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Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) set a framework for Medicare Part B clinicians to take part in the CMS Quality Payment Program (QPP) that rewards value and outcomes in one of two ways: through the Merit‐Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). On October 14, 2016, CMS released the final rule that updates the MACRA payment models, MIPS and Advanced APMs and now referred to as the Quality Payment Program.

The changes to the physician payment system are immense and complex. More than 1 million physicians, other practitioners, and medical suppliers receive Medicare payment under the Physician Fee Schedule. Changes in clinician behavior under this new framework are expected to yield gains in quality of care, resulting in lower morbidity and mortality, and in cost savings. Clinicians’ Medicare revenue will be at risk, so clinicians must act to determine how best to participate in the various payment options established in MACRA.

Background on MACRA Physician Payment Framework
MACRA set a framework for Medicare Part B clinicians to take part in the CMS Quality Payment Program that rewards value and outcomes in one of two ways: through the Merit‐Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs).

The Quality Payment Program replaces the Sustainable Growth Rate (SGR) mechanism that was set up by the Balanced Budget Act of 1997. The SGR was intended to cap the growth in Part B outlays by lowering fee rates if total spending exceeded a global target tied to growth in the overall economy.  But Congress routinely overrode the cuts the formula would have demanded starting in 2003 until new annual payment updates were put in place on July 1, 2015.

MIPS modifies and consolidates key components of the Physician Quality Reporting System (PQRS), the Value Modifier (VM) and the Medicare Electronic Health Record (EHR) Incentive Program (known as Meaningful Use or MU). Those existing quality reporting programs, for eligible providers, are combined into a single program based on performance in four categories: Quality, Resource Use, Clinical Practice Improvement Activities (CPIA), and Advancing Care Information (related to the electronic exchange of interoperable health information).

APMs have been undergoing testing through a variety of demonstration initiatives – such as the recently announced Comprehensive Primary Care Plus project – as well as statutory programs such as the Medicare Shared Savings Program. As discussed later, Medicare will offer a 5 percent bonus payment to clinicians reaching set thresholds for revenues derived from qualifying Advanced APMs – generally, ones that include more than nominal downside risk. CMS expects roughly 5 to 10 percent of clinicians will surpass the APM threshold.

MACRA provides for technical assistance to MIPS‐eligible clinicians in small practices – those having fewer than 15 eligible clinicians – as well as in rural areas or designated Health Professional Shortage Areas (HPSAs). CMS has included a number of proposals in the proposed rule to accommodate clinicians in rural areas and designated HPSAs.

APM Overview

Beginning in 2019 through 2024, clinicians participating in Advanced APMs may become QPs who are eligible for an annual lump‐sum bonus equal to 5 percent of their prior year’s payments for Part B covered professional services. This bonus payment would be in addition to any payment incentives that the clinicians receive through participation in the Advanced APM itself. In addition to the bonus payment, benefits to QP status include exemption from the MIPS payment adjustments and, beginning in 2026, QPs receive a higher annual payment update than non‐QPs (e.g., 0.75 percent vs. 0.25 percent).

Steps to Determine QP Status

CMS has proposed a multi‐step process for determining if a clinician qualifies as a QP who is eligible for the APM bonus payment for a given performance period.

Step 1: Is the Clinician Participating in an APM that is an “Advanced APM?”

CMS determines whether the design of an APM meets three specified criteria for it to be deemed an Advanced APM.  Namely, the APM must:

  • Require participants to use CEHRT;
  • Provide for payment for covered professional services based on quality measures comparable to those in the quality performance category under MIPS; and
  • Either require that participating APM Entities bear more than nominal risk for financial losses under the APM, or be a Medical Home Model.

Step 2: Is the Clinician Identified as Part of the Advanced APM Entity?

QP determinations apply to all of the individual eligible clinicians who are identified as part of the Advanced APM Entity. An eligible clinician would have to be listed on December 31 of the QP Performance Period as part of an Advanced APM Entity to attain QP status. CMS proposes to use the Advanced APM Entity’s Participation List to identify eligible clinicians, or if not available, CMS will use an Affiliated Practitioner List.

Step 3: Have the Eligible Clinicians in the Advanced APM Entity Collectively Received at Least a Specified Percentage of Payments or Patients Through the Advanced APM?  

