In mid-October, CMS released its final rule outlining how it plans to implement the clinician payment changes to the Quality Payment Program (QPP) mandated under the Medicare Access and CHIP Reauthorization Act of 2015. This is a complex piece of legislation with major implications for clinician payment across the next decade.
To help you understand some of the more specific nuances of CMS's final rule, we’ve put together this question navigator, which is categorized by topic area.
Please note this navigator will continue to be updated with new questions and answers so please continue to check back on this page for more details.
MACRA, QPP Overview
1. What is MACRA and when will it be implemented?
Besides repealing the Sustainable Growth Rate (SGR), The Medicare Access and CHIP Re-Authorization Act (MACRA) mandates critical updates to Medicare clinician payment across the next few years:
- First, it locks provider payment rates at near zero growth.
- Second, it stipulates the development of two new payment tracks under the Quality Payment Program (QPP)– the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APM). Starting in 2019, clinician Medicare payment adjustments each year will depend on which track the clinician’s medical group falls into.
MACRA implementation is slated for January 1, 2019. However, CMS has proposed to use performance data from 2017 to determine payment adjustments in 2019.
2. What clinicians and what elements of Medicare payment are impacted by QPP?
CMS estimates that approximately 712,000 clinicians will be affected by QPP changes in the first performance year (2017). However, not all clinicians will be subject to these changes.
Included payments and clinicians:
- Any services billed under the Medicare Physician Fee Schedule (MPFS) will be impacted. Specifically, the adjustments will apply to the work, practice expense, and physician liability insurance (malpractice) RVUs.
- Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse, Anesthetists and groups that include any of these clinicians
Exempt payments and clinicians:
- Inpatient Prospective Payment System
- Outpatient Prospective Payment System
- Ambulatory Surgical Center Payment System
- Clinicians or groups that fall under the low volume threshold that CMS defines as clinicians or groups with $30,000 or less in Medicare charges OR 100 or fewer Medicare patients
- Clinicians in their first year billing Medicare
3. What is the timeline for all of this?
MACRA was signed into law in April of 2015. CMS’s MACRA proposed rule was released in late April 2016 and the final rule was released in mid-October 2016. While clinician payment will not be impacted by the QPP until Jan 1, 2019, CMS plans to use 2017 as the performance year for determining clinician payment adjustments in 2019.
QPP Implementation Timeline
4. How will the Trump administration impact the roll out of QPP?
While Donald Trump and other prominent republicans have made it clear that they intend to repeal and replace part or all of the Affordable Care Act, this sentiment does not carry over to QPP. There are three key reasons why MACRA should proceed as planned:
- MACRA has strong bipartisan support. Repeals are unlikely due to the continued strong bipartisan support for MACRA. The Senate and the House voted in favor of MACRA 92-8 and 392-37 respectively. Critically, any delay to MACRA would have to go through Congress and due to the strong bipartisan support this is also unlikely.
- Delay would be tied to budgetary implications. MACRA is also a cost-saving mechanism and there would be budgetary implications if it were to be repealed or delayed.
- Bending the Medicare cost curve is not a partisan issue. Bending the Medicare cost curve is imperative to any presidential administration to ensure the future stability of the Medicare program. MACRA incentivizes providers to shift to value-based payment models and thus serves as the framework for driving future Medicare cost savings.
The pick your pace options for 2017 discussed in question #18 are likely the only delays to MACRA implementation.
Two New Payment Tracks for Clinicians
5. What are the key differences between the MIPS and AAPM and how will participation in either track impact clinician payment?
Under the MIPS, Medicare will consolidate and expand upon all three of clinicians’ pay-for-performance programs—Meaningful Use, the Value-Based Payment Modifier, and the Physician Quality Reporting System—into a single revenue-neutral program. Under this program, CMS will score clinicians and groups on their performance in four categories: Quality, Cost, Improvement Activities (IA), and Advancing Care Information (ACI).
Starting in 2019, physicians in this track will face a range of payment adjustments, starting with potential penalties of -4% and bonuses as high as 12% in 2019. These penalties and bonuses will grow to payment reductions as much as 9% and increases of up to 27% after the first few years of the program.
On the other hand, those that qualify for the Advanced APM payment track can earn favorable financial rewards. However, only clinicians or groups who are part of risk-based payment models will qualify, thus incentivizing a shift toward risk.
