Aug 1, 2019, 15:56 PM by System

1. What is MACRA?

Congress enacted the bipartisan Medicare Access and CHIP Reauthorization Act (MACRA) in April 2015, which fundamentally transforms Medicare payment for physicians and other non-physician practitioners.  The law shifts reimbursement away from the volume-based system that occurs under the Sustainable Growth Rate (SGR) toward a value-based system that ties Medicare payments, in part, to physician performance on quality and cost metrics. 

Under the Quality Payment Program (QPP) established by MACRA, physicians must participate in either the Merit-Based Incentive Payment System – commonly referred to as “MIPS” – or Advanced Alternative Payment Models – known as “Advanced APMs” – to receive Medicare reimbursement.  The first QPP performance period will begin January 1, 2017 and will serve as the basis for adjusting up to 4 percent of your Medicare payments in a positive, neutral, or negative manner two years later in 2019.   

On October 14, 2016, the Centers for Medicare & Medicaid Services (CMS) issued an interim final rule with comment implementing key policies of the QPP for performance year 2017 and beyond.  ASRA submitted comments on the proposed rule as one member of a coalition of pain specialty societies, which includes: the American Academy of Pain Medicine (AAPM), the American Academy of Physical Medicine and Rehabilitation (AAPMR), the American Society of Anesthesiologists (ASA), the American Society of Interventional Pain Physicians (ASIPP), the North American Neuromodulation Society (NANS), and the Spine Intervention Society (SIS). 

CMS emphasized in the interim final rule that MACRA implementation will be a “staged” process, which will occur over many years to ensure as smooth of a transition as possible to the new payment system.  Hence, physicians should pay particular attention over the next few years as CMS implements policies that link more Medicare payment over time to physician performance on cost and quality measures.

2. Why does this matter?

Most physicians will continue to receive Medicare reimbursement on claims on a fee-for-service basis under MIPS unless they participate in Advanced APMs (as described in detail in Question #13).  The significant change from the prior system, however, is that Medicare will modify a percentage of that fee-for-service claim based on the physician’s performance.  In assessing performance for most physicians, Medicare will look at measures that evaluate quality of care, cost of providing services, use of certain clinical practice improvement activities in patient care, and integration of health information technology into clinical care.  Adjusting Medicare payments in this manner will require physicians to demonstrate strong performance on these measures.

Table 1 below shows the maximum percentage of a physician’s aggregate Part B claims reimbursement that may be increased or decreased in a given year based on performance on cost and quality measures.  Note that these percentages represent maximum payment adjustments either upward or downward; a physician may receive a payment adjustment less than the maximum in a given year such that, for example, in 2019 a physician may receive a positive or negative 2 percent payment adjustment (as opposed to the maximum 4 percent adjustment). 

Table 1: Maximum Percent of Medicare Part B Claims Subject to MIPS Positive and Negative Payment Adjustments Annually

Year*	2019	2020	2021	2022 and beyond
Percentage of Medicare Part B Claims	+/-4%	+/-5%	+/-7%	+/-9%

   *Medicare will make payment adjustments in these years based on physician performance 2 years prior such that performance in 2017 will serve as the basis to adjust payments in 2019.

In addition to the positive payment adjustment they will earn, MACRA requires that certain physicians deemed “exceptional” performers on quality and cost measures will receive bonus payments from a pool of $500 million annually during the first 5 years of the Quality Payment Program.

3. Who will be affected by MACRA?

All physicians, physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and groups that include these professionals must participate in the Quality Payment Program established under MACRA in order to receive Medicare reimbursement, with certain limited exceptions.  CMS plans to expand the list of eligible participating providers beginning in the third year of the QPP.  Possible additional clinicians subject to QPP requirements could include physical or occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dietitians or other nutritional professionals.

4. What is the Merit-Based Incentive Payment System (MIPS)?

Effective January 1, 2017, MIPS will fold components of three current Medicare physician payment programs – the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the “Meaningful Use” (MU) program – into one reimbursement program.  An additional new component established under MACRA – clinical practice improvement activities – also will contribute to a physician’s MIPS final score used to adjust Medicare physician payments.  Table 2 shows the relative contribution of each MIPS performance category to a clinician’s final overall MIPS score. 

