Leverage MACRA to Support Long-Term Strategic Goals

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CMS Quality Payment Program – MIPS Path

As we mentioned in our previous MACRA blog, the CMS Quality Payment Program (QPP) provides a choice of two paths for Medicare reimbursement:

  1. Merit-based Incentive Payment Systems (MIPS);
  2. Advanced Alternative Payment Model (AAPM); or the Partial Qualifying APM.

We will review the AAPM methodology in the next blog series.

Organizations that wish to participate in 2017 have until October 2 to make the difficult decision of which path to choose.  However, they must be able to submit their performance data by March 31, 2018.  The first payment adjustments will go into effect on January 1, 2019.

It’s estimated that about 90% of clinicians will participate in traditional Medicare through the MIPS track, which carries a greater possibility for both reward and penalty than the AAPM and Partial Qualifying APM paths.

Decision Tree for CMS QPP


MIPS was created by the Medicare Access and CHIP Re-authorization Act of 2015 to streamline multiple value-based programs including Meaningful Use (MU), Physician Quality Reporting System (PQRS) and Value-Based Modifier (VBM).


Medicare Part B clinicians billing more than $30,000 a year AND providing care for more than 100 Medicare patients a year.


  • Physicians
  • Physician Assistants
  • Nurse Practitioner
  • Clinical Nurse Specialist
  • Certified Registered Nurse Anesthetists

Non-patient facing clinicians are eligible to participate in MIPS as long as they exceed the low-volume threshold, are not newly enrolled, and are not a Qualifying APM Participant (QP) or Partial QP that elects not to report data to MIPS.


  • Qualifying APM participant
  • Partial qualifying APM participant
  • Doesn’t meet the low volume threshold
  • Newly enrolled in Medicare (exempt until following performance year)


Pick Your Pace for Participation for the Transition Year

You have several options to determine how you will participate.  If you don’t submit anything to CMS for the 2017 performance period, you will receive a negative payment adjustment.  CMS is trying to make it really easy so that will not happen, hence Pick Your Pace.

Your choices are that you can:

Participate in an Advanced Alternate-Payment Model.

Choose to Test, which means you submit a minimum amount of data to avoid a downward adjustment in 2019.  So, what amount of data do you need to send?  That would be one quality measure, one Improvement Activity. or the required 4 or 5 required base scores of the Advancing Care Information Measures category.

You can participate for a partial year by submitting 90 days of 2017 data to CMS and you may earn a positive payment adjustment. So if you’re not ready on January 1, you can start anytime between January 1 and October 2, 2017.  Therefore, October 2nd is the last day that you can begin to collect your data and still have a full 90 days within calendar year 2017.

Full Participation: Submit a full year of 2017 data to CMS.  That also means that you would submit six quality measures, improvement activities that are either four medium-weighted or two high-weighted improvement activities, and either four or five Advancing Care Information measures.  Clinicians should pick what’s best for their practice.

Not participating in the Quality Payment Program for the transition year will result in a negative 4% payment adjustment.

Every MIPS Point Counts

(EPs) will be measured annually in the four performance categories (Cost/Resource use, Clinical practice improvement, Quality &Advancing Care) to derive a MIPS score between 0 and 100.  That score will determine positive, neutral, or negative adjustments to each provider’s annual Medicare reimbursement.

CMS will set a performance threshold score each year that equals the mean or median of all EPs’ MIPS scores from a prior period.

Calculating the Final Score Under MIPS for Transition Year 2017

Under MIPS, if clinicians participate as a group, they are assessed as a group across all four MIPS performance categories since . A group is defined as a set of clinicians (identified by their NPIs) sharing a common Tax Identification Number, no matter the specialty or practice site.

Providers’ scores will be publicly available to consumers via the Centers for Medicare & Medicaid Services (CMS) Physician Compare website.

Bonus Payments and Reporting Periods

MIPS, like many other pay-for-performance programs, uses retrospective data.  For example, MIPS uses data collected during 2017 to determine potential payment adjustments in 2019.  Positive adjustments are based on the performance data information submitted, not the amount of information or length of time submitted.

A full year gives you the most measures to pick from, BUT if you report for 90 days, you could still earn the max adjustment.  The best way to earn the largest payment adjustment is to submit data on all MIPS performance categories.  This option prepares you the most for the future of the program.

We’re encouraging clinicians to pick what’s best for their practice.


CMS Quality Payment Program MIPS graphics

Senior Consultant -Culbert Healthcare Solutions

MACRA Overview- Is Your Organization Prepared?

Part 1 of a 3 part series

The Medicare Access and CHIP Reauthorization Act, commonly known as MACRA, was signed into law in April of 2015.  This legislation both reflects and propels changes already underway in the healthcare industry, repealing the Sustainable Growth Rate formula and establishing a new federal program called the Quality Payment Program (QPP).

The Quality Payment Program went into effect on January 1, 2017, signaling the end of the old “fee-for-service” model and the beginning of a mandated industry-wide shift toward value-based care.  MACRA seeks to ensure Medicare’s sustainability by moving away from a reimbursement model that relies on the quantity of treatments provided by physicians, thus cutting overall Medicare costs over time.