Clinicians or groups that participate in Advanced Alternative Payment Models, as defined by CMS, and are able to convert a large enough share of their Medicare and/or other payer reimbursement to risk-based payment models, will earn a 5% annual payment bump from 2019-2024. They will also be exempt from the MIPS requirements.
6. Do clinicians get to choose which track they want to be in?
Yes and no. APM entities can choose to enter into Advanced APMs and strategically increase the amount of traditional Medicare payments or patient counts tied to those Advanced APM models so that clinicians in those APMs can qualify for the Advanced APM track (AAPM) instead of the MIPS.
However, clinicians that already meet the criteria to qualify for the AAPM track with their traditional Medicare book of business cannot opt out of the AAPM track and into the MIPS track.
7. Is there a third option between the MIPS and the AAPM tracks?
Yes. APM entities that participate in Advanced APM models, but have less than the required percentage of revenue at risk, can fall into a category that is straddling the line between the APM and the MIPS track, called Partial Qualifying APM Participants.
However, there are revenue and patient count at risk requirements for this category as well. Clinicians and groups in this category must have at least 20% (but less than 25%) of their Medicare payments tied to an Eligible APM in 2019, then at least 40% (but less than 50%) in 2021, and at least 50% (but less than 75%) in 2023, as shown in the chart below.
Payment, Patient Count Requirements for QPs, Partial QPs
Alternatively, clinicians and groups can qualify if they meet similar patient count thresholds. They must have at least 10% (but less than 20%) of their Medicare patients tied to an Eligible APM in 2019, then at least 25% (but less than 35%) in 2021, and at least 35% (but less than 50%) in 2023.
These Partial Qualifying APMs still do not qualify for the AAPM track (and the associated 5% bonus). However, they can choose whether or not they want to participate in the MIPS payment track.
If they opt into the MIPS track, they will be scored and assigned a payment adjustment alongside all other MIPS participants. If they opt out of the MIPS track, they will not receive any payment adjustments for that performance year.
8. Does qualification reset each year?
Yes. Each year clinicians will have a new opportunity to qualify for the AAPM track. Those clinicians that don’t qualify for the AAPM track will automatically be assigned into the MIPS track (unless they are below the low volume threshold or are in their first year accepting Medicare patients as explained in question #2).
9. What track will most clinicians fall into?
Based on CMS’s calculations 83-90% of eligible clinicians will fall into the MIPS track in 2017, while only 10-17% of clinicians will fall into the AAPM track.
10. How will clinicians be issued a performance score under the MIPS payment track?
Those that fall into the MIPS payment track will be scored based on their performance across four key categories:
- Improvement Activities
- Advancing Care Information
In 2019, the relative weights of each category will equal: Quality: 60%; Cost: 0%, Improvement Activities: 15%, and Advancing Care Information: 25%. However, over time the Cost category will grow in weight.
From 2021 on, the relative weights of each category will equal: Quality: 30%; Cost: 30%, Improvement Activities: 15%, and Advancing Care Information: 25%. Note some clinicians such as non-patient facing clinicians may have different weights for each MIPS category.
11. How are the MIPS categories different from current clinician pay-for-performance programs?
Below are the similarities and differences between the current programs (PQRS, VBPM, and MU) and the new MIPS categories.
This category builds upon the Physician Quality Reporting System (PQRS), with a few key similarities and differences:
This category builds upon the Value Based Payment Modifier (VBPM), with a few key similarities and differences:
Advancing Care Information:
This category builds upon the Meaningful Use (MU) program, with a few key similarities and differences:
This category is completely new and rewards clinicians for improvement activities including care coordination, beneficiary engagement, population management, and patient safety. CMS will offer over 90 activities to choose from across nine categories, with some activities weighted higher than others:
12. Does each clinician need to report to MIPS for him or herself?
No. Under MIPS, clinicians can submit performance data as an individual, a group, or an APM entity. However, they must report the same way across all four categories.
For example if an eligible clinician (EC) reports via their APM entity for the Quality category, they must report as part of the same entity for the other three MIPS categories as well.
13. In the MIPS Cost category, is Part D included?
Currently, CMS does not include Part D drug costs in the proposed assessment of a clinician’s resource use and only includes Part A and Part B (which includes some drug costs).
