The government has introduced a set of acronyms to describe MACRA, all of which, in practice, are being used interchangeably
MACRA – Medicare Access and Chip Reauthorization Act: the legislation that lays out the goals for the program
QPP – Quality Payment Program: the structure and regulations that CMS created to implement MACRA
MIPS – Merit-Based Incentive Payment System: the set of requirements and scoring methodology upon which most participants will be measured—and incentivized—in the first few years of MACRA
MACRA accomplishes 4 goals
Replaces the SGR (Sustainable Growth Rate calculation that previously served as the basis for annual Medicare professional fee schedule increases) and sets predictable Medicare rates
Accelerates the shift to “Value-Based Payment” to reward quality over quantity of care.
Ends MU, PQRS, and the Value-Based Payment Modifier as separate Medicare programs with their own incentive/penalty structures.
Consolidates these programs into a new program, effective 2017, with financial impact beginning in 2019.
Two Paths to Participation in MACRA
Advanced Alternate Payment Models
[Specific types of ACOs]
Involve financial risk
5% annual bonus + higher fee increases
Merit-Based Incentive Payment System
Reformats past programs: MU/PQRS
Payment adjustments based on performance
Although the APM option is attractive, the vast majority of providers should plan to participate in MIPS initially because only a few models qualify as Advanced APMs and because few physicians will meet the APM participation thresholds to qualify for that option.
Eligible Clinicians (formerly known as “eligible providers or EPs”)
Physicians and dentists
PTs/OTs/Audiologists/and others (effective 2019)
Clinicians can report as individuals or as a group
Providers are evaluated in 4 performance categories, weighted as follows in 2018
Quality (50% in 2018, 45% in 2019) – Replaces PQRS and the quality component of the Value-Based Payment Modifier.
Promoting Interoperability (25%) – Formerly called “Advancing Care Information”, this replaces MU. Uses performance-based scoring on measures that emphasize patient access to information, patient engagement, and health information exchange.
Resource Use (10% in 2018, 15% in 2019) – Replaces the cost component of the Value-Based Payment Modifier. Calculated by CMS with no additional action required of providers.
Improvement Activities (15%) – New category. Providers select activities of interest from a list of 90+ possibilities.
Options: CEHRT and ACI Measure Sets
Providers must use a certified EHR (CEHRT) to report the MIPS ACI measures. In 2018, either 2014-edition CEHRT or 2015-edition CEHRT is acceptable. This choice determines the available ACI measure sets.
In 2019, clinicians must use 2015 CEHRT.
Potential Payment Adjustments:
Clinician’s or group’s performance is compared to a national benchmark set annually by CMS. Clinicians whose MIPS score is above the threshold may receive a positive payment adjustment to their Medicare Part B claims in proportion to their score; those with scores below the threshold receive a negative payment adjustment.
Source: CMS and SRS Health
*Note: In the interest of facilitating clinician success, CMS has set the performance threshold at a very low level in the initial “transition years” of MIPS. Due to the program’s budget neutrality requirement, a scaling factor of less than 1 will likely apply, reducing the size of potential upward adjustments.