There are many federal quality programs that might impact AAHPM members. Mandated by the Affordable Care Act of 2010, the Hospice Quality Reporting Program (HQRP) website contains updates regarding program requirements through the Centers for Medicare & Medicaid Services (CMS).
PQRS and other legacy quality reporting programs, such as the Value Modifier and EHR Incentive Program, include penalties for clinicians who fail to satisfy reporting requirements through 2018 based on 2016 performance. This will be the last year that these quality programs are in effect. Payments starting in 2019 will be adjusted based on provisions included under the Medicare Access and CHIP Reauthorization Act (MACRA).
Medicare Access and CHIP Reauthorization Act (MACRA)
MACRA repealed the sustainable growth rate (SGR) formula and authorized a new incentive based system for Medicare physician payments, known as MIPS.
What is MACRA?
MACRA replaces legacy quality programs with the Quality Payment Program (QPP) in which physician Medicare payments will be based on participation in one of two tracks:
These programs reward physicians based on performance participation in new payment and delivery models.
In general, CMS will use performance in one year to determine payment adjustments two years later:
- Payment adjustments in 2019 will be based on performance in 2017. Clinicians participating under MIPS must report by March 31, 2018 to avoid penalty
- Payment adjustments in 2020 will be based on performance in 2018.
Note that the maximum penalty for performance under MIPS increases from 4% in 2019 (based on performance in 2017) up to 9% in 2022 onward (based on performance in 2020 onward). The maximum penalty for payments in 2020 (based on performance in 2018) is 5%.
Under MACRA, providers who quality for the Advanced APM Track of the QPP will be exempt from MIPS and will also receive a 5% bonus payment. Bonus payments are available from 2019-2024 based on Advanced APM participation in 2017-2022.
MIPS consolidates elements of legacy Medicare physician quality programs - including the Physician Quality Reporting Systems (PQRS), the Value Modifier (VM), and the EHR Incentive Program - into one new streamlined program.
Under MIPS, CMS is required to evaluate clinician performance based on four categories:
- Advancing Care Information (ACI, or meaningful use of EHRs)
- Improvement Activities (IAs)
CMS will add up performance across all four categories to calculate a MIPS Final Score.
Who is Eligible for MIPS?
CMS currently defines MIPS eligible clinicians as physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists who bill under Medicare Part B. This does not include providers, such as clinical social workers, physical and occupational therapists, and others that might have been reporting quality measures under PQRS. CMS will consider expanding the definition of eligible clinicians in future years.
Certain clinicians are expressly excluded from MIPS:
- Qualifying participants in Advanced APMs, or QPs (those who qualify for the Advanced APM Track of the QPP)
- Low-volume clinicians, defined as group practices and clinicians who bill less than or equal to $90,000 in Medicare Part B allowed charges OR see less than or equal to 200 Medicare patients. Note that these thresholds apply to the 2018 performance years; for 2017, lower thresholds of $30,000 in Medicare Part B allowed charges or 100 patients applied.
- Clinicians who newly enroll in Medicare during the performance period and have no previously submitted Medicare claims as an individual, part of a group, or under a different tax identifier.
Additionally, clinicians meeting certain criteria may qualify for special scoring accommodations based on special status designations, such as qualifying as a small, rural, or Health Professional Shortage Area (HPSA) practice, or as a hospital-based clinician. See the specific MIPS category links above and the QPP website for more information.
You can check your MIPS participation status using the MIPS Participation Status NPI Lookup Tool to determine whether you or your practice is required to participate in MIPS, and whether you fall into a MIPS “special status” category and qualify for specific reporting and/or scoring accommodations.
You can search the QP Lookup Tool for the most recent information regarding qualification for the Advanced APM Track of the QPP.
Group vs. Individual Reporting
Similar to the PQRS, clinicians will have the choice of participating in MIPS as either an individual or part of a group practice defined by CMS:
- Individual - a single clinician, identified by a single National Provider Identifier (NPI) number tied to a single Tax Identification Number (TIN).
- Group - a single Taxpayer Identification Number (TIN) with two or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their individual National Provider Identifier (NPI), who has reassigned their Medicare billing right to the TIN.
Clinicians are required to comply with MIPS under each unique practice (TIN/NPI) that they are associated with, so keep in mind that your eligibility and reporting obligations might vary across practices if you work under multiple TINs. The MIPS Participation Status Lookup Tool will display separate special status designations, at both the individual and group level, for each unique TIN that you are affiliated with.
Also, if you choose to participate in MIPS as a group, you must do so across all MIPS performance categories.
Find more information on data submission mechanisms for individual and group submitters.
CMS has included several provisions to assist small practices and the individual clinicians who are part of such practices, including solo practitioners. Small practices can benefit from:
- A 3-point floor on all reported quality measures, even if data completeness requirements are not met.
- Lower reporting requirements under the Improvement Activities category
- Availability of a new "small practice hardship exemption" under the Advancing Care Information category (subject to CMS approval)
- A small practice bonus of 5 points added to the MIPS Final Score
Complex Patient Bonus
For performance in 2018, CMS will add a “complex patient bonus” to the MIPS Final Score that is intended to account for the relative complexity of a clinician or group’s patient population. This bonus will be subject to a cap of 5 points.
Reporting Requirements for 2018
For the 2017 Transition Year, CMS implemented “Pick Your Pace” policies that allowed clinicians to report minimal, “test” amount of data to avoid a payment penalty in 2019.
For 2018, CMS has increased reporting requirements and modified scoring rules, requiring submission of additional data to avoid a payment penalty. The following provide a few illustrative examples of reporting options for avoiding a penalty:
- Fully report 6 measures under the Quality performance category with at least 60% data completeness for the year, including 1 outcome measure (or a high priority measure if an outcome measure is not available)
- Fully report under the Improvement Activities performance category, which may include attesting to 2 high weighted activities, 4 medium weighted activities, or 1 high and 2 medium weighted activities.
- Combine reporting under the Quality and Improvement Activities performance categories, to receive half credit under Quality and half credit under the Improvement Activities.
If you or your group qualifies for a special status, you may be able to report less and still avoid a penalty.
At a higher level of participation, those who report on more than what is required to avoid the penalty will be eligible for a neutral or small upward adjustment in 2020. Clinicians who report more measures and activities will have a greater chance of earning more points towards the overall MIPS Final Score, which could translate to a higher upward payment adjustment in 2020.
On the highest end of the spectrum, those who fully satisfy the requirements of multiple MIPS performance categories and performance above a certain threshold in 2018 have the potential to receive not only a larger upward payment adjustment, but also an additional bonus payment reserved for exceptional performers.
- QPP Resource Library: includes detailed guidance documents and other resources related to participation in both 2017 and 2018.
- QPP Webinar and Programs: includes webinars, online courses, and other educational resources related to the QPP.
- MIPS Scoring and Payment Adjustments - To calculate your MIPS score, CMS will evaluate your performance in four core areas. Scores in each area will be weighted. CMS has indicated the weights for 2017 but will adjust these as the program evolves.
- MIPS Participation Status NPI look-up tool - access the look-up tool to see if you are included in the MIPS participation and if you qualify for a special status designation.
- MIPS Participation and Overview Fact Sheet
- MIPS Bonus Overview Fact Sheet
Find more resources on the Quality Payment Program page.