However, the law establishes that Medicare Part D should be included “as appropriate and as feasible and applicable”. Critically, the key thing that is up for CMS interpretation is whether including Part D drug costs is in fact “feasible and applicable.” CMS is seeking public comment on whether and how to include Part D in the assessment of a clinician’s cost.
14. Will MIPS performance data be made publicly available?
Yes. CMS proposed to publish clinician and group performance under the four MIPS categories on either the Physician Compare website or CMS’s downloadable database. CMS will post composite scores as well as the range of performance scores within each MIPS category for all MIPS participants.
CMS proposes to allow a 30-day preview period in advance of the publication of any data on Physician Compare to allow clinicians to review and submit corrections before information is made public.
15. How will CMS use clinician performance under MIPS to determine clinician payment adjustments?
CMS will translate a clinician’s /group’s/APM entity’s performance score into a payment adjustment using the following three-step process:
- Clinicians/groups/APM entities will be assigned a performance score of 0-100.
- That score will be compared to the performance threshold (PT). The PT will either be the mean or the median—as selected by CMS—of the composite performance scores for all MIPS participants.
- Clinicians/groups/APM entities that fall above the PT will receive bonuses, whereas clinicians that fall below the PT will face penalties.
Note, only a MIPS score exactly equal to the performance threshold yields no payment adjustment. Even one point above or below the threshold will result in a positive or negative payment adjustment, respectively. However, payment adjustments are on a linear sliding scale. So the closer clinicians are to the PT the smaller their payment adjustment will be.
The chart below shows the maximum clinician penalties and bonuses under the MIPS program. While the upper echelon of clinician bonuses looks appealing with a 12-27% bonus potential, few clinicians will likely receive that high of a bonus.
Just like its predecessor quality program—the Value-Based Payment Modifier—MIPS is a revenue neutral program. The red arrows show what the payout could amount to if the total revenue in penalties CMS collects from low performers is significantly more than the total revenue in bonuses CMS plans to divvy out to high performers.
Maximum Provider Penalties and Bonuses
16. If I am in the MIPS track, what are the components of my Medicare Physician Fee Schedule Payment that are impacted by QPP?
The annual adjustment you can expect to receive based on the Medicare Physician Fee Schedule can be broken down into three parts: the RVU, the Conversion Factor, and the payment adjustment under MIPS. This can be expressed as:
Medicare Payment Calculation
To help you better understand Medicare payment under QPP we’ve compiled a detailed explanation of both the MPFS Conversion Factor and the MIPS Adjustment Factor.
MPFS Conversion Factor
Each year, CMS takes the previous year’s Medicare Physician Fee Schedule Conversion Factor (as updated annually through the MPFS rulemaking cycle) and adjusts it according to the following components:
As you can see, the annual update under MACRA is just one of several components used to calculate the Conversion Factor. If the negative adjustments associated with RVU budget neutrality and Misvalued Codes Initiative (Target Recapture Amount) are greater than the annual update under QPP, the Conversion Factor will be less than the year prior. However, this was not the case for CY 2017, and therefore the Conversion Factor saw a slight increase.
Looking forward, there will not be any Conversion Factor updates under MACRA from 2020 to 2025. Then in 2026, the Conversion Factor update will differ based on which track clinicians fall into: MIPS (.25%) and APM (.75%) as demonstrated by the chart below.
Medicare Physician Fee Schedule Conversion Factor Updates Under MACRA
MIPS Conversion Factor
In addition to the annual updates to the Conversion Factor as described above, MIPS participants will also receive a MIPS payment adjustment factor, which will either be a positive or a negative percentage.
To determine the MIPS payment adjustment factor, CMS plans to assign providers a score of 0-100 based on performance across four categories (Quality, Cost, Improvement Activities, and Advancing Care Information). This provider score will be compared to a CMS-set performance threshold (PT) and non-reporters will be given the lowest score.
Providers scoring above the PT will receive a bonus, or positive MIPS adjustment factor and providers scoring below the PT will be subject to a penalty, or negative MIPS adjustment factor.
Because this portion of the equation is based on performance and reporting capabilities each year, MIPS payment adjustments will change every year. Critically, all MIPS payment adjustments will impact clinicians on a two year lag, meaning that MIPS performance in 2017 will influence clinician payment in 2019.
