FAQ on MACRA and Medicare Payment Reform

FAQ on MACRA and Medicare Payment Reform

Frequently Asked Questions: Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

How does the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) impact my Medicare payments?

MACRA impacts Medicare payments in three ways. The law:

  • Repeals the flawed Medicare sustainable growth rate (SGR) formula that calculated payment cuts for physicians.
  • Creates a new framework for rewarding physicians for providing higher quality care by establishing two tracks for payment: 
    • Merit-based Incentive Payment System (MIPS), and
    • Alternative Payment Models (APMs)
  • Consolidates three existing quality reporting programs (Physician Quality Reporting System, Value-based Payment Modifier, and meaningful use), plus adds a new performance category, into a single system through MIPS.

Download a timeline of important MACRA dates »(1 page PDF)

The AAFP has created an introductory, on-demand series for members to provide an overview of the basics of the MACRA law. Watch the series now »

What is the Merit-based Incentive Payment System (MIPS)?

The Merit-based Incentive Payment System (MIPS) consolidates three existing quality-reporting programs: the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VBPM), and meaningful use (MU). The system also adds a new performance category, called clinical practice improvement activities (CPIA). The four categories establish a composite performance score (0-100) that will be compared against a threshold and then used to determine physician payment adjustments. The categories that make up the MIPS score are:

  • Quality – based on PQRS;
  • Resource use – based on VBPM;
  • Advancing Care Information (ACI) – based on MU; and
  • Clinical practice improvement activities – new performance category.

AAFP members can watch a short primer on MIPS, titled "MACRA: An Overview of the Merit-based Incentive Payment System (MIPS)." Watch the on-demand module now »

How will I be scored under MIPS?

Scores for each performance category will be weighted and rolled up into the composite performance score (CPS). The weights of each category shifts over the course of the program.

Performance Category

2019

2020

2021

Performance Category

:

Quality

2019

:

50%

2020

:

45%

2021

:

30%

Performance Category

:

Resource Use

2019

:

10%

2020

:

15%

2021

:

30%

Performance Category

:

ACI

2019

:

25%*

2020

:

25%*

2021

:

25%*

Performance Category

:

CPIA

2019

:

15%

2020

:

15%

2021

:

15%

*If the Secretary of the U.S. Department of Health and Human Services (HHS) determines the proportion of eligible clinicians who are “meaningful users of electronic health records (EHRs)” is estimated at 75 percent or greater, the weight of the ACI category may be reduced. The remaining performance categories will be increased by the corresponding number of percentage points. The lowest weight the ACI category can carry is 15 percent.

Who am I compared to?

The Centers for Medicare & Medicaid (CMS) will set performance thresholds based on the CPS for all MIPS-eligible clinicians for a previous performance period. Your composite performance will be compared to this threshold and determine your payment adjustment amount.

What are the reporting requirements under MIPS?

Quality

In the Quality performance category, you must report at least six measures, including one cross-cutting measure and one outcome measure. Measures previously available under the PQRS program will be available in the Quality category of MIPS.

CMS has proposed to calculate and report three population claims-based measures for clinicians. These measures include the acute and chronic composite measures for ambulatory care sensitive conditions (ACSC) and total all-cause hospital readmissions. All-cause hospital readmissions will only apply to groups of 10 or more eligible clinicians. These measures were previously included in the VBPM program.

Resource Use

There is no reporting requirement for the eligible clinician under the Resource Use category. CMS will calculate the clinician’s performance using claims data. As currently proposed, primary care will be predominantly measured on Medicare spending per beneficiary (MSPM) and total cost of care. These measures were previously included in the VBPM program.

To understand your previous performance compared to the national performance in quality and resource use, review your Quality and Resource Use Report (QRUR).

Clinical Practice Improvement Activities (CPIA)

Patient-centered medical homes (PCMH) will automatically receive full credit in the CPIA category. Organizations which currently offer PCMH accreditation include:

  • National Committee for Quality Assurance (NCQA)
  • Accreditation Association for Ambulatory Health Care (AAAHC)
  • Joint Commission (previously called the Joint Commission on Accreditation of Healthcare Organizations)
  • URAC (previously called the Utilization Review Accreditation Commission)

Clinicians who do not qualify for the automatic full credit must attest to three high-weighted or six low-weighted activities, or a combination of both to achieve a total of 60 points. CMS has proposed a list of more than 90 CPIAs. An activity must be performed for at least 90 days during the performance period to receive credit.

Advancing Care Information (ACI)

As proposed, clinicians will receive a base score and performance score in the ACI performance category. The base score accounts for 50 percent of the ACI performance category score and clinicians can earn the additional 50 percent through their performance score.

For the base score, clinicians must report a numerator (of at least one) and denominator, or yes or no (only yes would qualify for credit) for each measure within a subset of objectives. Failure to meet the submission criteria for any of the measures would result in a zero for the ACI performance category score. The objectives and measures are based on the 2015 EHR Incentive Program requirements. In 2017, a clinician can use the 2014 edition of certified EHR technology (CEHRT), 2015 CEHRT, or a combination. All clinicians must be on the 2015 edition of CEHRT beginning with the 2018 performance period.

