5. MACRA Models
Advanced Alternative
Payment Models (APMs)
Higher risk model
Risk is shared throughout APM
Limited number of acceptable models
Rules to being considered a qualified
provider (QP)
Merit Based Incentive
Program (MIPS)
Designed for individuals and small
group practices
Not all or nothing. Can receive partial
credit. Incentive based on sliding scale.
Replaces all current incentive
programs
Fee for service with adjustments based
on performance
Note: APM = Risk Most Providers are expected to choose MIPS
6. MACRA – MIPS Components
Quality Reporting
/PQRS
Resource Use or Cost
(Value-based Modifier)
Advancing Care
Information (MU)
Clinical practice
improvement activities
MIPS
7. 45%
15%
15%
25%
2020 MIPS
PAYMENT YEAR
30%
30%
15%
25%
2021+ MIPS
PAYMENT YEAR
*The weight for advancing care information could decrease (not below 15 percent) if the Secretary estimates that the proportion of
physicians who are meaningful EHR users is 75 percent or greater. The remaining weight would then be reallocated to one or more
of the other performance categories.
How is Performance Categorized in MIPS?
60%
15%
25%
2019 MIPS
PAYMENT YEAR
Quality Resource UseAdvancing Care Information* CPIA
Weighting
8. How is Performance Determined in MIPS?
Quality
performance
category score
x
Quality
performance
category weight
Resource Use
performance
category score
x
Resource Use
performance
category weight
CPIA
performance
category score
x
CPIA
performance
category weight
Advancing Care
Information performance
category score
x
Advancing Care
Information performance
category weight
100
Composite Performance Score (CPS)
0-100 point
scale
9. 2019 2020 2021 2022 +
4%
5%
7%
9%
4%
5%
7%
9%
Financial Incentives and Adjustments Through MIPS
Lowest 25% = maximum reduction
Exceptional performance bonuses can be up to another 10% up to $500M
available each year from 2019 to 2024
MIPS will be a budget-neutral program. Total upward and downward
adjustments will be balanced so that the average change is 0%.
Performance
Threshold
Mean/Median CPS
10. Penalties Comparison
< 2017
2019
Adjustments
PQRS - 2 %
MU - 5 %
Value Based Modifier - 4 % or more
Total Penalty Risk - 11 % or more
Bonus Potential
Value Based Modifier
Unknown
MIPS Factors
2019
Scoring
Quality (PQRS) 60 %
Advancing Care
Information (MU)
25 %
Clinical Improvement
Activities
15 %
Total Penalty Risk - 4 %
Bonus Potential 4 % Max
Bonus Potential for
High Performers
10 %
Prior to MACRA MACRA
11. Quality Reporting Basics - PQRS
•60% in 2019
•45% in 2020
•30% in 2022
MIPS weight
•6 measures instead of 9 (200 measures available), reported by physicians
•One cross-cutting measure, one outcome measure
•2 population health measures calculated by CMS administratively via claims
(Groups of 2 or more)
Measures
•Each measure worth up to 10 points
•80 total points for small groups 90 total points for groups >10
•Distribution of points for each measure based on performance benchmarks (80%
for claims reporting, 90% for registry reporting)
Scoring
•Up to 4 bonus points may be added for reporting on outcome and high priority
measures
•1 bonus point possible for each measure captured and reported through CEHRT
•Total bonus points capped at 5% of those used to calculate the quality score
Bonus points
12. Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or surrogate
decision maker documented in the medical record or documentation in the medical record that an advance
care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or
provide an advance care plan.
Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 years
and older for which the eligible clinician attests to documenting a list of current medications using all
immediate resources available on the date of the encounter.
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of patients
aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who
received cessation counseling intervention if identified as a tobacco user.
Controlling High Blood Pressure: Percentage of patients 18-85 years of age who had a diagnosis of
hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement
period.
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented: Percentage of
patients aged 18 years and older seen during the reporting period who were screened for high blood pressure
AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as
indicated.