Table 2: MIPS Total Performance Score Weights by Performance Category

Category	2019 Payment Year*	2020 Payment Year*	2021 and beyond*
Quality	60%	50%	30%
Cost	0%	10%	30%
Improvement Activities	15%	15%	15%
Advancing Care Information	25%	25%	25%

*Note this year refers to the MIPS payment year.  MIPS payment adjustments are based on the performance year 2 years prior such that 2017 MIPS clinician performance affects 2019 payment adjustments.

Quality

The quality performance category replaces the current PQRS program. The list of MIPS quality measures for 2017 in large part derives from the PQRS list of broad quality measures, as well as specialty-specific and subspecialty-specific quality measure sets. CMS will update the list of quality measures annually by November 1 prior to a new performance year.

Physicians must report at least 6 quality measures, including at least 1 outcome measure, or a specialty-specific or subspecialty-specific measure set.  If an outcome measure is not available, physicians must submit another “high priority” measure related to: appropriate use of medical items and services, patient safety, efficiency, patient experience, or care coordination.  If fewer than 6 measures apply, then physicians must report on each measure applicable to their practices. Physicians receive bonus points for submitting additional measures on outcomes and patient experience, as well as submitting quality measures through “end-to-end” electronic reporting using certified electronic health record technology (CEHRT). 

Cost

The cost performance category replaces the current VM program. Physicians do not submit any cost data to Medicare.  Instead, CMS will assess physicians on cost performance using measures taken from administrative claims data.  The cost measures are both global (including a total per capita cost measure and a Medicare Spending Per Beneficiary measure) and episode-specific (from a list of 10 defined episodes that CMS expects will expand in the future).

Importantly, not all physicians will be measured on cost performance; only those clinicians with a sufficient number of “attributed” beneficiaries will receive a MIPS cost performance score.  CMS expects, for example, that most “non-patient facing” physicians will not have enough beneficiaries “attributed” to them to receive a cost performance score.  CMS will not penalize physicians in their overall MIPS performance if they do not have cost measures.  Instead, CMS will calculate a physician’s overall MIPS score based strictly on the other 3 performance categories (quality, improvement activities, and advancing care information – if the physician is not excused from reporting on this category). 

Improvement Activities

MACRA established this new area, known as clinical practice improvement activities, to evaluate physician performance on integration of activities into clinical care that are expected to improve patient outcomes. MACRA identifies specific categories of improvement activities, including:

• Expanded practice access, such as same-day appointments or 24/7 availability;
• Care coordination, for example, timely exchange of clinical information with other clinicians;
• Beneficiary engagement, such as use of care plans or patient shared decision-making;
• Patient safety, for example, incorporation of clinical checklists; and
• Population management, such as monitoring patient health conditions to provide timely care interventions.

CMS further expanded the MACRA list to include activities that support achieving health equity; integrated behavioral and mental health; and emergency preparedness and response.

CMS developed an initial “Inventory” of improvement activities for 2017 and expects to update the Inventory annually.  Most physicians participating in MIPS must attest to engaging in 2 “high” weighted activities or 4 “medium” weighted activities in the Inventory to receive a full performance score in the improvement activities category.  “Non-patient facing” clinicians, clinicians in rural areas, and clinicians in small practices (those with less than 15 clinicians) must attest to only 1 “high” weighted activity or 2 “medium” weighted activity to receive a full performance score in the improvement activity category.

Advancing Care Information

The advancing care information performance category replaces the Medicare EHR Incentive Program, commonly referred to as “Meaningful Use.” To receive the minimum performance score in this MIPS category, physicians must report a minimum of 5 measures related to: (1) security risk analysis; (2) e-prescribing; (3) providing patient access to electronic health information; (4) sending a care summary; and (5) requesting and accepting a care summary.  Clinicians may submit up to 9 more measures for additional performance credit.  Additionally, clinicians may earn bonus points for reporting to 1 or more public health or clinical data registries, as well as for attesting to certain improvement activities in the improvement activities category using CEHRT functionality.