Additionally, MIPS payment adjustments will not be cumulative. For example, if a provider receives a penalty of -4% in 2019 (based on performance in 2017) and another penalty of -3% in 2020 (based on performance in 2018)—their overall MIPS payment adjustment for 2020 will still be -3%.
17. Do high performers under the MIPS track get an extra bonus?
Yes. CMS has set aside a pool of $500 million for the first six years of the program, with the intent of providing rewards to exceptional performers in the MIPS track.
CMS proposes to set an additional performance threshold for exceptional performers at the 25th percentile of the range of possible composite performance scores (CPS) above the normal performance threshold.
For example, if the normal performance threshold is 60, then the range of possible CPS above the performance threshold would be 61-100. The 25th percentile of those possible values is 70. Thus, anyone with a CPS above 70 would be an exceptional performer, and be eligible for a bonus from the $500 million pool.
The amount of the bonus is determined on a linear sliding scale such that clinicians with a CPS at the exceptional performance threshold would receive an adjustment factor of 0.5 percent, and those at a CPS of 100 would receive a 10 percent maximum additional adjustment factor. CMS intends to announce this exceptional performance threshold with the normal performance threshold prior to the performance period.
18. Is it true that the final rule allows for more reporting flexibility in 2017?
Yes. After receiving overwhelming feedback that the proposal to fully implement MACRA in 2017 would be too challenging for clinicians, CMS decided to ease the MIPS reporting requirements for the first performance year. The final rule allows groups to pick their pace for 2017 by introducing three MIPS reporting options:
Clearly, more MIPS participants can now avoid a negative payment adjustment in 2019 by simply reporting one metric in 2017. This is particularly helpful to smaller groups that might not have invested in quality reporting under the Physician Quality Reporting System (PQRS).
Importantly, while the three options may make scoring seem categorical, in reality scores for 2017 will be much more continuous. This is because positive adjustments are based on performance data for the information submitted, not the amount of information or length of time submitted.
19. What do these three reporting options in 2017 mean for the potential bonus payouts to top performers in 2019?
With the implementation of the three options outlined in the previous question, CMS has lowered the bar for reporting requirements in 2017. Simply reporting one measure will allow MIPS participants to reach the performance threshold, which has been set at only 3 points for 2017. This means that no one will be penalized for poor performance, and instead only those who do not report will see negative payment adjustments in 2019. With these changes, CMS estimates that there will be approximately $199 million in penalties for non-reporters in 2017.
Critically, MIPS is a budget-neutral program, which means that the reduction in negative payment adjustments in 2017 will result in a smaller bonus pool for higher performers. Clinicians that meet the minimum reporting requirements and perform well on the measures they report will likely only see a small positive payment adjustment in 2019. CMS estimates that there will only be a $336 net upward base adjustment per clinician that is subject to MIPS in the first payment year.
While the upward payment adjustment might not be as high in 2019, there is still an incentive to be a high performer. Clinicians or groups that achieve a MIPS performance score of 70 or higher, can earn a higher positive adjustment up to an estimated 2.4%. Additionally, CMS has allocated $500 million to be distributed to clinicians that score above a 70 point threshold.
20. What are the minimum requirements for reporting in the ACI category?
Clinicians must possess and use Certified EHR Technology to report the ACI category measures. The minimum reporting requirements for the ACI category are the “base” measures, which are required to earn the base score. In 2017, this translates to four measures for groups reporting modified stage 2-equivalent measures1, and five measures for groups reporting stage 3-equivalent measures2.
When reporting ACI as a group, CMS will assess performance at the group TIN level, as opposed to each individual within the group. In order to meet the minimum requirements for the base score, a group must be able to report “Yes” to the Security Risk Analysis measure and have 1 or more in the numerator for the numerator/denominator measures. As long as the group as a whole can meet these requirements, it’s not required that each individual within the group also meet these requirements. For example, even if only one provider within a TIN contributes data for the Health Information Exchange measure, then the entire TIN receives credit for this measure when they elect to report as a group.
1. The modified stage 2-equivalent base measures are security risk analysis, electronic prescribing, provide patient access, and health information exchange.
