The Nitty-Gritty of MACRA 2017


MACRA (Medicare Access and CHIP Reauthorization Act of 2015) basically repealed the SGR formula for determining Medicare Fee for Service payments. This act also included a replacement where Congress directed CMS to implement the Medicare Incentive Payment System (MIPS) as a new physician payment system that incentivizes quality and efficiency rather than volume. MIPS rolls the existing PQRS, Value Based Modifier and Meaningful Use into one program. The previous programs were merely baby steps to implement MACRA.

If you are a Medicare provider who is not newly enrolled and bills Medicare charges of $30,000 or more on behalf of 100 or more Medicare Part B beneficiaries per year, you are covered under MACRA and will receive either a positive or negative adjustment based on your performance under MACRA. The inclusion in MACRA is a phase-in process. For years 1-2 it covers these providers: MD, DO, DMD, DDS, PA, NP, CNS and CRNA. Years 3 and forward add PT, OT, SP, LCSW and others.

There are two paths to participation in MACRA. The Gold-standard with the greatest benefit is for the provider to participate in an Alternative Payment Model (APM). Those qualifying receive a 5% APM incentive payment in 2019 for 2017 participation. Those not qualifying for an APM must participate in MIPS receiving a positive or negative adjustment based on your score in different areas of focus. There is no official “election” where you sign up to do one or the other- the provider just reports the appropriate measures by March 31, 2018. The significance of the recordkeeping will require providers to know before January 2017 what your plan of action will be. The result of participation in 2017 will affect 2019 either positively or negatively. The budget neutral adjustments range from +/- 4% in 2019 to +/_ 9% in 2022.

If an APM is the Gold-Standard- How Does a Provider Participate?

An Alternative Payment Model is a payment approach, developed in partnership with the clinician community, that provides added incentives to clinicians to provide high-quality and cost-efficient care. Advanced APMs are a subset of APMs and let practices earn more for taking on some risk related to patients’ outcomes. Advanced APMs must meet the following requirements:

  • Be CMS Innovation Center models, Shared Savings Program tracks, or certain federal demonstration programs

  • Require participants to use certified EHR technology

  • Base payments for services on quality measures comparable to those in MIPS

  • Be a Medical Home Model expanded under Innovation Center authority or require participants to bear more than nominal financial risk for losses.

To qualify for the 5% APM incentive payment, the provider must receive a certain percentage of payments for covered professional services or see a certain percentage of patients through the Advanced APM during the associated performance year.

For 2017 the Advanced APMs are:

  • Comprehensive End Stage Renal Disease Care Model (Large Dialysis Organization arrangement)

  • Comprehensive End Stage Renal Disease Care Model (non- Large Dialysis Organization arrangement)

  • Comprehensive Primary Care Initiative (CPC+)- Currently only available in Arkansas, Colorado, New Jersey, New York (Capital District-Hudson Valley Region), Ohio and Kentucky (Cincinnati-Dayton Region), Oklahoma (Greater Tulsa Region) and Oregon.

  • Medicare Shared Savings Program Accountable Care Organization – Track 2

  • Medicare Shared Savings Program Accountable Care Organization – Track 3

  • Next Generation Accountable Care Organization

  • Oncology Care Model (OCM): two-sided risk arrangement

For 2018 the Advanced APMs anticipated additions are:

  • Accountable Care Organization Track 1 +

  • New Voluntary Bundled Payment Model

  • Comprehensive Care for Joint Replacement Payment Model (CEHRT)

  • Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT)

  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer Accountable Care Organization

Ok, So I Don’t Qualify for an APM- Now What?

If a provider cannot participate or decides not to participate in an official Alternative Payment Model and wishes to avoid a payment penalty or possibly receive a positive adjustment, he or she must participate in MIPS. There is some flexibility in reporting MIPS for the 2017 data but only for 2017.

MIPS measures are a combination of PQRS (Physician Quality Reporting System), the Value-Based Payment Modifier and Medicare Meaningful Use. Providers who participated in these programs in the past or currently have an advantage in MIPS because the requirements should be familiar.

4 MIPS Categories Used to Score Providers for 2017:

Category 1: Quality (Replaces PQRS)

2017 Score Weight: 60%

What is Required: Report up to 6 quality measures including an “Outcome” measure

Look up Measures: HERE

The Measures are, for the most part, the same type of measures providers used in previous years. The biggest difference is that the Reporting GROUPS available where only 20 patients had to be reports for a specific set of measures (like Diabetes, Diabetic Retinopathy, Dementia, etc.) are not available. Providers can continue to report the same measures included in the groups; however instead of reporting on only 20 patients, providers are required to report on 50% of ALL Medicare patients or transactions for which this measure applies (increases to 60% in 2018). This will require the gathering of data at the transaction level using claim entry or EHR Reporting. Going back after-the-fact will be prohibitive for most providers. There are “Specialty Measure Sets” which may or may not have 6 measures. Each measure is scored a possible 10 points. High Priority Measures provide bonus points.