Clinicians using EHRs certified to either the 2014 or the 2015 edition can report the following objectives:

Objective

Measure

Objective

:

Protect Patient Health Information

Measure

:

Security Risk Analysis

Objective

:

Electronic Prescribing

Measure

:

ePrescribing

Objective

:

Patient Electronic Access

Measure

:

Patient Access

Objective

:

View, Download, or Transmit (VDT)

Objective

:

Patient-Specific Education

Measure

:

Patient-Specific Education

Objective

:

Secure Messaging

Measure

:

Secure Messaging

Objective

:

Health Information Exchange

Measure

:

Health Information Exchange

Objective

:

Medication Reconciliation

Measure

:

Medication Reconciliation

Objective

:

Public Health Reporting

Measure

:

Immunization Registry Reporting

Objective

:

Syndromic Surveillance Reporting

Objective

:

Specialized Registry Reporting

Clinicians using technology certified to the 2015 edition can report the following objectives and measures:

Objective

Measure

Objective

:

Protect Patient Health Information

Measure

:

Security Risk Analysis

Objective

:

Electronic Prescribing

Measure

:

ePrescribing

Objective

:

Patient Electronic Access

Measure

:

Patient Access

Objective

:

Patient-Specific Education

Objective

:

Coordination of Care through Patient Engagement

Measure

:

View, Download, or Transmit (VDT)

Objective

:

Secure Messaging

Objective

:

Patient-Generated Health Data

Objective

:

Health Information Exchange

Measure

:

Patient Care Record Exchange

Objective

:

Request/Accept Patient Care Record

Objective

:

Clinical Information Reconciliation

Objective

:

Public Health and Clinical Data Registry Reporting

Measure

:

Immunization Registry Reporting

Objective

:

(Optional) Syndromic Surveillance Reporting

Objective

:

(Optional) Electronic Case Reporting

Objective

:

(Optional) Public Health Registry Reporting

Objective

:

(Optional) Clinical Data Registry Reporting

For the performance score under ACI, a clinician can earn 50 points above the base score for their performance in the measures in the patient electronic access, coordination of care through patient engagement, and health information exchange objectives.

Can I participate without an EHR?

Clinicians without an EHR can still participate in MIPS, but will not be eligible for any of the points under the ACI performance category.

While still possible, the reporting requirements will be more burdensome without the use of an EHR. The reporting mechanisms available to a practice without an EHR would be claims or qualified registry. However, use of the qualified registry option would require a manual data collection process. As proposed, this would require reporting on at least 90 percent of the clinician’s denominator-eligible patients.

How would I be paid under MIPS?

According to the current legislation, beginning in 2019, physicians participating in MIPS will be eligible for positive or negative Medicare payment adjustments that start at four percent and gradually increase to nine percent in 2022. Distribution of payment adjustments will be made on a sliding scale and will be budget neutral. Payment adjustments will be based on the following:

  • Physicians who score at the threshold will receive no payment adjustment.
  • Physicians whose composite score is above the threshold will receive a positive payment adjustment on each Medicare Part B claim for the following year.
  • Physicians whose composite score is below the threshold will receive a negative payment adjustment on each Medicare Part B claim for the following year.
  • Physicians whose composite score is in the lowest quartile will automatically be adjusted to the maximum negative adjustment on each Medicare Part B claim for the following year.

Since physicians in the lowest quartile will receive the maximum negative adjustment to maintain budget neutrality, physicians with higher composite scores may be eligible for a positive payment adjustment up to three times the baseline positive payment adjustment for a given year. For example, the baseline positive payment adjustment for 2019 will be four percent, so higher performers may be eligible for a positive payment adjustment of up to 12 percent.

For 2019 through 2024, an additional sliding scale positive payment adjustment of up to 10 percent will be available to “exceptional” performers. “Exceptional” performers must meet an additional performance threshold that will be set by CMS. This additional positive payment adjustment does not fall under the budget-neutrality requirements.

Beginning in 2026, all physicians participating in MIPS will be eligible for a 0.25 percent increase in their Medicare Part B physician fee schedule (PFS) payments each year.

Are there any exemptions from MIPS?

Yes. Exemptions from MIPS include:

  • Providers in their first year billing Medicare;
  • Providers whose volume of Medicare payments or patients fall below the proposed threshold (100 patients AND $10,000 or less in Medicare Part B charges); and
  • Providers who qualify for payment under APMs with the associated bonuses exempt from MIPS.

Additionally, it is anticipated that providers practicing in rural health clinics or Federally Qualified Health Clinics (FQHCs) are also exempt from MIPS.

What is an Alternative Payment Model (APM)?