2. The stage 3-equivalent base measures are security risk analysis, electronic prescribing, provide patient access, send a summary of care (previously referred to as health information exchange), and request/access summary of care.
21. How will ACI be scored if my group is not on an EHR or if some providers are not on our EHR?
As stated previously, in order to meet the minimum requirements for the base score in ACI, a group must use CEHRT and be able to report “Yes” to the Security Risk Analysis measure and have 1 or more in the numerator for the other required measures. As long as the group as a whole can meet these requirements, it’s not required that each individual within the group also meet these requirements. So, if you participate in a group that uses CEHRT and has performed a Security Risk Analysis, and at least one clinician in the group can report data for each measure in the base score, your group as a whole will meet the minimum reporting requirements.
However, if no clinicians within your group are on CEHRT, your group will not be able to meet the minimum requirements for the ACI category. That being said, some providers will not be scored on the ACI category if they experience hardship. The hardship exceptions providers can qualify for are:
- Insufficient internet connectivity
- Extreme and uncontrollable circumstances
- Lack of control over the availability of CEHRT
- Lack of face-to-face patient interaction
To qualify for most of these hardship exceptions, providers must submit an application to CMS to reweight their ACI performance category to zero for each applicable year. Providers who are determined non-patient facing will be automatically granted hardship, and the ACI performance category will be reweighted to zero. In other words, all providers that are granted hardship (automatically or via the application) will not be assessed on the ACI performance category, and CMS will redistribute the ACI scoring percentage to the Quality category.
Additionally, hospital-based providers and advanced practitioners (i.e., NPs, PAs, CRNAs, and CNSs) may not have implemented CEHRT because they did not qualify for the Medicare Eligible Professional Meaningful Use program. CMS will reweight the ACI performance category to zero for these providers.
When reporting ACI as a group, CMS allows groups to exclude data for these providers for whom the ACI measures do not apply (i.e., hospital-based, advanced practitioners, non-patient facing, and providers that qualify for hardship exception). There would be no reweighting of the ACI performance category for these clinicians that are excluded from the group ACI data, and all clinicians in the group would receive the group's MIPS final score.
22. I'm in the MSSP Track 1 program. Do I get preferential treatment under the MIPS track?
Yes. While MSSP Track 1 does not qualify clinicians or groups for the AAPM track, it does qualify them for favorable scoring under the MIPS track. This favorable scoring is called “MIPS-APM Scoring Standard”.
To receive the MIPS-APM Scoring Standard, eligible clinicians and groups that participate in MIPS eligible APMs like the MSSP Track 1 must report to MIPS through the aggregate ACO entity. All MIPS eligible clinicians in the ACO would receive the same score that is calculated at the ACO level.
Under the favorable MIPS-APM scoring standard, MSSP Track 1 participants do not receive a Cost score. This means that in 2017 and 2018 MIPS-APM participants’ scores will be weighted as 50% quality, 20% Improvement Activities, and 30% Advancing Care Information.
Additionally, MSSP Track 1 participants will automatically receive full credit under the Improvement Activities category.
23. If I participate in an MSSP track 1 ACO, is my group responsible for reporting our performance under each category of the MIPS track?
Yes and no. In 2017 groups that participate in the MSSP Track 1 program will only be responsible for reporting under the Advancing Care Information category of the MIPS track. Below are the specific requirements for each category:
- Quality: Individual TINs and Clinicians that participate in an MSSP Track 1 ACO will not be responsible for reporting quality to CMS outside of their ACO entity as long as the ACO submits quality data using CMS’s web interface under the MSSP track 1 program. If clinicians or groups do submit quality outside of their ACO, CMS will use the ACO’s composite performance score instead of the individual group or clinician’s performance score to determine those participating clinicians’ payment adjustment.
- Cost: Clinicians and groups that participate in the MSSP Track 1 program and meet the requirements for the MIPS-APM Scoring Standard will have their cost category re-weighted to zero and will not receive a score in this category. Please see the previous question for more details.
- Improvement Activities: In 2017, eligible clinicians participating in MIPS-APMs such as MSSP Track 1 ACO will receive a full score for the improvement activities performance category and will not need to submit additional data in this category for MIPS.
