MACRA? MPP can help.

Payment Reform is fast approaching with the first baseline measurement period of MACRA (Medicare Access and Chip Re-authorization Act) starting in calendar year 2017 which will affect payment adjustments in 2019.

In two prior newsletters titled “Are you Ready for Payment Reform” and “Medicare Payment Innovations”; MPP has provided education on payment reform and MACRA which includes MIPS (Merit-Based Payment System) and APMs (Alternative Payment Models). This third newsletter in the series will provide an update on the newly released proposed rules for MACRA.

In brief, MACRA provides two new payment tracks: MIPS and APM. As stated in the prior newsletters; the traditional FFS (Fee-For-Service) payment model is going away and payment will now include some tie to value-based performance.

MIPS Track: rolls existing quality programs PQRS (Physician Quality Reporting System), VBPM (Value-Based Payment Modifier), and MU (Meaningful Use) into one budget-neutral pay-for-performance program. Providers will be scored on 4 categories to calculate an overall MIPS score:

  1. Quality

    • Providers choose 6 measures (down from 9 in PQRS)
    • Over 200 measures to choose from with 80% tailored to specialists
    • Selections must include 1 outcome metric and 1 cross-cutting metric:
      • Sample outcome metrics: Hemoglobin A1c control, Depression remission in 6 months, ED visit in last 30 days of life, Surgical site infections
      • Sample cross-cut metrics: Documentation of advanced care plan, Tobacco use screening and intervention, Control of high blood pressure
    • CMS will use claims to calculate 3 population-based measures:
      • All-cause hospital readmission measure
      • Acute conditions composite measure
      • Chronic conditions composite measure
    • Bonus points are awarded for:
    • Reporting extra outcome metrics
    • Reporting metrics in high-priority domains:
      • Appropriate use, patient safety, efficiency, patient experience and care coordination
    • Reporting via certified EHR technology

  2. Cost/Resource Use

    • Score based on Medicare claims, no additional reporting required
    • Total per capita costs for all attributed beneficiaries and Medicare spending per beneficiary
    • New episode-based cost measures for specialists
    • Expected to include Part D costs

  3. Clinical Practice Improvement

    • Reward for clinical practice activities such as activities focused on care coordination, beneficiary engagement, and patient safety
    • Over 90 activities to choose from, some weighted higher than others
    • Clinicians in certain APMs and qualified PCMH will receive favorable scoring
      • An ACO (Accountable Care Organization) is an APM
      • NCQA, Joint Commission or URAC PCMH certifications qualify

  4. Advancing Care Information

    • Replaces Medicare EHR Incentive Program for eligible professionals (EP’s) (also known as (MU) Meaningful Use)
    • Applies to all clinicians, unlike MU (which only applied to Medicare physicians)
    • No longer requires all-or-nothing measure reporting
      • Proposed partial credit available
    • Requires fewer measures, providers scored on participation and performance
    • Opportunity to report as group or individual

For scoring weights and annual changes; see the infographic below from The Advisory Board Company

four categories that determine mips score
  1. Merit-Based Incentive Payment System.
  2. Medical homes are recognized if they are accredited by: the Accreditation Association for Ambulatory Health Care; the National Committee for Quality Assurance (NCQA) PCMH recognition; The Joint Commission Designation, or the Utilization Review Accreditation Commission (URAC).
  3. Eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians.

©2016 The Advisory Board Company·

MIPS is a zero sum game with the high performers benefiting at the lower performers expense.

  • Providers are assigned a score of 0-100 based on performance across four categories
  • Provider score compared to a CMS-set performance threshold (PT); non-reporting groups given the lowest score
  • Providers scoring above the PT receive bonuses; providers scoring below the PT subject to penalty
maximum provider penalties and bonus

APM Track:

  • Requires significant share of revenue in contracts with two-sided risk, quality measurements and EHR requirements
  • APM track participants would be exempt from MIPS payment adjustments and would qualify for a 5% Medicare part B incentive payment in 2019-2024
  • Minimum 2 criteria must be met to qualify for APM track:
    • Participate in Advanced APMs:
    • Eligibility criteria:
      1. Threshold to trigger losses no greater than 4%
      2. Loss sharing at least 30%
      3. Maximum possible loss at least 4% of spending target
      4. Certified EHR use, quality requirements comparable to MIPS
    • Meet Percent of Revenue or Percent of Patient Threshold Under APM
  • Only 4.5-12% clinicians projected to qualify for APM track in 2019

Advanced APM – Ineligible Payment Models

  • Bundled Payments for Care Improvement Initiative (BPCI)
  • Comprehensive Care for Joint Replacement (CJR) Model
  • Medicare Shared Savings Program (MSSP) Track 1 (50% sharing: upside only)

Advanced APM – Eligible Payment Models

  • Medicare Shared Savings Program Tracks 2 and 3
  • Next Generation ACO Model
  • The Oncology Care Model Two-Sided Risk Arrangement
  • Comprehensive ESRD Care Model (Large Dialysis Organization Arrangement)
  • Comprehensive Primary Care Plus (CPC+)
  • Certain commercial contracts with sufficient risk, including Medicare Advantage (starting in 2021)

How can MPP help with MACRA?

  • MPP is submitting an application to CMS to apply for an MSSP (Medicare Shared Savings Program) Track 1 ACO (Accountable Care Organization)
    • Although not a qualified Advanced APM, a track 1 ACO will allow MPP to perform quality measure reporting on behalf of ACO participating clinicians
    • As an APM, an ACO gives favorable scoring benefits in the Clinical Practice Improvement category- proposed minimum 50% scoring credit, cost/resource use metric dropped
  • MPP will be expanding its Patient-Centered Medical Homes program and will be seeking NCQA certification
  • Use of the MPP supported patient disease registry, MD Insight from Symphony Performance Health, will assist with chronic disease management and patient care gap closure which will improve performance on HEDIS based metrics. This will prepare providers for quality measure performance reporting in the MIPS track.
  • Development of a care coordination model which will assist with Cost/Resource Use and Clinical Practice Improvement categories by helping to manage transitions of care opportunities, decreased unnecessary utilization and enabling the provision of care in the appropriate setting at the right time.
  • Creation of a tiered-membership model based on quality and efficiency thereby encouraging providers to utilize higher performing specialists and PCP’s.
  • Monthly quality performance reports will allow tracking and performance improvement opportunities.
  • MPP website allows providers to see patient rosters, prospective gaps in care, quality scorecards to track progress and is sortable by payer, patient, or HEDIS metric to enable individualized focus on quality improvement opportunities.
  • MPP is investigating MIPS reporting solutions for MPP members not participating in the ACO
  • Investigate, develop and support solutions such as Cerner HealtheIntent population health platform to capture quality metrics and other data to meet Medicare, Blue Cross and Medicaid reporting requirements.

Physician Payment Timeline

MACRA | Medicare Access and CHIP Reauthorization Act of 2015

physician payment timeline


MU = Meaningful Use
PQRS = Physician Quality Reporting System
VBPM = Value-Based Payment Modifier
RVU = Relative Value Unit

  1. The projected 0.5% update, established by MACRA, was negated due to other legislative provisions. As a result, the 2016 conversion factor will be $35.93, which is a net reduction of 11 cents per Relative Value Unit (RVU).
  2. Lowest quartile performers automatically receive the maximum negative payment adjustment.
  3. Payment adjustment listed for 2023 through 2024 is an assumption based on currently available information.
  4. Exceptional performance criteria has not been defined.

If you have questions, please contact Dr. Michael Ziccardi, Associate Medical Director at (810) 610-1038 or