Archived Publications eBook: MACRA is Reinventing the Structure of the P | Seite 5

Who is in the Quality Payment Program?
Medicare Part B physicians and clinicians will be subject to
the Quality Payment Program if they are in an Advanced
APM or if they bill Medicare more than $30,000 per year
and care for more than 100 Medicare patients per year. For
MIPS, clinicians include:
• Physician
• Physician Assistant
• Nurse practitioner
• Clinical nurse specialist
• Certified registered nurse anesthetist
Regardless of the path, CMS has set 2017 as the performance
period for the first payment adjustment in 2019. Payment
adjustments under MIPS will be based on performance
on measures and activities in four categories, as
summarized below.
MIPS Performance Category
Quality
Advancing Care Information
Clinical Practice
Improvement Activities
THE QUALITY PAYMENT PROGRAM
Cost (Resource Use)
Prior to implementation of the MACRA the Medicare
program gathered performance metrics on physicians and
other clinicians through a patchwork of programs, including
the Physician Quality Reporting System (PQRS), the Physician
Value-based Payment Modifier (VM), and the Medicare
Electronic Health Record (EHR) Incentive Program. With
the new MACRA law, Congress has streamlined elements
of these programs through a framework called the Quality
Payment Program. The new program offers clinicians two
paths for participation:
1
The Merit-based Incentive
Payment System (MIPS)
or
2
Advanced Alternative
Payment Models (APMs)
Most Medicare clinicians will initially participate in the Quality
Payment Program through MIPS, which will include
components of the existing PQRS, VM, and EHR Incentive
Program. As an alternative, CMS has established incentives
for clinicians to participate in Advanced Alternative Payment
Models (APMs). Under this pathway, providers who take on
significant financial risk through entities such as accountable
care organizations or bundled payments programs can
bypass MIPS and become eligible to receive consistent 5%
annual payment increases. At least initially, few physicians will
qualify to participate under the Advanced APM path, which
requires that Medicare comprise 25% of their payments or
that Medicare recipients be 20% of their patients through
the APM in order to receive the incentive payment.
Replaces 2019
Percentage of
MIPS Score 2020
Percentage of
MIPS Score 2021
Percentage of
MIPS Score
PQRS 60% 50% 30%
Medicare EHR
Incentive
Program 25% 25% 25%
New 15% 15% 15%
Value-based
Modifier NA 10% 30%
MIPS clinicians stand to receive a positive, negative, or neutral
payment adjustment of up to 4% in 2019. That percentage
increases to 9% in 2022. The positive adjustments will be
scaled up or down to achieve budget neutrality, meaning that
the maximum positive adjustment could be lower or higher
than 4%. In the first five years of the program, CMS has also
allocated $500 million in an additional performance bonus
that is exempt from budget neutrality to reward exceptional
performance. This bonus will provide high performers a
gradually increasing adjustment based on their MIPS score
that can add up to an additional 10%. In addition, CMS has
allocated $20 million per year to small practices to provide
technical assistance on MIPS performance criteria or
assistance transitioning to an APM.
Payment Adjustments Under MIPS
+/-4%
+/-5%
+/-7%
HealthStream.com/ProviderAdvisor • 800.521.0574 • HealthStream.com/contact •
Reprint from WINTER 2017 Provider Advisor
+/-9%
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