- Advancing Care Information: MIPS eligible clinicians participating in the Shared Savings Program will need to submit data for the Advancing Care Information (ACI) performance categories through their respective ACO participant billing TINs, independent of the Shared Savings Program ACO. CMS will take each ACO participating TIN’s performance in this category and calculate the weighted average of all TINs within the ACO to determine the ACO’s composite performance score.
All clinicians participating in an MSSP Track 1 ACO will receive the same MIPS composite score and thus the same payment adjustment, unless the specific clinician is also participating in another shared savings program that was assigned a higher performance score.
24. How does Reporting for the ACI category work for MIPS-APMs?
Overall, eligible clinicians participating in MIPS-APMs must report, at a minimum, the ACI base measures outside of their separate ACO reporting requirements.
If you participate in an MSSP ACO, each participant billing TIN within your ACO will need to submit data for the ACI performance category according to the MIPS group reporting requirements. Please see the previous question for more detail on ACI scoring methodology for MSSP track 1 participants.
The process works slightly differently for some other MIPS-APMs such as Next Generation ACO. In this type of APM, clinicians have a choice to report through either group reporting (i.e., at the TIN level) or individual reporting.
If you participate in an APM that can report MIPS at the individual level, and choose to report MIPS individually, CMS will assess individuals separately and then average individual scores together to determine the APM entity’s score. In order for an individual to meet the ACI base score, they must report “Yes” to the Security Risk Analysis measure, and have 1 or more in the numerator for the other required measures. Individual scores are averaged to yield an APM entity score, and if any particular individual in the APM entity does not meet the Base score, they will lower the overall ACI score of the APM entity.
25. Are there different MIPS reporting requirements for patient-facing vs. non-patient-facing clinicians?
Yes. One concern with the initial passage of MACRA was that MIPS performance metrics may not take into account the unique needs of non-patient-facing clinicians, such as radiologists, anesthesiologists, and pathologists. In the final rule, CMS addressed these concerns in two ways:
- Finalized the definition of non-patient-facing clinicians and groups. In the proposed rule, CMS defined non-patient facing clinicians as any clinician or group that performed fewer than 25 patient-facing services per year. This lead to confusion over who would qualify as non-patient facing. In the final rule, CMS clarified these definitions as the following:
Developed different MIPS reporting requirements for non-patient-facing clinicians. Below is a brief summary of those differences for each MIPS category:
- Non-patient-facing clinician: A MIPS-eligible clinician that performs fewer than 100 procedures with patient facing codes annually.
- Non-patient-facing group: A group where at least 75% of eligible clinicians in the group are designated as non-patient facing.
- Patient-facing encounter: An instance in which the MIPS-eligible clinician or group billed for services such as general office visits, outpatients visits, and surgical codes under the Physician Fee Schedule (PFS). To better define these encounters, CMS released a list of patient-facing codes which you can download here.
- Quality: In the final rule, CMS eliminated the requirement to report one “cross-cutting measure” for all clinicians including non-patient-facing clinicians. Thus like other MIPS participants, non-patient facing clinicians will need to report 6 quality measures, one of which must be an outcomes measure.
- Cost: Non-patient facing clinicians will be subject to the cost category. Starting in 2018 performance year, the cost category will be weighted at 10% for non-patient facing clinicians that meet the minimum case number for each cost measure (20 cases for episode-based measures and total cost per capita and 35 cases for Medicare spending per beneficiary). Thus, if an Interventional Radiologist is part of a non-patient facing group but meets the minimum case threshold for the cost category measures then the group will be subject to the cost category. That being said, CMS anticipates that very few non-patient facing clinicians will be subject to the cost category. In most cases cost will be re-weighted to zero and quality will be weighted at 85%.
- Advancing Care Information: For non-patient facing clinicians the ACI category is re-weighted to zero, meaning these clinicians will not be assessed on their EHR usage.
- Improvement Activities: Non-patient facing clinicians are only required to report one high-weighted or two medium-weighted Improvement Activities in order to receive full credit.
Learn more about CMS’s new patient-facing encounter codes
26. How will CMS determine what clinicians are deemed non-patient facing?
To determine which providers qualify for non-patient-facing status, CMS will use Medicare claims from two twelve-month time periods, with the first beginning September 1 two years prior to the performance year. Providers and groups will only be deemed patient-facing if they exceed the revised thresholds for two consecutive assessment periods.