To qualify for the APM bonus, clinicians participating in an Advanced APM must over time receive an increasing share of their revenue, or see an increasing percentage of their patients, through the Advanced APM. CMS proposes a payment amount model and a patient count model for calculating the threshold percentages that eligible clinicians participating in an Advanced APM Entity must meet in order to be QPs. CMS proposes to calculate the threshold percentages for the Advanced APM Entity under both the payment amount and the patient count methods simultaneously, and determine which method is most favorable for determination of QP status.

In the first two years of the program (2019 and 2020), the percentage of revenue or patients received through an Advanced APM must be from Medicare only. Starting in payment year 2021, an Advanced APM Entity can meet the threshold based on either Medicare‐only revenue/patient count or revenue/patient count from all payers, as long as at least a certain percentage of the all‐payer count is from Medicare. Other payer revenue applicable to the all‐payer threshold could include revenue from Medicaid programs and commercial payers, including Medicare Advantage plans.

In sum, if an APM is deemed an Advanced APM, an eligible clinician is identified as a participant in an Advanced APM Entity that is participating in the Advanced APM, and applicable revenue or patient counts reach the specified QP percentage thresholds identified above, then all of the eligible clinicians in the Advanced APM Entity will be designated as QPs for the payment year associated with the QP Performance Period. Those clinicians would receive the 5 percent lump‐sum APM bonus payment. For the individual clinician participants in the Advanced APM Entity, QP status is applied to the clinician’s National Provider Identifier (NPI) across all of the Tax Identification Numbers (TINs) to which the clinician has reassigned the right to receive Medicare payment, not just the billing TIN affiliated with the Advanced APM Entity.

If an Advanced APM Entity does not meet the QP percentage thresholds, the eligible clinicians within the Advanced APM Entity may qualify as Partial QPs instead, if their revenues or patient counts reach the applicable Partial QP percentage thresholds. Partial QPs do not qualify for the APM bonus payment, but they can choose whether to report under MIPS for a performance year. Partial QPs that elect not to report under MIPS are exempted from the MIPS payment adjustment for that year.

Composite Performance Scoring

CMS has proposed using a unified scoring system to keep the scoring as simple as possible. The following characteristics are suggested to be incorporated into the proposed scoring methodologies for each of the 4 performance categories:

  • For the Quality and Resource Use performance categories, all measures would be converted to a 10‐point scoring system;
  • The measure and activity performance standards would be published, where feasible, before the performance period begins;
  • CMS is not looking to include an “all or nothing” reporting requirement for MIPS, but providers who fail to report on an applicable measure or activity will receive the lowest possible score (zero points);
  • The scoring proposals provide incentives to invest and focus on certain measures and activities that meet high priority goals; and
  • Performance at any level would receive points towards the performance category scores.
MIPS Overview
Beginning in 2019, MIPS eligible clinicians will receive a positive, neutral, or negative payment adjustment based on how their performance on MIPS‐reported measures and activities compares to a baseline performance threshold. MIPS eligible clinicians are incentivized to engage in proven improvement measures and activities that impact health care quality, efficiency, and patient safety and are relevant for their patient population.

For the first two years of MIPS (payment years 2019 and 2020), MIPS eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such professionals. Starting with payment year 2021, CMS may specify other professionals as MIPS eligible clinicians, including physical or occupational therapists, speech‐language pathologists, audiologists, certified nurse midwives, clinical social workers, clinical psychologists, and registered dietitians or nutrition professionals. CMS proposes to allow clinicians who do not qualify as MIPS eligible clinicians to voluntarily report measures and activities for MIPS. These clinicians would gain experience with reporting under MIPS, but would not receive a payment adjustment under MIPS.

Certain clinicians are excluded from participation in MIPS: clinicians who are in their first year of Medicare Part B participation will not be treated as MIPS eligible clinicians until the subsequent year and performance period for that year. Clinicians who are Qualifying APM Participants (QP) or Partial Qualifying APM Participants (Partial QP) who do not report on MIPS measures and activities will not be treated as MIPS eligible clinicians. The same is true for clinicians who are below a low‐volume threshold. CMS proposes to define the low‐volume threshold as an individual or group that, during the performance period, has Medicare billing charges of less than or equal to $10,000 and provides care for 100 or fewer Part B enrolled Medicare beneficiaries.