MACRA Payment ReformWhat practices need to know
about MIPS and APMs in 2017
MACRA payment reform
MIPS APMs
Choose your own adventure
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Merit-Based Incentive
Payment System
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
MIPS: Who’s in and who’s out in 2017
Included Medicare part B payments
Physicians, PAs, NPs, CNSs, and CRNAs
Groups that include the above clinicians
Excluded Medicare Part A (e.g., hospital payments)
Clinicians, groups that fall under the low-volume threshold
Providers billing Medicare for the first year
Groups with significant participation in APMs
About 45%
of clinicians
About 55%
of clinicians
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Low volume threshold
$30k in Medicare Part B charges
OR
During one of the year-long determination periods:
• Sept. 1, 2015 - Aug. 31, 2016
• Sept. 1, 2016 - Aug. 31, 2017
includes a 60-day claims run-out
100 unique Part B patients
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
2016 2017 2018 2019 2020 2021 2022+
MIPS timeline
+7%
-7%
+5%
-5%
+4%
-4%
+9%
-9%
First
performanceyear for MIPS
First MIPS payment
year (based on
2017 performance)
Last
performanceyear for MU,
PQRS, VM
Last payment year for
MU, PQRS, VM
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Quality
30%
Advancing
Care Info
(EHR Use)
25%
Cost
30%
MIPS performance category weights
2017
IA
15%
ACI
25%
Quality
60%
IA
15%
ACI
25%
Quality
50%
IA
15%
ACI
25%
Cost
30%
Quality
30%
Over time, the cost category will gradually become larger and the quality
category will become smaller
2018 2019
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Quality
30%
Advancing
Care Info
(EHR Use)
25%
Cost
30%
MIPS category weights for MIPS APMs
MSSP Track 1 and
Next Gen ACOs
IA
20%
ACI
30%
Quality
50%
IA
25%
ACI
75%
Other MIPS APMs
* Does NOT include cost * Does NOT include cost or quality
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Reporting mechanisms
QCDR Qualified
Registry
EHR Attest Web
Interface
(Groups
of 25+
only)
CAHPS
vendor
(groups
only)
Claims
(indiv.
only)
Quality
ACI
CPIA
• Report either as a group (TIN) or individual (NPI) across all 4 categories
• Choose 1 submission mechanism per performance category:
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Report 6 measures, including an outcome measure (or high-
priority if none available) from choice of over 200 individual
measures or select from one of 30 specialty measure sets
• Tip: When a specialty measure set contains less than 6 measures,
you are only responsible for the measures within the set
Plus, for groups of 16 or more clinicians with at least 200
attributed cases, CMS will automatically calculate an all-cause
readmissions measure from administrative claims
Each measure is worth up to 10 points and is evaluated based
on performance relative to benchmarks
• Bonus points for reporting additional outcome or high-priority
measures and for end-to-end reporting
Quality
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Quality
Reporting
Mechanism
Reporting
Threshold
Performance
Period
Example
QCDR, Registry,
EHR
50% of all patients Any 90 consecutive
days
Diabetes: Foot
Exam
Claims 50% of Medicare
Part B patients
Any 90 consecutive
days
COPD: spirometry
testing
Web Interface Meet sampling
requirements
Up to a full year Falls: Screening for
future risk
CAHPS Meet sampling
requirements
Up to a full year Patient experience
questions
Reporting threshold and performance period vary by submission mechanism:
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Improvement ActivitiesAttest to participating in activities that improve clinical
practice; select up to 4 from inventory of high- and medium-
weighted activities
• For 2017, report via a yes/no attestation; CMS to provide
forthcoming technical guidance on future year reporting
Preferential scoring for certain ECs and groups
• Half credit: non-patient facing ECs; small and rural practices
• Full credit: accredited medical homes; MIPS APMs
Tip: Only 1 EC in group needs to participate in an activity for
entire group to get credit
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Improvement Activities
Activity Weight Points
Provide 24/7 access to clinicians for urgent
careHigh 20
Participate in an AHRQ-listed patient safety
organizationMedium 10
Regularly assess the patient experience of
care through surveys, advisory councils,
and/or other mechanisms.
Medium 10
Total score: 40 / 40
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
ACI
Base score: Mandatory- failing to report any measure
results in a total ACI score of 0
Performance score: Measures are scored up to 10 or 20
points relative to historic benchmarks
Bonus points: Available for reporting data to additional
registries (5 pts) and reporting certain IAs via EHR (10 pts)
Base Score
(50%)
Performance Score
(50%)
Bonus points
Total ACI
score
0-50 pts 0-90 pts Out of 100 pts0-15 pts
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
2017 ACI Measures
• Syndromic surveillance reporting
• Specialized registry reporting
• Report certain IAs using EHR
Ba
se 1. Protect patient health information
2. e-Prescribing
3. Health information exchange
4. Provide patient access
5. Patient-specific education
6. View, download, or transmit
7. Secure messaging
8. Medication reconciliation
9. Immunization registry reporting
Pe
rfo
rma
nce
Bonus
x2
x2
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
ACI: Exceptions• ACI automatically reweighted to zero for:
• Hospital-based ECs (75%+ of services at POS 21, 22, 23)
• Non-patient facing clinicians
• Non-physicians
• Other clinicians may apply for a hardship exception for one
or more for the following reasons:
• Insufficient Internet Connectivity
• Extreme and Uncontrollable Circumstances
• Lack of Control over the Availability of CEHRT
• CMS will no longer automatically exclude clinicians based
on specialty designation
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Not counted toward MIPS score in 2017; may count in 2018
No separate reporting is required
• CMS will calculate score from administrative claims collected for a
full calendar year
Tip: CMS will provide feedback based on claims data in 2017; prepare
for 2018 and future years by assessing feedback reports
Measures include:
– Total per capita costs (Parts A and B) for all attributed beneficiaries;
– Medicare spending per beneficiary (MSPB); and
– Episode-based measures
Cost
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Pick your pace options for 2017
Option Requirements 2019 Payment Outcome
Test the
program
Report:
-one quality measure or
-one improvement activity or
-the required ACI measures
Avoid penalty
Report
some data
Report for at least 90 days:
-more than one quality measure or
-more than one improvement activity or
-more than the required ACI measures
Avoid penalty and eligible
for partial positive
adjustment
All-in Report all MIPS data for at least 90
consecutive daysAvoid penalty and eligible
for full positive adjustment
and exceptional
performance bonus
Do nothing 4% penalty
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
4%
3%
2%
1%
0%
-1%
-2%
-3%
-4%
MIPS Performance
Threshold
Projected MIPS Adjustments for the 2017 Performance Year
MIP
S P
aym
en
t A
dju
stm
en
t Fa
cto
r
As a result of “pick your pace” combined with MIPS’ budget-
neutral design, the expected max incentive of < 1% is much
lower than the 4% allowed under statute.
