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Prepare for MIPS

| Jan 17 2017

It’s time to begin preparing for federal changes – the Medicare Access and CHIP Reauthorization Act (MACRA) took effect on Jan. 1, 2017.

MACRA aims to change care delivery and physician payments by rewarding providers for better care, rather than quantity. The Centers for Medicare & Medicaid (CMS) released the final rule on Oct. 14, 2016, with a request for comments from interested stakeholders by Dec. 31, 2016. Some changes were made to the rule proposed earlier this year. And we may see technical corrections or changes around the edges to address the more recent comments, but those will likely be very minor.

Although the first year of MACRA is a transition year, it’s important that providers get ready now for new reporting requirements in 2018.

Under MACRA, eligible clinicians and groups will participate in the Quality Payment Program (QPP) under the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs).

Of the four pathways to participate in QPP, the first three apply to clinicians subject to MIPS in 2017. These pathways offer different opportunities to receive an upward adjustment or bonus in Medicare payments, and to avoid a downward adjustment or penalty.

Avoiding a penalty

The MIPS track is scored on four categories that will be used to calculate Medicare Part B bonuses and penalties:

  • Quality;
  • Resource Use (or Cost);
  • Advancing Care Information (ACI); and
  • Clinical Practice Improvement Activities (CPIA).

The first pathway is for clinicians who feel they are ready to fully participate in MIPS. These clinicians can report on all of the required measures for at least a 90-day period or for the full year. Doing so can make them eligible for an additional positive adjustment each year.

The second pathway allows a clinician to participate for part of the calendar year, and submit data for less than the full calendar year of the reporting period, to qualify for a small bonus. This would get a clinician on the ramp to full participation in 2018 while gaining a bit of positive payment adjustment.

The third pathway is an opportunity to avoid a penalty by submitting just some data during 2017. The reporting period can be less than 90 days, with reporting on only one measure from the Quality category and one CPIA activity, or by reporting on all the reduced number of ACI measures.

The fourth pathway is for clinicians participating in an advanced Alternative Payment Model (APM). They’ll qualify for a 5 percent bonus incentive payment in 2019 if they receive a sufficient portion of Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM.

Choosing MIPS or APM

Consistently high performers in MIPS can financially outperform physicians in APMs in the coming years. Therefore, clinicians who are in APMs and are confident of scoring well on relevant quality and value metrics might prefer to be judged as a group under MIPS.

In assessing your options, it’s important to recognize that performance under MIPS as an individual clinician or in a small group practice may be less predictable than as part of an APM. This is due to the performance in MIPS being relative to that of other clinicians.

Looking for short-term gain at the expense of long-term stability is not a good strategy.

About the payments

The program is required by law to be budget-neutral. For every dollar paid out in upward adjustments, there must be a corresponding reduction in downward adjustments.

There is an additional bonus for exceptional performance, however, that escalates up to 10 percent for progressively higher performers who exceed a threshold number of MIPS points. MACRA does not require exceptional performance bonuses to be budget-neutral.