MIPS Proposed Cross-Cutting Measures
13. Closing the Referral Loop: Receipt of Specialist Report: Percentage of patients with
referrals, regardless of age, for which the referring provider receives a report from the
provider to whom the patient was referred.
Tobacco Use and Help with Quitting Among Adolescents: The percentage of adolescents
12 to 20 years of age with a primary care visit during the measurement year for whom
tobacco use status was documented and received help with quitting if identified as a
tobacco user.
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling:
Percentage of patients aged 18 years and older who were screened at least once within
the last 24 months for unhealthy alcohol use using a systematic screening method AND
who received brief counseling if identified as an unhealthy alcohol user
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan:
Percentage of patients aged 18 years and older with a BMI documented during the
current encounter or during the previous six months AND with a BMI outside of normal
parameters, a follow-up plan is documented during the encounter or during the previous
six months of the current encounter.
MIPS Proposed Cross-Cutting Measures
14. Advancing Care Information - MU
•25% in 2019
•25% in 2020
•25% in 2022
• May be reduced if >75% of clinicians are successful
MIPS weight
•Protect Patient Information (Security Risk Analysis) – Yes/No
•e-Prescribing - Numerator/Denominator
•Provide Patient Access - Numerator/Denominator
•Send Summary of Care - Numerator/Denominator
•Request/Accept Summary of Care - Numerator/Denominator
• Public Health and clinical data registry reporting – Yes/No
Measures
•50 points for achieving 6 objectives (pass/fail)
•Immunization registry reporting required;
•Provide numerator/denominator or yes/no attestation for each
Scoring
•Reporting to more than one public health registry earns bonus pointBonus points
15. Advancing Care Information
▪ To receive the base score, physicians must simply provide the
numerator/denominator or yes/no for each objective and measure
▪ The overall Advancing Care Information score would be made up of
a base score and a performance score for a maximum score of
100 points
▪ Protect Patient Information (Security Risk Analysis) yes required or
no points allotted
16. Advancing Care Information Performance Category
Score capped at 100 points with greater than 100 points available to allow more flexibility to
achieve the maximum score. 100 points or more translates into 25 points in final score
Base Score
Performance
Score
Bonus Point
Composite
Score
50 Points 80 Points 1 Point
Maximum
100 points
17. Advancing Care Information – Base score
▪ Protect Patient Information (Security Risk Analysis) – Yes/No
▪ e-Prescribing - Numerator/Denominator
▪ Provide Patient Access - Numerator/Denominator
▪ Send Summary of Care - Numerator/Denominator
▪ Request/Accept Summary of Care - Numerator/Denominator
• Public Health and clinical data registry reporting – Yes/No
18. Advancing Care Information – Performance Score
Performance Score (80 Points)
▪ Patient Electronic Access
▪ Coordination of Care through patient engagement
▪ Health Information Exchange
Bonus Point (1 Point)
▪ Immunization registry is required, but reporting to another
surveillance registry will award 1 bonus point to over all ACI score.
