Understanding the MIPS Payment Model in MACRA

Welcome to Part II of our series on MACRA you will learn about which providers are subject to the MIPS payment model and how CMS scores the four MIPS categories.

MACRA’s MIPS Payment Model

MIPS is a payment program established by MACRA that applies payment adjustments to Medicare Part B payments and replaces a patchwork system of Medicare reporting programs with what is expected to be a more flexible system. The MIPS payment adjustments are based on an eligible clinician’s or group’s performance across four performance categories that comprise a Composite Performance Score. In contrast to prior programs, MIPS is expected to provide clinicians the flexibility to choose the activities and measures that are most meaningful to their practice to demonstrate performance. CMS estimates that 90-95% of Medicare Part B providers will be subject to MIPS for 2017.

Furthermore, MIPS will effectively merge the Medicare Electronic Health Records (EHR) Incentive Program, often referred to as the Meaningful Use (MU) program, the Physician Quality Reporting System (PQRS) program, and the Value-Based Payment Modifier (VBM) into one streamlined program that consolidates certain aspects of those programs. The law also sunsets payment adjustments for the prior programs in 2018.

Eligible Clinicians

CMS has proposed that under the first two years of MACRA, a MIPS eligible clinician (EC) will be following licensed providers and any group that includes such professionals:

  • Doctors of Medicine
  • Doctors of Osteopathy
  • Doctors of Dental Surgery/Dental Medicine
  • Doctors of Podiatry
  • Doctors of Optometry
  • Chiropractors
  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Registered Nurse Anesthetists

These clinicians would be subject to payment adjustments beginning in 2019 if they do not successfully participate in MIPS or meet the required Advanced APM requirements in 2017.

Measuring MIPS Performance

With the new payment model comes new criteria for evaluating performance and enforcing a stronger focus on quality and total cost of care. Starting in 2017, under MACRA’s MIPS payment model, an eligible clinician’s or group’s performance will receive a single annual quality score (per performance year) called the Composite Performance Score (CPS). A clinician’s earned Composite Performance Score (CPS) for a given performance year determines the MIPS payment adjustments in the second calendar year after the performance year. The CPS is the sum of four weighted components that will be used as the annual measurement for Medicare Part B providers and will directly impact a provider’s Medicare reimbursement in each payment year (payments or adjustments begin in 2019). Based on the Composite Performance Score, an eligible clinician (EP) may receive an upward payment adjustment, a downward payment adjustment, or no payment adjustment. Since each clinician’s annual CPS performance data will be released to the public by CMS, this information will likely impact a provider’s reputation as consumers gain stronger insights into the quality and value these providers represent.

MIPS Composite Performance Score

The Composite Performance Score (CPS) categories and their respective weighted values are:

  • Advancing Care Information (formerly Meaningful Use) – 25 points
  • Quality (PQRS/VBM) – 50 points
  • Resource use – 10 points
  • Clinical practice improvement – 15 points

MIPs Categories

Over time, resource use performance–measuring the costs associated with clinicians’ practice and referral patterns–will grow to 30 percent of the performance formula.

Understanding the Performance Categories and their Criteria

Let’s take a look at the Composite Performance Score categories are qualified.

Advancing Care Information (25% of MIPS CPS total

Advancing Care Information (ACI) is a performance category under the Merit-based Incentive Payment System (MIPS) requiring the meaningful use of electronic health record (EHR) technology. ACI scoring is based on key measures of patient engagement and information exchange.

Advancing Care Information includes measures that will reinforce the collection of patient-generated health data, help providers determine best care options for individual cases, and include patients and their families in treatment plans. An electronic health records (EHR) system’s ability to ensure interoperability, information exchange, provide appropriate security, and enable patients to access to their health information through patient portals and APIs is paramount. By rating a provider’s ability to incorporate electronic health record technology, CMS hopes to see improvements in care coordination and more accountable care.

Unlike its Meaningful Use (MU) predecessor, ACI offers flexible scoring for measures to promote care coordination and better patient outcomes. Clinicians will be rewarded for their performance on measures that most to them and they can choose which categories to emphasize in in their scoring. Additionally, quality reporting measures are now aligned with other Medicare programs and past reporting redundancy have been eliminated.

For ACI, a Base Score is used to account for 50 percentage points of the total Advancing Care Information category score.