The timeline below outlines the assessments periods for the 2017 performance year:
Non-patient-facing determination timeline for the 2017 performance year (PY)
For example, in the 2017 performance year, CMS will examine claims from September 2015-August 2016 and from September 2016-August 2017. If an eligible clinician or group’s claims during either period qualify that clinician or group for non-patient facing status, that’s what will determine MIPS scoring and payment in 2019. In other words, clinicians and groups have two chances to qualify.
Therefore, if Dr. Jones bills for 88 patient encounters in assessment period one, and then 110 in period two, she is classified as a non-patient facing clinician because she was below the 100 encounter threshold in one of those two assessment periods. On the other hand, if the next assessment period she bills for 105 patient encounters, she would be classified as a patient-facing clinician the following performance year—because she exceeded the threshold for two consecutive periods.
27. Are there different MIPS reporting requirements for hospital-based providers?
Yes. CMS finalized a new definition for a hospital-based clinician as a MIPS eligible clinician who furnishes 75% or more of their covered professional services in POS 21 (inpatient hospital), POS 22 (on campus outpatient hospital), or POS 23 (emergency room).
The ACI performance category will be reweighted to zero for hospital-based clinicians if they decide to report individually. As discussed in question #21, when reporting ACI as a group, the group may exclude hospital-based providers from reporting ACI performance. However, hospital-based clinicians are generally subject to the requirements for other MIPS performance categories, and would still need to report Quality and Improvement Activities.
Advanced APM Track
28. How do I qualify for the advanced APM track?
There are two key conditions clinicians collectively in the APM entity must meet in order to qualify for the AAPM track.
First, CMS makes a clear distinction between APMs and Advanced APMs. To qualify for the APM track clinicians must participate in an Advanced APM. Models that qualify as Advanced APMs must:
- Require use of certified EHR technology,
- Tie clinician payment to certain quality measures comparable to those under the Merit-Based Incentive Payment System (MIPS), and
- Bear a certain amount of greater than nominal financial risk (as outlined below) OR qualify as a Medical Home Model
- Meet revenue-based standard (average of at least 8% of revenues at-risk for participating APMs or
- Meet benchmark-based standard (maximum possible loss must be at least 3% of spending target)
CMS has outlined which alternative payment models will qualify as Advanced Alternative Payment models in 2017, 2018, and 2019. See the chart below for the specific models that will qualify each year:
The list of qualifying Advanced APMs will be updated by November 1st each year under the Quality Payment Program (QPP). In addition to the models listed above, CMS has indicated that it will modify the Bundled Payments for Care Improvement Initiative (BPCI) models through additional rulemaking so that they qualify in performance year 2018 and beyond.
Advanced APM Qualification Thresholds
Second, the APM entity must also meet stringent requirements for the minimum percentage of payments OR patients tied to an Advanced APM. CMS will choose to use whichever threshold is more favorable for the APM entity in determining eligibility for the APM track. Over time, the payment and patient count percentages will gradually increase.
29. How does qualification for the AAPM track work? Is it at the individual level or the group level?
Clinicians that qualify for the AAPM track will do so at the APM Entity level, not as individual clinicians. An APM entity is a legal entity formed by multiple clinicians or groups in order to participate in an alternative payment model.
Note, if clinicians are listed on the participation list of multiple qualifying APM entities, CMS will assess those clinicians on an individual basis to determine AAPM track eligibility.
30. I’m interested in joining CPC+. Does that qualify as an Advanced APM?
Yes. The Comprehensive Primary Care Plus (CPC+) program qualifies as an Advanced APM under the QPP final rule. The final rule states that APM’s must bear a certain amount of greater than nominal financial risk OR meet different standards to qualify as a Medical Home Model, in order to be an Advanced APM. CPC+ qualifies as an Advanced APM by meeting the Medical Home Model standards.
For a Medical Home Model to be an Advanced APM, it must include provisions that potentially:
- Withhold payment for services to the APM Entity and/or the APM Entity’s eligible clinicians;
- Reduce payment rates to the APM Entity and/or the APM Entity’s eligible clinicians;
- Require the APM Entity to owe payment(s) to CMS; or
- Lose the right to all or part of an otherwise guaranteed payment or payments
The four provisions stated above should go into effect if either of the following occurs:
- Actual expenditures for which the APM Entity is responsible under the APM exceed expected expenditures during a specified performance period; or
- APM Entity performance on specified performance measures does not meet or exceed expected performance on such measures for a specified performance period.