MACRA defines any of the following as a qualifying Alternative Payment Model (APM):

  • An innovative payment model expanded under the Center for Medicare & Medicaid Innovation (CMMI), with the exception of Health Care Innovation Award recipients;
  • A Medicare Shared Savings Program (MSSP) accountable care organization (ACO);
  • Medicare Health Care Quality Demonstration Program or Medicare Acute Care Episode Demonstration Program; or
  • Another demonstration program required by federal law.

In order for a provider to receive a bonus payment through an APM, the qualified APM must also meet the following eligibility requirements:

  • Use of quality measures comparable to measures under MIPS;
  • Use of a certified electronic health record (EHR) technology; and
  • Assumes more than a “nominal financial risk” OR is a medical home expanded under the CMMI.

A physician receiving the designated percentage of Medicare payments or patients through a qualified, eligible APM based on the above requirements is considered a “qualifying participant” (QP).

Which Alternative Payment Models (APMs) are eligible for the bonus?

The following APMs apply to primary care and are proposed as Advanced APMs (AAPMs) for the performance period beginning in 2017:

  • Comprehensive Primary Care Plus (CPC+)
  • Medicare Shared Savings Tracks 2 and 3
  • Next Generation ACO Model

In order to be eligible for the AAPM bonus, an eligible clinician must receive a set percent of payments or see a percentage of patients through the AAPM. Physicians meeting these requirements will be considered “qualifying participants” (QPs) and are eligible for a five percent bonus.

AAFP members can watch a concise overview of APMs, titled "MACRA: What are Alternative Payment Models (APMs)?” Watch the on-demand module now »

How would I be paid under an APM?

If you are a QP, from 2019 through 2024, you will receive an annual five percent lump-sum bonus based on your Medicare Part B payments. This bonus will be in addition to the incentive paid through existing contracts with the advanced APM. Beginning in 2026, you will qualify for a 0.75 percent increase in your Medicare Part B PFS payments each year.

How do I know if I’m in MIPS or an APM?

Most physicians will move through MIPS until more AAPMs become available. However, family physicians interested in an APM model need to be prepared to start in the MIPS program.

How does MACRA help small practices?

There is $20 million a year allocated to provide technical assistance to practices with 15 or fewer eligible clinicians participating in MIPS. This assistance is intended to assist practices in a successful transition into the MIPS payment pathway. Priority will be given to practices in rural areas, health professional shortage areas (HPSAs), and medically-underserved areas.

For practices that do not qualify for the MACRA technical assistance, there is the Transforming Clinical Practice initiative (TCPi). This program was launched in September 2015 to position practices for participation in alternative payment models. Practice Transformation Networks (PTNs) are available across the country to provide coaching, resources, and tools to help practices prepare for value-based payment models. Call (800) 274-2237 or contact the AAFP to connect with a PTN near you.

What is the AAFP doing to help me?

As always, we’re committed to keeping you informed, developing resources to support your quality improvement efforts, and helping you provide cost-effective care. As information, tools, and resources to help you comply with and benefit from MACRA become available, we will update AAFP.org and spread the word through AAFP News and FPM.

We will continue to advocate vigorously for the following:

  • Improved payment for primary care
  • Administrative simplification, including reducing prior authorizations
  • Harmonization of measures across all private and public payers through the use of the Core Quality Measure Collaborative Core Measures Sets
  • Reasonable reporting requirements

What can I do now to prepare for MACRA implementation?

While the first year for MACRA is 2019, the AAFP anticipates that performance in 2017 may determine payments for the first year of MIPS in 2019. The AAFP is advocating on behalf of its members that the performance period be delayed to give physicians more time to prepare.

If you haven’t reported data on quality measures through the Physician Quality Reporting System (PQRS) or as part of meaningful use, start as soon as possible. Negative payment adjustments for not reporting or for low quality may impact you this year.
More information on Medicare payment adjustments »

If you submitted quality data during the last calendar year, you should access your Quality and Resource Use Report (QRUR). This report will help you understand your performance in terms of cost and quality so you can prioritize potential areas for improvement. The AAFP has created a MACRA Readiness Assessment to walk you through steps you can take to prepare for MIPS.

If your practice doesn’t provide chronic care management (CCM) services, consider the cost-benefit opportunity for increasing revenue to support needed practice transformation or quality improvement projects. Medicare began paying for CCM codes on January 1, 2015.
CCM resources to help your practice start providing CCM services »
 

The AAFP also offers a comprehensive CCM Toolkit available to assist you in implementing CCM in your practice. Learn more »

Where can I find more information on MACRA?

Information, tools, and resources to help you comply with and benefit from MACRA are available from the AAFP and from FPM. We encourage you to bookmark our MACRA Ready landing page for quick access to up-to-date news and resources.

The latest news about MACRA and other payment reform topics is available from AAFP News.

How can I get answers to my practice-specific questions?

AAFP members can contact an AAFP subject matter expert or call (800) 274-2237.

Last updated: September 2016