Overview of MACRA- Presented by: Dixon Davis

Senior Consultant

Provide high level understanding of the Medicare Access and the CHIP Reauthorization

Act of 2015 (MACRA)

Understand how MACRA will impact practices and their approach to patient care

Objectives

MACRA Review

Creates the Merit-Based

Incentive Payment System

(MIPS).

Repealed the

Sustainable Growth Rate

(SGR) formula and prevented

the 21% reimbursement cut.

Combines and replaces

existing Medicare quality

reporting programs beginning

in 2019 (based on 2017

reporting period).

Promotes development of

Alternative Payment Models

(APMs) through

incentive payments.

Signed into law in April 2015

Sets Medicare fee schedule moving forward

MACRA Timeline

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Timeline.PDF

What is MIPS?

How will practices get paid for Medicare services?

Two Payment Tracks

Merit-Based Inventive

Payment System (MIPS)

Beginning in 2019, practices will be reimbursed from

CMS under one of two payment tracks:

How is an APM different from MIPS?

How will practices get paid?

Alternative Payment

Models (APMs)

Merit Based Incentive Payment System

(MIPS)

MIPS Overview

MIPS replaces

the old SGR formula

and will provide

updates to the

physician

payment system,

moving forward.

MIPS introduces a

fourth program:

Clinical Practice

Improvement

Activities

MIPS sunsets and

consolidates the

following programs:

Quality: Physician

Quality Reporting

System (PQRS)

Advancing Care

Information:

Meaningful Use

Resource Use: Value

Based Payment Modifier (VBPM)

Existing program penalties sunset at the end of 2018

Quality Category

• Practices will report on 6 measures (as opposed to 9 in current PQRS model) with at least one

cross-cutting measure.

• Additional reporting options to accommodate differences in practice size and specialty.

• Focus on decreasing reporting burden.• Accounts for 50% of the MIPS score in 2019, but

will decrease in subsequent years.

Replaces the Physician Quality

Reporting System (PQRS)

Advancing Care Information Category

• Very similar to Meaningful Use, but with more reporting flexibility.

• Increased emphasis on interoperability and

secure information exchange • Score made up of two components: Base Score

and Performance Score• Accounts for 25% of the MIPS score in 2019.

Replaces Meaningful Use

Cost Category

• Based on Medicare claims, so no additional reporting is required.

• Category uses 40 episode-specific measures to

account for specialty differences.• Accounts for 10% of the MIPS score in 2019, but

will increase in subsequent years.

Replaces the Value Based

Payment Modifier Program

(VBPM)

Focused on practice improvement in the

areas of care coordination, patient

engagement, and patient safety.

Practices will choose from more than 90

CPIAs in 9 categories.

Some activities will have a higher weight than

others.

Accounts for 15% of MIPS score in 2019.

Clinic Practice Improvement Activities (CPIA)

Expanding

patient access

Patient

engagement

Achieving

health quality

Population

management

Patient safety and

practice assessment

Emergency

preparedness and

response

Care

coordination

Participating in

an APM

Integrated behavioral

and mental health

9 CPIA Categories

How will practices get paid under MIPS?

Eligible professionals (EPs) will receive a composite score of

0-100 based on the 4 categories.

Score will be compared to a performance threshold based on

the mean or median composite score.

EPs that meet the threshold will see no change in

reimbursement.

EPs that fall below/above certain threshold will receive

payment adjustment (+/-).

Beginning in 2026, MIPS participants will receive annual

payment updates of 0.25%.

MIPS scores to be publicly accessible.

2019 MIPS Weighted Categories

Clinic Practice Improvement

Activities15%

Quality (PQRS)50%

Resource (VBPM)10%

Advancing Care Information

(Meaningful Use)25%

Based on 2017 Reporting Period

Future Changes to MIPS Categories

2019 20202021 (and

beyond)

Quality (PQRS) 50% 45% 30%

Advancing Care Information (Meaningful Use) 25% 25% 25%

Resource Use 10% 15% 30%

Clinical Practice Improvement Activities 15% 15% 15%

Alternative Payment Models (APMs)

Alternative Payment Models (APMs)

In addition to the clinic practice improvement activities under MIPS, CMS continues to promote the concept of Alternative Payment Models.

Current examples of APMs include Medicare Shared Savings Program ACOs, all CMS Innovation Center initiatives, and other demonstration programs.

In future years of the program, practices can possibly earn incentive payments through non-Medicare payers, now referred to “Other Payer Advanced APMs.”

CMS to annually review new payment models that would qualify as Advanced APMs.

Must use certified EHR

technology

Provide payment based on quality

measures (comparable to

MIPS)

Bear financial risk for monetary

losses

APM Entity Requirements

How will practices get paid under an APM?

Incentive payments will apply for those eligible

professionals that receive a certain % of revenue or

see a certain % of patients through their APM.

From 2019 – 2024 providers qualifying for the APM

track will receive a 5% annual lump-sum bonus on

their Medicare fee-for-service payments.

Providers must meet increasing revenue and

patient thresholds in future years.

How will practices get paid under an APM?

Participants who fail to meet the required will be

paid under the MIPS system.

Participants who are close to the percentage can

partially qualify.

Starting in 2026, APM participants will receive

annual payment updates of 0.75% compared to

0.25% for MIPS participants.

Advanced APM Requirements

Requirements for Incentive Payments for Significant Participation in

Advanced APMs

(Clinicians must meet payment or patient requirements)

2019 2020 2021 2022 2023 2024 or

later

Percentage of

Payments

through an

Advanced

APM

25% 25% 50% 50% 75% 75%

Percentage of

Patients

through an

Advanced

APM

20% 20% 35% 35% 50% 50%

Local Market Activity

Pay attention to market changes with payers and health systems

Trade Associations

Pay attention to resources and programs offered by trade associations

How can practices stay up-to-date on these changes?

Final MIPS/APM Rule

• Look for educational resources to be

provided by CMS

• Determine CPIAs that will be applicable

• APM criteria to be updated annually

Current Reporting

Requirements

2019 MIPS score to be based on

2017 reporting

Where do we start?

Focus on Quality measurements

– 50% of MIPS and focus of commercial payers

Review technology for proper tracking

Develop long term plan

– Resource use

– Advancing care information

– Clinical practice improvement activities

Focus on patient-reported outcomes and satisfaction.

Explore new ways to track and

report data on patient/disease

populations.

Reviewing CPT utilization in their groups.

Explore ways to proactively

collaborate with commercial

payers.

Be open to changing

business models.

What can practices focus on internally at this

time?

Continue to meet Meaningful Use

and PQRS Requirements

Summary

Traditional fee for service is not going away, but does change with MIPS.

Practices must be open in adapting to new payment models.

Change is coming, but there are a lot of details still to be worked out.

Practices who are proactive now will be in better position with CMS and commercial payers in the future.