Providers will want to reassess the measures they choose to report and consider whether measures can be reported that do not require significant data-tracking. Bear in mind that at least one “Outcome” Measure must be reported. If no Outcome measure is applicable, then the provider is required to choose another High Priority Measure. An outcome measure assesses the results of health care as experienced by patients.

Category 2: Advancing Care Information

(Replaces Medicare EHR Incentive Program known as Meaningful Use)

2017 Score Weight: 25%

What is Required: Fulfill the required measures based on EHR (base measures):

  • Security Risk Analysis

  • E-Prescribing

  • Provide Patient Access

  • Send Summary of Care

  • Request/Accept Summary of Care

Choose to submit up to 9 measures for additional credit. Look up Measures: HERE

Some providers may not have to report if not applicable; i.e., hospital-based providers. In this case the weighting will be zero and redistributed to other MIPS performance categories.

Category 3: Cost-Resource Use (Replaces Value-Based Modifier)

2017 Score Weight: 0% for 2017 (increases in future years)

What is Required: No data submission is required. CMS will use claims data to assess MIPS providers’ performance based on cost measures that account for different clinical specialties.

CMS will not weight the cost component of MIPS for 2017. 2018 weight will be 10%. Ultimately, the weighting will be 30%, so close examination of your score for 2017 will be crucial in planning for the future.

Category 4: Clinical Practice Improvement Activities (CPIA) - new category

2017 Score Weight: 15%

What is Required: Attest that up to 4 improvement activities have been completed. Groups with fewer than 15 participants or Rural Health or Health Professional Shortage Area (HPSA) only required to do 2 improvement activities.

Look up Activities: HERE

There are 93 Improvement Activities. Providers are rewarded for care focused on care coordination, beneficiary engagement and patient safety. Each activity is assigned a subcategory. Each activity is given a weight of either medium or high. A rating of high is based on alignment with CMS national priorities and programs. For the first year, all MIPS eligible providers or groups, or third party entities, must designate a yes/no response for activities on the Improvement Activities Inventory. Some responses may be available as a modifier on claims submission.

Total Possible MIPS Score+ 100%

If a provider sends MIPS data in as an individual, the payment adjustment will be based on individual performance. An individual is defined as a single NPI tied to a single Tax ID Number.

If a provider sends MIPS data with a group, the group will get one payment adjustment based on the group’s performance. A group is defined as a set of clinicians (identified by their NPIs) sharing a common Tax ID number, no matter the specialty or practice site.

Individual providers will send data for each of the MIPS categories through:

  • CEHRT

  • Registry

  • Qualified Clinical Data Registry (QCDR)

  • Routine Claims

Group providers will send in group-level data for each of the MIPS categories through:

  • CMS Web Interface (must register by 6/30/2017)

  • CEHRT

  • Registry

  • Qualified Clinical Data Registry (QCDR)

To receive assistance, CMS has developed programs for MIPS eligible providers.

Where Do I Start?

  1. Your Quality performance will be determined on how your compare to peers on Quality, Outcomes and Population Health. Start with the Quality and Resource Use Report (QRUR). This report compares your scores relative to your peers by calculating standard deviations from the national mean for both quality and cost. It also includes a high-risk bonus adjustment that is based on ICD-10 coding. Use the QRUR to identify measures where your practice falls below the average, especially in areas where you have a large volume of patients. QRUR also includes Cost data using a cost composite score and performance derived by Per capita costs for all attributed beneficiaries and those with specific conditions and Cost for the medical spending per beneficiary measure surrounding specific hospital stays. The QRUR can be obtained through your online account.

  2. Review the Quality Measures. Review your most frequent diagnoses to determine which measures might be a good fit for your practice. If you submitted a PQRS group measure previously, start with those measures, but keep in mind some may be very tedious to report at the 50% reporting requirement.

  3. The Advancing Care Information measures were adopted from Stage 3 of Meaningful Use. Review with your EHR vendor on your ability to meet the requirements.

  4. For the new category of Clinical Practice Improvement Activities, providers should review the list of 93 activities to determine the ones you are already doing. Build on activities already started.

  5. Compile a “to-do” list based on your review of your current standing with the measures and where you need to be. Plan early for 2017 to make certain all data capture processes are in place prior to January 1.

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