For 2017, when reporting advancing care information, clinicians may use CEHRT certified to the 2014 Edition or 2015 Edition or a combination of the two.  For 2018, clinicians must use CEHRT certified to the 2015 Edition. 

Hospital-based clinicians (discussed in more detail in Question #8) and those clinicians who earned a “significant hardship” exemption under “Meaningful Use” program do not have to report advancing care information data.  Additionally, although CMS encourages them to do so, CMS is not requiring NPs, PAs, CRNAs, and CNSs to report advancing care information data at this time because they have little to no experience with the adoption or use of CEHRT and may not have applicable measures available to them.  Medicare will not penalize any of the aforementioned clinicians for not reporting advancing care information data; rather, these clinicians’ total MIPS score will be based strictly on performance in the other MIPS performance categories (quality, improvement activities, and cost – if sufficient numbers of beneficiaries are “attributed” to them) without consideration of the advancing care information category.

5. How is 2017 different from other years of MIPS?

To make the transition as smooth as possible to the new payment system, CMS is implementing certain policies that apply in 2017 only to minimize the administrative and reporting burden on physicians participating in MIPS.  These policies include:

• Continuous 90-day reporting period rather than full year: Rather than having to report a full year of data, physicians can report data for each MIPS performance category for a continuous 90-day period during any time of 2017 (except cost data where Medicare never requires data submission). Physicians can choose the 90-day reporting period for each measure submitted.  That 90-day period does not have to be the same for each measure.  Instead, physicians can choose the best time for them to report each measure so long as the reporting period lasts a continuous 90 days.  While CMS encourages physicians to report on a full year’s data, it will not require physicians to do so in 2017.

• No cost performance score: CMS will not include the cost performance score in a physician’s total MIPS performance score in 2017. Instead, CMS will calculate cost performance scores on each specific cost measure that a physician is eligible to receive and provide informational feedback only as to how the physician performed on each measure.  CMS expects this information will give physicians a better understanding of whether or not they will have enough “attributed” patients to be evaluated on cost performance and, if so, how they actually perform on their relative efficiency in the delivery of health care services.

• Performance and payment options: Physicians may earn positive, neutral, or negative 2019 payment adjustments based on 2017 performance under the following scenarios:

• To maximize potential to earn the highest possible positive payment adjustment, physicians must report 6 quality measures, report on the 5 required advancing care information measures, and attest to 4 improvement activities. These clinicians also potentially are eligible to receive additional bonus payments as “exceptional” MIPS performers allocated annually from a $500 million pool.  Note that certain reporting requirement exceptions apply to members of small practices and “non-patient facing” clinicians, as discussed in Question #4 and Question #7.

• To avoid a negative payment adjustment and possibly receive a positive payment adjustment, physicians may report more than 1 quality measure, more than 1 improvement activity, or more than the required 5 measures in the advancing care information category.

• To avoid a negative payment adjustment, physicians can report 1 quality measure, 1 improvement activity, or the required 5 measures in the advancing care information category.

• To receive a full negative 4 percent payment adjustment, the physician chooses to not report a single measure or improvement activity.

• Minimum score for each MIPS measure: CMS is establishing a minimum performance score – a “floor” – that physicians will earn for each measure submitted in 2017. This policy ensures that no physician receives a negative payment adjustment in 2019 so long as he or she submits performance data.

6. Will 2018 be a transition year for MIPS similar to 2017?

Yes, 2018 will be a transition year for MIPS.  Medicare will continue the option of allowing for a continuous 90-day reporting period for the improvement activities and advancing care information MIPS performance categories.  However, CMS expects to stop transition policies related to quality data submission and instead to fully implement all quality reporting requirements in 2018, including reporting quality data for the full calendar year.  CMS will specify additional MIPS transition policies for 2018 next year.

7. How does Medicare define a “non-patient facing” physician? Are MIPS performance requirements different for “non-patient facing” physicians?

MACRA requires CMS to make special considerations for physicians who are “non-patient facing” when developing MIPS performance requirements.  An individual “non-patient facing” clinician is one who bills 100 or fewer “patient-facing” encounters (including Medicare telehealth services).  A group of “non-patient facing” clinicians is defined as having more than 75 percent of the National Provider Identifiers (NPIs) billing under the group’s Tax Identification Number (TIN) meeting the definition of an individual “non-patient facing” clinician.  CMS expects to publish the list soon of procedures that qualify as “patient-facing” encounters.