The Centers for Medicare & Medicaid Services (CMS) has laid out six strategic objectives for the Quality Payment Program[1]

  1. Improve patient outcomes and engagement through patient-centered policy development.
  2. Enhance clinician experience by incentivizing the use of tools that make accurate data available, modernize payment systems, and provide big picture insights that will help clinicians make informed decisions that add value to their practice.
  3. Increase the availability and adoption of a diverse range of Advanced APMs to reduce overall healthcare costs and improve quality of care.
  4. Promote education, outreach, and support for patients and communities.
  5. Improve sharing of information to ensure clinicians are empowered to make decisions based on accurate, timely, and actionable EHR data from multiple sources
  6. Ensure “operational excellence” in program implementation and ongoing development.

The QPP provides a choice of two paths for Medicare reimbursement: Merit-based Incentive Payment Systems (MIPS) or the Advanced Alternative Payment Model (AAPM).

An eligible clinician may become a Qualified Professional (QP) or a Partial QP by participating in an Advanced APM in which the eligible clinicians as a group meet specific payment or patient thresholds.  During each QP Performance Period CMS would determine if an eligible clinician met one of the thresholds to become a QP or Partial QP.

MIPS combines three previous programs — the Physician Quality Reporting System (PQRS), the Medicare EHR Incentive Program (also known as Meaningful Use), and Value-Based Payment Modifier into one program that evaluates providers in four performance categories1. The categories are Quality, Cost, Improvement Activities, and Advancing Care Information.




Scores for an organization’s performance in each category will be combined into a Composite Performance Score (CPS) with 100 potential points.

The financial decision-makers at hospitals must work closely with their provider groups to determine which of the three paths, MIPS, AAPM, or Partial Qualifying APM, will yield the most return for their specific organization.


These categories are weighted for the 2017 performance period, which is also the MIPS transition year. The weights are as follows:

  1. The Quality category replaces the Physician Quality Reporting System (PQRS) and is weighted at 60% of the CPS in performance year (PY) 2017. Its CPS weight decreases to 50% in PY 2018 and 30% in PY 2019, and beyond.
  2. The Cost/Resource Use category replaces the Value-Based Modifier and will not be counted for PY 2017. It will be weighted at 10% of the CPS in PY 2018 and 30% in PY 2019, and beyond.
  3. Clinical Practice Improvement Activities (CPIA) is a new MIPS category that did not exist previously. It is weighted at 15% of the CPS in PY 2017 and beyond.
  4. The Advancing Care Information category replaces the Meaningful Use/Medicare EHR Incentive Program and is weighted at 25% of the CPS in PY 2017 and beyond.

MIPS payment adjustments occur two years after the performance year.  As such, payment adjustments will begin in 2019 for PY 2017.  While Advanced APMs have a fixed bonus incentive of 5% through 2024, MIPS payment adjustments are variable.  Depending on how well a group’s Composite Performance Score ranks against scores nationwide, physicians can see no adjustment at all, a positive adjustment, or a negative adjustment up to a determined percentage each year.


It’s very possible that these weights will change over time, but right now, these are the weights that we’re working with.


Organizations that fail to prepare for MACRA may be faced with the financial stress of a negative payment adjustment in an already harsh economic climate.

Once the financial decisions have been made about which path is most suitable and which measures should be reported on, the organization must develop and implement a strategy for gathering that data in an accurate, timely, and cost-efficient manner.

MACRA compliance calls for a high level, strategic reevaluation of IT systems and processes. Hospitals and APM entities that have fallen behind the MACRA schedule must take immediate action to assess their organizational needs and develop a strategy that will drive both financial and quality of care growth under MACRA.



What is the Most Important Thing to Know About MACRA for 2017

You might be hoping that I’m going to say the most important thing about MACRA is that it will go away with a new president and the promise to tear apart Obamacare.   However, MACRA received overwhelming bipartisan congressional support, so ignoring is not an option.

The most important aspect of the Quality Payment Program in 2017 is that it offers everyone an opportunity to pause and reorganize.   2017 is a transition year which requires very little reporting to avoid any penalty to your 2019 FFS payments.   That is great news for the many clinicians who have not participated in PQRS, VM and Meaningful use programs.

However, many organizations that are already reporting all the required measures may not consider pausing and be full steam ahead to report all required measures in hopes of receiving that illusive positive incentive.   Beware, because there will be almost no negative penalty, there will be almost no upside incentive.   Remember the program is based on a balanced budget. Only those at the very top of performance will be eligible to receive part of the $500 million set aside for exceptional performers.

Therefore, the most important thing a health care group can do is pause and decide how they want to focus their energies in 2017.   Are you a top national PQRS/VM performer and therefore likely to earn the exceptional performer bonus based on your 2017 work?  Or, is this an opportunity to regroup and focus on setting up a longer term organizational strategy?  Consider using the Quality Payment Program to help focus resources on longer term cost reduction and quality initiatives so that you hit 2018 in full force.