The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015.
MACRA created the Quality Payment Program that:
Repeals the Sustainable Growth Rate formula
Changes the way that Medicare rewards clinicians for value over volume
Streamlines multiple quality programs under the new Merit Based Incentive Payments System (MIPS)
Gives bonus payments for participation in eligible Alternative Payment Models (APMs)
Quality Payment Program
You can learn more about the Quality Payment Program at qpp.cms.gov
CMS is required by law to implement a quality payment incentive program, referred to as the Quality Payment Program, which rewards value & outcomes in one of two ways: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).
MIPS is a new approach to paying for Medicare Part B items and services in which clinicians may receive an increase or decrease in their payments based on their performance. Performance is measured through the data clinicians report in four areas – Quality, Improvement Activities, Advancing Care Information, and Cost. We designed MIPS to update and consolidate previous programs, including: Medicare Meaningful Use (MU), Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM).
How It Works
There are 4 performance categories that make up your final score.
Your final score determines what your payment adjustment will be. These categories are:
What do you need to do?
Replaces the Physician Quality Reporting System (PQRS).
Most participants: Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days.
Groups using the web interface: Report 15 quality measures for a full year. To submit data as a group through the CMS Web Interface, you must register your group between April 1, 2017 and June 30, 2017.
Groups in APMs qualifying for special scoring under MIPS, such as Shared Savings Track 1 APM or the Oncology Care Model one-sided risk APM: Report quality measures through your APM. You do not need to do anything additional for MIPS quality.
Advancing Care Information
Replaces the Medicare EHR Incentive Program, also known as Meaningful Use.
Fulfill the required measures for a minimum of 90 days:
- Security Risk Analysis
- Provide Patient Access
- Send Summary of Care
- Request/Accept Summary of Care
Choose to submit up to 9 measures for a minimum of 90 days for additional credit.
For bonus credit, you can:
- Report Public Health and Clinical Data Registry Reporting measures
- Use certified EHR technology to complete certain improvement activities in the improvement activities performance category
You may not need to submit advancing care information if these measures do not apply to you.
Most participants: Attest that you completed up to 4 improvement activities for a minimum of 90 days.
Groups with fewer than 15 participants or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days.
Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit.
Participants in certain APMs under the APM scoring standard, such as Shared Savings Program Track 1 or OCM: You will automatically receive points based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit.
Replaces Value-Based Modifier.
No data submission required. Calculated from adjudicated claims.
How It Works
An Alternative Payment Model (APM) is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.
Advanced APMs In the Advanced APM track of the Quality Payment Program, you may earn a 5% incentive for achieving threshold levels of payments or patients through Advanced APMs. If you achieve these thresholds, you are excluded from the MIPS reporting requirements and payment adjustment.
If you’re in a specific type of APM called a “MIPS APM” and you are not excluded from MIPS, you may be scored using a special APM scoring standard. The APM scoring standard is designed to account for activities already required by the APM. For example, the APM scoring standard eliminates the need for MIPS clinicians to duplicate submission of Quality and Improvement Activity performance category data and allows them to focus instead on the goals of the APM.
Most Advanced APMs are also MIPS APMs so that if an eligible clinician participating in the Advanced APM does not meet the threshold for sufficient payments or patients through an Advanced APM in order to become a Qualifying APM Participant (QP), thereby being excluded from MIPS, the MIPS eligible clinician will be scored under MIPS according to the APM scoring standard.
Information for Advanced APMs and MIPS APMs may change each Performance Year (PY).