CMS modifies a number of requirements for “non-patient facing” clinicians, consistent with the MACRA specifications.  First, “non-patient facing” clinicians must report 1 “high” weighted activity or 2 “medium” weighted activities to earn a full performance score in the improvement activities category (as opposed to 2 “high” activities or 4 “medium” activities for most MIPS participants).  Second, all of those who have a “significant hardship” hardship exemption under the “Meaningful Use” program do not have report data on the advancing care information performance category.  Finally, CMS expects that most “non-patient” facing physicians will not have a sufficient number of beneficiaries “attributed” to them to receive a cost performance score.  While these modifications are in place for the near future, Medicare expects to develop and implement MIPS policies in the future more tailored to “non-patient facing” clinicians.

8. How does Medicare define a “hospital-based” clinician? Are MIPS performance requirements different for “hospital-based” clinicians?

CMS defines a “hospital-based” clinician as a clinician who furnishes 75 percent of more of his or her covered professional services in sites of service identified by the following Place of Service (POS) codes: (1) inpatient hospital (POS 21); (2) emergency room (POS 23); and (3) on-campus outpatient hospitals (POS 22). 

Medicare will not assess hospital-based clinicians on performance in the advancing care information category, consistent with prior “Meaningful Use” requirements.  Hospital-based clinicians will not be penalized under MIPS for lack of an advancing care information score; rather, their MIPS total score simply will be based on all other applicable performance categories (quality, improvement activities, and cost – if a sufficient number of beneficiaries is “attributed” to them).  Additionally, CMS is exploring the possibility of allowing hospital-based and other facility-based clinicians to use their institution’s quality and cost performance scores as a proxy for their MIPS performance score in the future and plans to outline policies on this possibility as early as next year.

9. Who does not have to participate in MACRA?

Most physicians have to participate in MIPS.  However, certain providers are excluded, including those who: (1) participate in Advanced APMs (described in detail in Question #13); (2) are newly-enrolled into Medicare; and (3) meet the “low-volume threshold.”  To meet the “low volume threshold,” a physician either must have less than or equal to $30,000 in Medicare Part B charges or 100 or fewer Medicare patients.  CMS may modify the definition of the “low-volume threshold” in future years of the MIPS program.

10. Can physicians submit the data required by MIPS as individuals or as members of a group?

Physicians may report MIPS data as individuals or as members of a group.  To assess MIPS performance of individual clinicians, CMS will use a combination of a unique billing TIN and NPI as the identifier of the clinician.  Each unique TIN/NPI will be considered a different MIPS eligible clinician and MIPS performance will be assessed separately for each TIN under which an individual bills.  CMS has policies in place that address the possibility that a clinician may switch practices or merge with a group during the MIPS performance year.

For a physician to report MIPS data as a member of a group, the physician must be a part of a single TIN associated with 2 or more clinicians – including at least one MIPS eligible clinician (as identified by an NPI) – that have their Medicare billing rights reassigned to the TIN.  CMS will measure the group collectively on all MIPS performance categories: quality, cost, improvement activities and advancing care information. If a physician decides to participate in MIPS as a member of a group, he or she must do so for the entire calendar year performance period.   

Additionally, MACRA specifies that MIPS eligible clinicians may report MIPS data as members of “virtual groups.” Such groups may consist of no more than 10 MIPS eligible clinicians.  CMS expects to outline procedures next year whereby physicians can report MIPS data collectively as members of a “virtual group” beginning in 2018.

11. Will clinicians learn how they perform on MIPS performance measures?

MACRA requires that MIPS eligible clinicians receive performance feedback at least annually beginning by July 1, 2017.  Given that the first year of MIPS will not be complete by July 1, 2017, CMS will provide historical data based on prior quality and cost performance in the PQRS or VM, respectively, as initial physician feedback and will include fields similar to those in the Quality and Resource Use Reports (QRURs). 