Exceptional Performance
Threshold
3 70 100
MIPS
score
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Alternative Payment ModelsAdvanced
AAPMs
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Why should my practice consider
participating in an Advanced APM?
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Qualifying participants get:
• Exemption from MIPS;
• 5% annual lump sum bonus payments through 2024; and
• A 0.5% higher fee schedule update from 2026 onward.
Partially qualifying participants get:
• The option to forego participating in MIPS.
• Favorable scoring in MIPS.
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Does my APM meet the
requirements to be considered
an Advanced APM?
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
1. Requires participants to use CEHRT.
– Minimum of 50% of participating ECs in 2017
2. Provides payment based on quality measures
comparable to those used in MIPS.
3. Must satisfy financial risk requirements.
• Be a CMMI expanded medical home model*
• OR Meet financial and nominal risk standards.
Characteristics of an AAPM:
*To date, CMS has not issued any expanded medical
home models that would meet this definition.
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
AAPM Financial Risk Standard
If actual aggregate expenditures exceed expected
expenditures, the AAPM must:
• Withhold payments;
• Reduce payment rates; OR
• Owe payments to CMS.
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
AAPM Nominal Risk Standard:
Under the terms of the APM, the total annual
amount that the APM Entity would potentially owe or
forego to CMS is at least:
• 8% of average estimated total Medicare Parts A and B
revenues; OR
• 3% of expected expenditures for which the APM Entity is
responsible for under the APM.
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Advanced APM Models in 2017 and 2018
2017
• MSSP ACO Tracks 2 & 3
• Next Gen ACOs
• Comprehensive ESRD Care Models
• CPC+
• Oncology Care Model (2-sided risk)
• CJR CEHRT Track
Anticipated for 2018
• Advancing Care Coordination
through Episode Payment
Models (Track 1)
• Cardiac Rehabilitation
Incentive Payment Model
• MSSP ACO Track 1+
CMS anticipates 25% of
clinicians will be considered
advanced APM qualified
participants in 2018 with
the additional models.
CMS anticipates 10% of
clinicians will be considered
advanced APM qualified
participants in 2017.
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Does the APM Entity meet the
QP or partial QP threshold?
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
AAPMs must meet either the Medicare payment or patient
threshold during one of 3 following snapshots of time:
Jan-March, April-June, July-Aug
Participation Thresholds in 2017-2018
Patient
count
Payments
25%
20%10%
= QP
= partial QP
= non-QP
20%
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
How do I know if my practice will be
granted qualifying participant (QP)
status with the APM Entity?
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
• Depends on rules of particular AAPM
• CMS will look at relevant participant list on 3 specific dates
during the performance year (March 31, June 30, Aug. 31).
• A clinician or practice must appear on the list on at least 1 of
these dates to be considered (not necessarily all 3).
Determining QP Status
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
When will my practice get
the 5% lump sum bonus?
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
Advanced APM Timeline
2017 2018
2019 payment
year
2019 2020
2020 payment
year
2021 payment
year
2022 payment
year
QP status
determined based
on participation
thresholds
QP status
determined based
on participation
thresholds
QP status
determined based
on participation
thresholds
QP status
determined based
on participation
thresholds
Payments used
to determine 5%
lump sum bonus
Payments used
to determine 5%
lump sum bonus
Payments used
to determine 5%
lump sum bonus
APM bonus
distributed to
qualifying
participants
APM bonus
distributed to
qualifying
participants
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
• Do we want to be evaluated collectively at the APM Entity
level, or would my practice fare better at the TIN level
under MIPS?
• What are the benefits of participating in a particular APM
model outside of the lump sum bonus?
• What are the start-up and ongoing costs that go along with
participating in an APM?
• Should we participate in MIPS in 2017 and wait for
additional APMs in 2018 (or later)?
Questions your practice should consider
if it’s thinking about joining an AAPM:
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
What physician practices can do now:
Assess performance under current programs
Consider which pathway is best suited for your practice
Evaluate EHR and other vendor readiness and costs
Protect yourself against a MIPS penalty
Establish a game plan for participating/reporting
Engage in ongoing learning about MACRA
Keep an open mind, your strategy could change in 2018+.
For more, check out MGMA’s participation checklist >>
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
MGMA Resources
Washington Connection (mgma.com/Washington)
Weekly enewsletter with breaking updates and everything
you need to know coming from our nation’s capital
MACRA/QPP Resource Center (mgma.com/MACRA)
Your one-stop shop for new MGMA resources and helpful
information
Dedicated MIPS/APMs e-group
Get your questions answered and engage in a robust
conversation with your MGMA peers about all things
MACRA
Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.
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