19. Clinical Practice Improvement Activities - New
•15% in 2019
•15% in 2020
•15% in 2022
MIPS weight
•9 activity categories
•90+ activities
•Do not need activities in each category
•Attest to four medium-weighted or two high-weighted activities
Measures
•60 points = 100% CPIA score
•7 of 8 categories have both high (20 points) and medium (10 points) weighted
activities
Scoring
21. CPIA categories and examples
Expanded Practice Access
24/7 access to
clinicians/care teams
Use of telehealth
Patient experience data
used to improve practice
Population Management
Participation in systematic
anticoagulation program
Participation in CMMI
models such as Million
Hearts Campaign
QCDR participation that
includes use of data for QI
Care Coordination
Participate in Transforming
Clinical Practice Initiative
Closing the referral loop
Develop and update
individual care plans
Beneficiary Engagement
Collect / follow up on patient
experience & satisfaction
data
Use QCDR for shared clinical
decision making
Provide access to enhanced
patient portal
20 point activities All others are 10 point activities
22. CPIA categories and examples--continued
Patient Safety & Practice
Assessment
Consult PDMP for Schedule-
II opioid prescriptions of >3
days
Participate in MOC part IV
Complete AMA STEPS
Forward program
Achieving Health Equity
Timely care for Medicaid
patients (including duals)
Participate in State
Innovation Model activities
Use QCDR to screen for
social determinants of
health
Emergency Response &
Preparedness
Participate in Disaster
Medical Assistance teams
Participate in domestic or
international humanitarian
volunteer work
Integrated Behavioral &
Mental Health
Colocation of mental health
services in clinical care
settings
Depression screening and
follow-up planning
Prevention & treatment for
unhealthy alcohol or tobacco
use
20 point activities All others are 10 point activities
23. Resource Use – Value Modifier
•0% in 2019
•15% in 2020
•30% in 2022
MIPS weight
•CMS will calculate administratively via claims over full year
•40+ episode specific measures
•No data submission required
Measures
•10 points, calculated average of all attributable cost measures (worth 10 points
each)
•20 patient sample required for measure attribution
•If patient volume insufficient for all measures, score is zero and other MIPS
categories will be reweighted
Scoring
24. Submission of Data – Individual
Quality (PQRS)
• CAHPS for MIPS
• Administrative
Claims
• EHR Vendors
• Qualified
Registry
• Qualified Clinical
Data Registry
Advancing Care
(MU)
• Attestation
• EHR Vendors
• Qualified
Registry
• Qualified Clinical
Data Registry
Clinical Practice
Improvement
Activities
• Attestation
• Administrative
Claims
• EHR Vendors
• Qualified
Registry
• Qualified Clinical
Data Registry
CAHPS = Consumer Assessment of Healthcare Providers and Systems
25. Submission of Data – Groups
Quality (PQRS)
• CMS Web
Interface (Groups
of 25 or more)
• Administrative
Claims
• EHR Vendors
• Qualified
Registry
• Qualified Clinical
Data Registry
Advancing Care
(MU)
• Attestation
• CMS Web
Interface (Groups
of 25 or more)
• EHR Vendors
• Qualified
Registry
• Qualified Clinical
Data Registry
Clinical Practice
Improvement
Activities
• Attestation
• CMS Web
Interface (Groups
of 25 or more)
• EHR Vendors
• Qualified
Registry
• Qualified Clinical
Data Registry
27. Options
- % + % + %0
Don’t Participate
• No data
Submitted
• Receive a
negative 4%
payment
adjustment
Submit
Something
• Submit
minimum
amount of data
• Avoid downward
adjustment
Partial Year
• Submit 90 days
• May earn a
neutral or small
positive
adjustment
Full Year
• Submit a full
year
• May earn a
moderate
positive
payment
adjustment
Current
Payment
Don’t
Participate
Submit
Something
Partial
Year
Full Year
28. Considerations and Recommendations
Considerations
Bipartisan
Support – not
going anywhere
Budget Neutral
Measurements
started 1 Jan
2017
Payment
adjustments
begin 1 Jan
2019
Recommendations
Submit
Meaningful Use
Attestation
Analyze current
data collection
and select
measures
Aim to submit
data for full
year
Review
measures
monthly
Initially metric start out with very high quality focus and everything else relatively small but transient transition very quickly to a more balanced approach where resource use and quality are weighted equally.
There was also a focus that if greater than 75% hit the information care metric that this weight will be decreased giving more weight to the other metrics
Use a composite scoring much like they use for value-based purchasing to determine MIPS bonuses
Maximum potential is actually three times adjustment however extremely unlikely
Lowest 25% of physicians will get the maximum reduction on a yearly basis
A $500 million bonus each year available for exceptional performers. These are top 25%
Of note this is all budget neutral
Many points available with base performance and bonus however can still only get 25 points
Seem to want people to score high in this category so they can decrease the weight