MACRA,  MIPS, medicare, doctor, treatment


MIPS: The next phase of the value-based care movement

| Feb 01 2017

The Merit-based Incentive Payment System, or MIPS, which went into effect on Jan. 1, 2017, is how most clinicians who provide services to Medicare beneficiaries will be paid under the new law.  In “Prepare for MIPS,” I outlined the four pathways and described the flexibility that CMS has provided in the first year of the program to help clinicians prepare.

Eligible clinicians can maximize MIPS incentives under the  Medicare Access and CHIP Reauthorization Act (MACRA), as well as avoid downward payment adjustments or penalties. However, MIPS-eligible clinicians can also participate in an Advanced APM beginning in 2017.

The bottom line for clinicians and entities involved in this work is this:

Do not do nothing!

CMS has deemed 2017 a transition year, but I prefer to call this the year of preparation. There is really no way to tell what will precisely happen in Washington D.C. but we have an existing law, MACRA, wrapped in current implementation regulations that clearly spell out policy implications.  Aetna has deep expertise and experience in these matters and Medicity along with our sister companies have technology solutions that can help you to thrive in these uncertain times.  The movement towards value based care will continue, and under the current administration it will likely accelerate within the commercial market.

Clinicians who receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM in 2017, will qualify for a 5 percent bonus incentive payment in 2019. Participation in the Advanced APM exempts a MIPS-eligible clinician from the specific reporting requirements they would otherwise need to fulfill under the MISP track of the QPP.

Changes to Advanced APMs

For CMS, APMs are an important step forward in moving our health care system from volume-based to value-based care. CMS has reiterated its intention for payment incentives for APM participants to drive delivery of better health outcomes and smarter spending. To qualify as an APM under the MACRA statute, the entity must use Certified Health IT, report quality measures comparable to measures under MIPS, and bear financial risk in excess of a nominal amount ; or it can be a Medical Home Model.

The provisions of the proposed rule early last year were mostly kept in place, under the final rule now in effect. However there were some changes that provide more possible options for qualifying as an Advanced APM. Advanced APMs are a subset of APMs that let practices earn increased bonus payments for taking on additional shared risk.

The final rule eases the risk criteria for Advanced APMs and permits flexible uptake and a broader range of future models to broaden opportunities for clinicians to participate.

The following Advanced APM models were named in the proposed rule:

  • Comprehensive Primary Care Plus
  • Medicare Shared Savings Program (Accountable Care Organizations) Tracks 2 and 3
  • Next Generation ACO Model
  • Oncology Care Model Two-Sided Risk Arrangement
  • Comprehensive ESRD Care Model, both non-large and large dialysis organization arrangement

For the transition year, CMS has designated certain one-sided risk value-based payment models that do not qualify as “Advanced APMs” – such as the Medicare Shared Savings Program Track 1 Model – as “MIPS APMs.”

MIPS Performance Categories MIPS Scoring MSSP
NextGen ACO
Quality 60% 50% 0%
ACI 25% 30% 75%
CPIA 15% 20% 25%
Cost 0% 0% 0%

Clinicians participating in such MIPS APMs will be scored using the APM scoring standard instead of the MIPS framework, and will not have additional reporting requirements under MIPS for the Quality and Improvement Activities performance categories other than those already taken care of through the APM entities. This should make it easier for MIPS-eligible clinicians already engaged in APMs to gradually transition to the Advanced APM track of QPP without duplicating their reporting obligations.

A chart depicting how clinicians will be paid under MACRA, the new law.

CMS has released new guidance approving a new ACO Tract 1+ Model as an eligible Advanced APM beginning in 2018, with lower risk-sharing requirements than currently available to Medicare ACOs. So now there is a solid framework in place for Advanced APMs with an on ramp from APMs that don’t meet the advanced threshold towards getting fully onto that track.