Under CMS’s proposal, CPC+ is currently the only Medical Home Model that qualifies as an Advanced APM. However, even though CPC+ qualifies as an Advanced APM model, not all participants in the CPC+ program will qualify for the AAPM track. CPC+ participants must meet two conditions to qualify for the AAPM track:
- Be part of a group that has fewer than 50 clinicians starting in 2018. The AAPM Medical Home Model criteria was specifically designed as a way for smaller organizations—which may have less experience with financial risk than larger organizations and limited capability to sustain substantial losses—to participate in the AAPM track.
For this reason, starting in performance year 2018, practices that participate in the CPC+ program must be owned and operated by organizations with 50 or fewer total eligible clinicians in order to qualify for the AAPM track. However, CMS did make an exception for 2017, where groups with over 50 clinicians can still qualify.
- Meet specific revenue at-risk thresholds under the medical home model. The total annual amount that an Advanced APM Entity potentially owes CMS or foregoes under the Medical Home Model must be at least the following amounts in a given performance year:
- In 2017, 2.5 percent of the APM Entity’s total Medicare Parts A and B revenue;
- In 2018, 3 percent of the APM Entity’s total Medicare Parts A and B revenue.
- In 2019, 4 percent of the APM Entity’s total Medicare Parts A and B revenue.
- In 2020 and later, 5 percent of the APM Entity’s total Medicare Parts A and B revenue.
Revenue at risk thresholds under CPC+ to qualify for AAPM track
While CPC+ offers small groups entrance into the AAPM track, program participation is capped—only 5,000 physician practices will be permitted to participate in CPC+.
Clinicians that participate in the CPC+ program and do not meet the two conditions above will automatically be subject to the MIPS track and—because of their participation in a medical home model—will be awarded full credit in the Improvement Activities (IA) category under the MIPS.
31. Our group takes Medicare Advantage patients; do I qualify for the Advanced APM track?
Not in the first few performance years of the program. Starting in 2021 (based on the 2019 performance year), CMS will allow clinicians to use their “other payer” book of business including Medicare Advantage contracts to help meet the revenue or patient count thresholds for qualifying for the Advanced APM model.
But not all downside risk Medicare Advantage plans will qualify clinicians for the AAPM track in 2021. The commercial alternative payment model must meet the same criteria that CMS uses to assess CMS-run APMs. It must:
- Require use of certified EHR technology,
- Tie clinician payment to certain quality measures comparable to those under the Merit-Based Incentive Payment System (MIPS)
- Bear a certain amount of greater than nominal financial risk (as outlined below) or qualify as a Medical Home model
- APM Entities must share with the payer in at least 30% of the losses in excess of the expected expenditures
- The maximum possible APM Entity loss must be at least 4% of expected expenditures
CMS also proposes that full capitation risk arrangements would meet this Other Payer Advanced APM financial risk criterion. CMS defines a full capitation contract as a payment arrangement in which a per capita payment is made to an APM Entity for services furnished to a population of beneficiaries.
Under this type of arrangement, no settlement is performed for the purpose of reconciling or sharing losses incurred or savings earned by the APM Entity.
More MACRA Resources
32. Where can I learn more about MACRA?
The Advisory Board has a number of resources on the new payment changes mandated and proposed under MACRA.
33. Our organization wants more targeted support on how to prepare for MACRA. Is that something Advisory Board offers?
Yes. Our Consulting division offers hands-on MACRA support through our MACRA Intensive to help your organization prepare for the impending Medicare Part B payment changes.
The Intensive includes the following components:
- Research and policy briefing on the details of the MACRA legislation and proposed rule, and how these decisions will impact your organization and local market
- Readiness assessment diagnostic designed to identify critical performance improvement opportunities in preparation for measurement in January 2017
- Review of the different options available to your organization within the MIPS and AAPM tracks, and recommendations on how to maximize payment potential
- Strategic action plan customized to your organization’s specific goals within MACRA, including best practice recommendations for making the transition
Learn more about the Intensive and request a session here.