MACRA 2017 Update:
Practices NOT participating with Signature Partners’ Medicare Shared Savings Program must designate how they intend to report MIPS data to CMS by June 30, 2017
Medicare Quality Payment Program & Medicare Access & CHIP Reauthorization Act of 2015 Overview
- The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) permanently repealed the Medicare Sustainable Growth Rate (SGR). The SGR tied the Medicare Physician Fee Schedule (PFS) to Gross Domestic Product (GDP); cuts to the PFS were predicted to be as high as 21%.
- All physicians (MD, DO, doctor of dental medicine or surgery, podiatry, optometry and chiropractors), nurse practitioners, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists (future MACRA rule-making may include speech language pathologists, physical or occupational therapists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dieticians) that bill Fee for Service (FFS) Medicare are subject to MACRA*.
*Three Exclusions may apply: (1) this is the provider’s FIRST year billing Part B Medicare, (2) the provider billed LESS than $30,000 in Part B charges in the year, or (3) the provider billed services for FEWER than 100 FFS Medicare patients in the year.
- Providers must decide before June 30th on how they intend to participate in the Quality Payment Program (QPP). MACRA designates two separate Medicare payment paths in the QPP (qpp.cms.gov):
- The Merit Based Incentive Payment System (MIPS) and
- Alternative Payment Models (APMs)
The QPP stays budget neutral by paying the high performing clinicians’ positive adjustments and bonuses with the low performing clinicians’ negative adjustments.
- 2017 is the first performance year in the QPP. Providers will submit data in 1Q2018 from 2017, CMS will report back 2017 performance results in 3Q2018, and the corresponding financial adjustment will begin on 1/1/2019.
Which Path is Right for You?
Are you on an EHR? If so, your vendor can facilitate individual and group MIPS reporting.
Are you a part of an APM? Or more precisely, is the tax identification number (TIN) that you bill your Medicare Part B claims through a participant in an APM? If so, consult with your APM to better understand your reporting obligations.
- Nominal financial risk
- Positive or negative adjustments applied to payments up to +/- 4% in 2019 to 9% in 2025 and beyond (high-achievers also earn additional bonuses).
- 25% update to the PFS annually (2026)
- Providers report individually or as a group (defined by TIN)
- Quality (formally PQRS)
- Resource Use (formally VBPM)
- Improvement Activities (new)
- Advancing Care Information (formally Meaningful Use/EHR Incentive Program).
- Providers earn points in each category listed above; the categories are weighted and used to calculate a MIPS Composite Performance Score (CPS).
- The CPS is applied to a Performance Threshold that is calculated annually using the scores of all eligible clinicians.
- Providers in the bottom quartile will automatically receive the maximum negative adjustment that applies in the period, while those earning scores above the performance threshold will receive positive adjustments and potential bonuses.
- Advanced APMs incur financial risk and are obligated to repay CMS according to their program design when they spend beyond the expected cost of care benchmark
- Advanced APMs must meet a threshold of patients or payments associated to the program e.g., amount of billing from attributed beneficiaries
- Other APMs (not deemed Advanced) will fall into the MIPS payment path
- Advanced APMs receive 5% lump sum bonuses
- 75% update to the PFS annually (2026)
- Providers report according to the requirements of APM participation (check with your APM)
- Track One MSSP ACOs report through the GPRO web interface, but, certain data must be reported through each participants’ EHR
- When an APM falls into the MIPS payment path, each participating TIN in the APM will receive a MIPS Composite Performance Score (CPS).
- The APM’s TINs’ scores are weighted by the number of providers in each TIN and averaged to derive one score for all of the providers in the APM that is then applied to the Performance Threshold.
The Quality Payment Program applies to all Medicare Part B services and future Physician Fee Schedule (PFS) Updates impacting services rendered in physician offices, hospitals, ambulatory surgical centers, skilled nursing facilities, hospices, outpatient dialysis facilities, clinical laboratories, beneficiaries’ homes including observation stays, office visits, surgical procedures, anesthesia services, and other diagnostic and therapeutic services.
- PFS annual updates under MACRA depend on the payment track that the provider/tax id falls into for the payment year: after 2026 (MIPS = +0.25% and advanced APMs = +0.75%), 2017-2019 PFS updates projected to be +0.5%, and 2020-2025 no projected change.
- PFS payment rate formula continues to apply:
[wRVU x wGPCI + peRVU x peGPCI + mpRVU x mpGPCI] x CF = payment
CF (2017 = $35.89)
wRVU = Work Relative Value Unit which the time and intensity associated with the service
peRVU = Practice Relative Value Unit reflects the cost of maintaining a practice/overhead
mpRVU = Malpractice Relative Value Unit reflects the cost of malpractice insurance
GPCI = Geographic Practice Cost Indices, each RVU component is modified by geography
In order for the advanced APM participant to receive bonuses through 2026, and 0.75% PFS updates thereafter, Eligible Clinicians within the Advanced APM must COLLECTIVELY meet payment OR patient count thresholds.
When an advanced APM does not meet either the payment or patient count threshold, they will fall back into the MIPS payment structure. This determination will be made in the year following the performance year (and prior to the payment year) e.g., 2018, for performance year 2017/payment year 2019.
MIPS and the Performance Threshold
- The Performance Threshold calculation is the key to the program’s budget neutrality. Each entity, be it an individual physician, group practice (defined by TIN), or APM (non-qualifying or non-risk bearing), will receive a MIPS Composite Score (CPS) calculated by the point values obtained in the 4 performance categories (Quality, Cost, Improvement Activities, and Advancing Care Information). CMS calculates the Performance Threshold annually, applies each entity’s CPS, and assigns the financial adjustment for the payment year.