, all conversations to date indicate no plan to change the path outlined for the QPP.  Regulatory deadlines remain in effect and healthcare organizations should stay the course. Jim Brulé shares some of the finer points of MACRA’s QPP in additional blog posts, including:

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