Value Based Payment (MACRA) & Alternative Payment Models

MIPS Proposed Changes for Performance Year 2018/ Payment Year 2020

Performance period Clinician Type Submission mechanism Submission criteria Data completeness
Jan 1–Dec 31 Individual MIPS eligible clinicians Part B Claims Report at least six measures including one out come measure, or if an outcome measure is not available report another high priority measure; if less than six measures apply t hen report on each measure t hat is applicable. Individual MIPS eligible clinicians would have t o select their measures from either the set of all MIPS measures list ed or referenced in Table A or one of the specialty measure set s list ed in Table B of the Appendix in this proposed rule.
 
50 percent of individual MIPS eligible clinician’s Medicare P art B patients for the performance period.
 
Jan 1–Dec 31  
Individual MIP S eligible clinicians,groups or virt ual groups
 
QCDR, Qualified Registry, & EHR
 
Report at least six measures including one out come measure, or if an outcome measure is not available report another high priority measure; if less t han six measures apply t hen report on each measure that is applicable. Individual MIPS eligible clinicians, groups, or virtual groups would have to select t heir measures from eit her the set of all MIPS measures list ed or referenced in T able A or one of the specialty measure set slist ed in Table B of t he Appendix in this proposed rule.
 
50 percent of individual MIPS eligible clinician’s, group’s, or virtual group’s patients across all payers for the performance period.
Jan 1–Dec 31 Groups or virtual groups CMS Web Interface Report on all measures included in t he CMS Web Interface; AND populate dat a fields for the first 248 consecutively ranked and assigned Medicare beneficiaries in the order in which they appear in the group’s or virtual group’s sample for each module/measure. If the pool of eligible assigned beneficiaries is less than 248, then the group or virtual group would report on 100 percent of assigned beneficiaries.
 
Sampling requirements for the group's virtual group's Medicare Part B patients
Jan 1–Dec 31 Groups or virtual Groups CAHPS for MIPS Survey CMS-approved survey vendor would need to be paired with another reporting mechanism to ensure the minimum number of measures is reported. CAHPS for MIPS survey would fulfill the requirement for one patient experience measure towards the MIPS qualit y data submission criteria. CAHPS for MIPS survey would only count for one measure under the qualit y performance category .
 
Sampling requirements for the group's or virtual group's Medicare Part B patients

Success in Quality Payment Webinar Series

Part 1: MACRA Program Overview, originally aired Dec. 8, 3pm ET

Part 2: Making MIPS Work, originally aired Dec. 14, 12pm ET

MACRA Resources:

CMS releases Quality Payment Program proposed rule 
5 Things you need to know about MACRA
Merit Based Incentive Payment System Performance Categories 

CMS MACRA Resource Center 
A Guide to Physician-Focused Alternative Payment Models
Implementing Alternative Payment Model under MACRA: How the Federal Government can Accelerate Successful Health Care Payment Reform

CMS Web Resources:

MIPS Overview
Quality Measures- Review and identify measures that fit your practice
Advancing Care Information
Improvement Activities


President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) into law on April 16, 2015. Congress passed the bill as a fix for the Sustainable Growth Rate (SGR) which was implemented in the 1990s to determine payment for clinicians’ services. MACRA represents a shift from a volume- to value-based based payment. The next few years bring a number of changes to Medicare Part B physician reimbursement including:
  • repeal of the SGR Formula 
  • a period of stable payments which include a .5% update from 2015- 2019 
  • implementation of the Merit Based Incentive Payment System (MIPS) and Alternative Payment Models (APM); and 
2016
  • MACRA provides funding from CY2016 to CY2020 to help small practices participate in APMS and MIPS.
  • Physicians may participate in Physician Quality Reporting System  via Qualified Clincial Data Registries ( like ImageGuide)
  • Part D claims must list the prescribers National Provider Identifier.    

2017

  • Performance period for MIPS and APMs.
2018
  • Claims must identify care episode, patient’s condition, and patient relationship to the clinican to attribute resource use 
  • Separate reporting penalties levied under PQRS, MU, VBM sunset on December 31, 2018. 
2019
  • Physician payments based on MIPS performance and participation in APMs.


MACRA has two pathways for clinicians. The first is the Merit Based Incentive Payment System and the second is an Alternative Payment Model. Physicians not in an alternative payment model will be evaluated under MIPS.


Summary of Provisions

MIPS (Merit Based Incentive Payment System)


MIPS repalces quality reporting programs currently administered under CMS. MIPS will apply to MD or DO, DDS, or DDM, DPM, OD, Chiropractors, PA, NP or clinical nurse specailists, and RN anesthetists at the outset. The statute gives the Secretary authority to expand the program to other professsionals billing under the fee schedule in 2021. 

MIPS is comprised of the following four categories on which physician performance will be score and will form the basis of Part B payments beginning Jan. 1, 2019:
Negative adjustments for physicians who do not meet performance benchmarks will be capped at 4% in 2019, 5% in 2020, 7% in 2021, and 9% in 2022 and beyond. Positive adjustments are available for physicians who achieve scores above national benchmarks and will be limited to three times the cap on negative adjustments.

APMs (Alternative Payment Models)


Physicians who participate in alternative payment models will not be subject to MIPS. 

Qualified APMS are further required to use a certified EHR, have quality measures similar to those in the MIPS program, and bear financial risk above a nominal amount. ACOs, patient centered medical homes, and model payment are examples of entities that could be considered APMs.