CMS intends to develop easy to understand and meaningful performance feedback for the QPP beginning July 1, 2018, most likely in a dashboard format.  The agency intends to leverage mechanisms such as health IT vendors, registries and QCDRs to help disseminate performance feedback where appropriate.  Initially, CMS will distribute performance feedback information annually, but hopes in the future to be able to provide feedback on a more than annual basis.

12. Will patients and the public know about clinician performance in the Quality Payment Program?

CMS will publish on the existing Physician Compare website information about individual and group clinician performance in the Quality Payment Program.  Information will include:

• The MIPS clinician or group’s final MIPS score;
• The MIPS clinician or group’s performance on each MIPS performance category (quality, cost, improvement activities, and advancing care information, as applicable);
• Aggregate information on the MIPS program, posted periodically, including the range of final scores for all MIPS eligible clinicians and the range of the performance of all MIPS eligible clinicians on each MIPS performance category; and
• For clinicians participating in Advanced APMs (described in more detail in Question #13), the names of those clinicians and details as available and appropriate about the Advanced APM in which they are participating.

13. What are Advanced Alternative Payment Models (Advanced APMs)?

MACRA established financial incentives for clinicians to participate in entities that broadly coordinate care across multiple specialties and the care continuum through alternative payment models, or APMs.  These entities may include accountable care organizations (ACOs), patient-centered medical homes, participants in bundled payment models, episode payment model participants, and other shared savings program participants.  Under these risk-based models, clinicians share in financial rewards or losses for cost and quality efficiencies gained or lost, respectively, in the delivery of healthcare services. 

MACRA provides bonuses to clinicians who participate in certain special APMs, termed “Advanced APMs,” for the first 6 years of the Quality Payment Program.  The bonus payments equal 5 percent of a physician’s prior year’s aggregated payments for covered Medicare Part B professional services. 

Advanced APMs generally have to meet more stringent performance and financial risk criteria than other APMs.  Among many other requirements, organizations that qualify as Advanced APMs must: (1) use quality metrics similar to those used for MIPS to assess clinician performance; (2) require at least 50 percent of their clinician participants to use CEHRT; and (3) accept financial risk of greater than a “nominal” amount.  Typically, clinicians who participate in Advanced APMs have a greater portion of their reimbursement tied to meeting quality and cost metrics than those participating in other, non-Advanced APMs.

14. Are chronic and acute pain specialists likely to participate in Advanced APMs?

To date, most APMs have centered on primary care or certain specific disease like end-stage renal disease, rather than specialty care.  CMS expects in the future to develop more specialty-specific APMs and Advanced APMs.  In fact, MACRA established the Physician-Focused Payment Model Technical Advisory Committee (PTAC) as an independent committee that will provide advice and guidance CMS on the development of physician-focused payment models – including specialty-specific physician payment models – for testing in the Medicare program. 

In the interim, however, acute pain specialists who work with hospitals that take part in the Comprehensive Care for Joint Replacement (CJR) Model may qualify to participate in the Quality Payment Program through Advanced APMs beginning in 2018.  CMS expects it will deem CJR participating hospitals that use CEHRT functionality as “Advanced APMs” effective for 2018. 

As such, physicians in these CEHRT Track CJR participating hospitals will qualify as Advanced APM participants in 2018 if either they: (1) receive 25 percent of their Medicare payments through the CJR; or (2) receive 20 percent of the Medicare patients through the CJR.  These clinicians participating in the CEHRT track of the CJR then would not have to report MIPS data and instead will receive the Advanced APM 5 percent bonus payment.  Additionally, clinicians who receive 20 percent of their Medicare payments through the CJR or 10 percent of their Medicare patients through the CJR will not receive the Advanced APM bonus payment, but will have the option to decide whether or not they would like to participate in MIPS and be subject to the MIPS payment adjustment, which could be positive, neutral, or negative.

15. How can I find out more information on the Quality Payment Program?

ASRA will continue to provide members with important updates about the QPP.  In the interim, please refer to the CMS Quality Payment Program website for important information and educational tools about the program.  Additionally, CMS has developed a number of webinars regarding MIPS and APMs that you may find useful.