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10 Things You Should Know About MIPS and APM

MIPS Deep DiveAlexis IsabelleSenior Manager Quality Performance

This event is live as of XYZ

Welcome and introduction1


Its pretty clear that the government has fundamentally shifted the way our country provides health care since the arrival of the Affordable Care Act in 2010. Within recent years, these changes are specifically felt in how providers are reimbursed for giving care. But, what is the real reason prompting all these changes?6/14/2016athenahealth inc. - confidential2

Source: CMS, 2013 Annual Report of the Boards of Trustees of the Federal Hospital Insuranceand Federal Supplementary Medical Insurance Trust Funds, May 31, 2013, available at:http://downloads.cms.gov/files/TR2013.pdf;

Projected Medicare Fee-for-service Payment Cuts per the ACA 2014201520162017201820192020

Projected number of Medicare beneficiaries54M56M57M59M61M63M64M


Source: CMS, 2013 Annual Report of the Boards of Trustees of the Federal Hospital Insuranceand Federal Supplementary Medical Insurance Trust Funds, May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf

Well, the number of Medicare beneficiaries continues to grow, payer reimbursements are a huge target for Medicare cuts to try and offer a solution to a cumulating financial problem. Rather than cutting public payer programs altogether, the government has decided to tie payments to the demonstration of quality rather than just cut public payer programs altogether. It is by the Affordable Care Act, the government continues to move toward a consistent delivery of quality care.

As you can see the number of Medicare beneficiaries has been and will continue to increase exponentially over the next five to ten years, mostly driven by the baby-boomers hitting the retirement age. So as to not bankrupt the country, the Medicare fee cuts have to be cut just as much to compensate. As a result the payment system is shifting from fee-for-service to fee-for-value6/14/2016athenahealth inc. - confidential3

FFS versus FFVEliminates incentive to increase volume Eliminates incentive to provide high-cost services over equally effective low-cost servicesQuality-based incentives Shared risk Emphasizes the role of primary care providers Encourages coordination of careFees billed per units of serviceIncome maximized through volumeNo penalty for poor quality Providers lose money if they reduce unnecessary services

Volume Driven Health Care

Value-BasedHealth Care



Fee-for-serviceValue-based payments

The big shift is moving from what is known as a fee-for-service environment to a fee-for-value environment, or value based. These value based payments are very different in that they really incentivize quality based care. Instead of high volume where money is made from providing more care, it is all about high quality, where payments come from the type of care that is provided.6/14/2016athenahealth inc. - confidential4

Medicare Access and CHIP Reauthorization Act (MACRA) signed into law April 16th, 2015Repealed the flawed sustainable growth rate (SGR) formulaExtends Childrens Health Insurance Program (CHIP) for two yearsNew two-track Medicare physician payment system emphasizing value-based payment modelsLandmark legislation alters howMedicare reimburses physicians

And this shift happened in a big way last year. On April 16th, the Medicare Access and CHIP Reauthorization Act (MACRA), H.R. 2 was signed into law. While this law permanently repealed the flawed sustainable growth rate (SGR) formula, the new legislation included a small addition that has huge repercussions on the Medicare framework for paying physicians called MACRA.

Sources: http://www.familydocs.org/payment-reform/macra


Image source: http://www.healthcarefinancenews.com/news/icd-10-debate-hits-washington-most-prepared-worry-persists5


New legislation, rulings, announcements, proposals, and constant changes from the government surrounding the healthcare community Just remembering all these developments can feel a bit like youve wandered off the path into uncharted territory, especially now that youre put in the position of needing to know more about new reporting and documentation measures than ever before.

Image source: https://www.flickr.com/photos/33346716@N03/80361770296


Before we dive into these measures, there are a whole score of new acronyms that have come out of the MACRA legislature, adding to what already might have felt like an acronym soup.7


QPPAPMMIPSMerit-based Incentive Payment Systemcombination of MU, PQRs, VM, and new CPIAAlternative Payment ModelQuality Payment Programthe overarching name that covers MIPS and APM tracksCPSMIPS composite performance score

The four pertaining most to our conversation today are the following8

MIPS Deep Dive

Okay, now lets take a deeper look into what MIPS is all about and how this will affect ECs going forward from 2017 on.9



MIPSMerit-Based Incentive Payment System

Consolidates three existing programs, adds in additional performance category

APMAlternative Payment Models

Incentive payments available to qualified and eligible APM12

So, under MACRA, two new systems of payment are set to begin in 2017. Both methods allow practices to be awarded incentives for providing improved care. The first option is MIPS, or the merit-based incentive payment system. MIPS combines the MU, PQRS, and VM programs will all merge into one system with adjustments for that year implemented in 2019.

The second track is the option to become an Alternative Payment Model Entity. APMs are for clinicians who can demonstrate that a significant portion of their revenue comes from two-sided risk contracts and who utilize a certified EHR technology.10


MIPS Eligibility Years 1 and 2Physicians (MD/DO and DMD/DDS)PAsNPsClinical nurse specialistsCRNsAnesthetistsGroups (defined by TIN) that include such clinicians

The MIPS ECs will include those listed here. 11


MIPS Eligibility Years 3+Physical or occupational therapistsSpeech-language pathologists,Audiologists,Nurse midwivesClinical social workersClinical psychologistsDietitians/Nutritional professionals

Secretary may broaden Eligible Clinicians group to include others12

Everyone reports MIPS in 2017.

Despite the previous list of eligibility, CMS states that all ECs will report MIPS in 2017. CMS will then determine which ECs are excluded from MIPS due to APM, low volume threshold or new to Medicare. This means about 90% of providers in country will be performing in MIPS in 2017 based on CMS 2019 payment adjustment estimation. This leaves less than 10% of providers, to become QPs through Advanced APMs and receive incentive payments for 2019.13

Three clinician groups not subject to MIPSExclusionsECs can volunteer to reporting but wont receive any money

Has not submitted claims under any group prior to performance periodQualifyingparticipants (QPs)Partial qualifying participants who opt not to report MIPS