The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created a Quality Payment Program which moves Medicare toward their goal of paying for value and better health care. There are three principles under MACRA:
- Repeal of the Sustainable Growth Rate Formula for Medicare Physician Fee Schedule adjustments
- Creation of a new framework for rewarding providers for value instead of volume
- Combine multiple quality reporting programs (MU, PQRS, VM) into one new system
The Quality Payment Program final rule was published on October 14, 2016, and provides two paths for eligible clinicians in 2019:
1) The Merit-based Incentive Payment System (MIPS)
2) Advanced Alternative Payment Models (APMs)
Simply put, provider reimbursements for Medicare Part B services will be determined by participation in one of these two paths. The first performance year (the period time where participation is “graded”) was 2017 and determined what 2019 reimbursements for Medicare services will look like for each clinician. Similarly, reimbursements for any given year will be determined based on performance two years earlier.
The Merit-based Incentive Payment System (MIPS) represents the path that most clinicians will be following in the early days of the Quality Payment Program. In 2019, MIPS creates a “final score” of 0-100 for each clinician based on their performance in 4 categories:
- Promoting Interoperability (formerly known as Advancing Care Information) – 25% of final score
- Quality (formerly known as PQRS) – 45% of final score
- Improvement Activities - 15% of final score
- Cost – 15% of final score
How does MIPS alter reimbursements?
The final score of an eligible clinician is compared to a value known as the performance threshold. In 2019, this value has been set at 30 to represent a slightly increased expectation vs. 2018, but still low enough to allow those involved to satisfy minimum requirements with a small amount of effort.
- A final score above the performance threshold will receive an increased reimbursement
- A final score below the performance threshold will receive a decreased reimbursement
- The further away from the performance threshold, a provider’s final score is, the more significant the upward or downward revision of reimbursements
How much will MIPS affect my reimbursements?
- as much as +/- 4% in 2019
- as much as +/- 5% in 2020
- as much as +/- 7% in 2021
- as much as +/- 9% in 2022
The years 2019-2024 will also offer the potential for exceptional performance bonuses ranging from 0.5% to 10%.
How else might MIPS information affect me?
MIPS information will be made available on Medicare’s Physician Compare website. Physician Compare will allow the general public to search for providers within a specific zip code or city, see their MIPS final score and how they performed within the various performance categories (Advancing Care Information, Quality, Improvement Activities, and Cost).
How long do I need to participate in MIPS for 2019?
- Promoting Interoperability: any 90 consecutive days
- Quality: full calendar year
- Improvement Activities: any 90 consecutive days
- Cost: full calendar year