CMS has proposed 6 objectives and their measures that would require reporting for the base score:

  1. Protect Patient Health Information
  2. Electronic Prescribing
  3. Patient Electronic Access
  4. Coordination of Care Through Patient Engagement
  5. Health Information Exchange
  6. Public Health and Clinical Data Registry Reporting

In the current proposed rule, the maximum possible points for the ACI category is 100 points and this sum accounts for 25% of the Composite Performance Score.

Resource Use (10% of MIPS CPS total)

The Composite Performance Score’s Resource Use category will compare resources used to treat similar care episodes and clinical condition groups across practices. CMS calculates this score based on claims so there are no reporting requirements for clinicians. This category includes key changes to the current program (Value Modifier).

For payments in 2019, CMS proposes to use the following measures to assess the performance use of MIPS eligible clinicians (for performance year 2017):

  • Total per capita cost
  • Medicare Spending Per Beneficiary (MSPB); and
  • Several episode-based measures

See the remainder of the Resource Use proposed changes here.

For providers looking to implement telehealth programs can positively impact their CPS score in this category due to the following:

For new value-based payment models that reward outcomes (including lower total cost of care) rather than utilization, telehealth is not only cost-effective solution to access to care, but ideally, can reduce unnecessary hospital care while improving overall patient wellness.

Clinical Practice Improvement Activities (15% of MIPS CPS total)

Improved information sharing, expanded practices access, increased patient engagement and broader provider partnerships are all activities rewarded in the Clinical Practice Improvements Activities (CPIA) category. For CPIA, the proposed rule suggests 90 activities and each score is based on the weight of the activity (e.g., High, Medium). Most providers must report a combination of activities that add up to 60 points (there are some exceptions for certain groups). A total of 60 points is available in this category and amounts to 15% of the total MIPS Score starting in 2017, however this category’s weighted value will rise to 30% of the total MIPS score in a few years. Notably, full credit (60 pts) if given if provider participates in patient-centered medical home (PCMH). Furthermore, these activities must be performed for at least 90 days within the performance period and providers must report a yes/no to indicate whether they met the requirements.

Under MIPS, providers will be required to extend their reach beyond the office setting as they aim to deliver more holistic, quality care that avoids costly and unnecessary services.

For example, the following CPIA activities are each qualify as 20 points towards the total category score:

  • Expanded evening & weekend hours
  • Collection of patient experience and satisfaction data

For physicians and other providers seeking greater continuity in care delivery and expanded access, Fonemed’s 24/7 nurse advice line can provide immediate benefit to clinicians looking to improve in the area of clinical practice improvements.

Beyond expanded practice access, and among the 90 other activities possibilities, other relevant avenues to improve the CPIA score include:

Quality (50% of MIPS CPS total)

Quality measure are derived from self-reported data from EHRs or physician practice management systems and submitted to CMS. These systems typically offer a means to count patients, visits or episodes of care data and report on that data. The quality measures in this category consist of those currently used in the existing quality performance programs (PQRS, VBM, EHR) with additional measures solicited by the Secretary for the U.S. Department of Health and Human Services from professional organizations and others in the health care community. Unlike PQRS however, MIPS is not a pass/fail program and performance at any level counts. The determining factor in whether a provider receives an incentive or a penalty on their 2019 Medicare part B fee-for-service payments is how their Composite Performance Score (CPS) in 2017 compares to the threshold set by Medicare.

The quality measures selected address five of the following quality domains: clinical care, safety; care coordination; patient and caregiver experience; and population health and prevention. Read more about MIPS’s Quality Category and scoring here.

Submitting Performance Data is Mandatory

MIPS can effectively be considered the “new default” for Medicare Part B, and in order to receive incentives, a provider must submit their performance data. For MIPS, clinician performance data for the Advancing Care Information, Quality, and Clinical Practice Improvement Activities categories for a performance year are generally due to CMS by March 31st of the following calendar year. If a provider does not submit either MIPS or APM data, the law requires CMS to furnish a zero performance score and the provider is subject to a negative adjustment (starting in 2019 for the 2017 performance year).

Based on the Composite Performance Score, EPs may receive an upward payment adjustment, a downward payment adjustment, or no payment adjustment.

MIPS End Date and Providers Excluded from MIPS Eligibility

At present, there is no official end date to MIPS and clinicians are exempt from MIPS only under certain circumstances. Organizations excluded from MIPS eligibility determination include: billings for Medicare Part A, Medicare Advantage Part C, Medicare Part D, FQHC or Rural Health Clinic payment methodologies, and CAH Method I payments.



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