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Five Things You Should Know About MACRA: Page 2 of 3

Five Things You Should Know About MACRA: Page 2 of 3

2. What is MIPS?

MIPS will subject physicians participating in Medicare Part B to a performance score composed of four categories: quality, resource use, clinical practice improvement activities, and Meaningful Use of EHR technology. Starting in 2019, this composite score will be used to adjust payments up or down by a designated percentage. In 2019 that percentage will be +/- 4 percent and increase to +/- 9 percent by 2021. Additionally, MIPS adjustments are required to be budget neutral, so the increased adjustments must equal the downward adjustment, and upward adjustments may be subject to a scaling factor and thus potentially less than the projected percentage. MIPS will only apply to individual physicians and not to hospitals or facilities. Additionally, three groups of physicians will be exempt from MIPS: those in their first year of Medicare participation, those in the APMs that qualify for bonus payments, and those whose panel of Medicare patients fall below the low volume threshold. The measurement systems for the categories already exist under three systems: Physician Quality Reporting System, Value Based Modifier Program, and Medicare Electronic Health Record Incentive Program ("Meaningful Use"). These programs will be combined into one reporting system under MIPS with some changes that are purported to have more flexibility, accommodating different practice methods and goals as well as elimination of the "all or nothing" measurements. Initially, CMS believes that most Medicare providers will participate in MIPS, but eventually most will progress to an APM.

3. What are APMs?

Alternative Payment Models or APMs are the second track for MACRA. CMS hopes to utilize these new approaches to payment by incentivizing quality and value. Some examples of APMs include some Accountable Care Organizations (ACO) and Patient-Centered Medical Homes (PCMH), as well as many other models being tried around the country. However, only some of these current APMs will be eligible. Participants in APMs that are not deemed eligible will still be able to participate in MIPS but their participation in the APM will give them favorable scoring in the clinical practice improvement activities performance category, allowing for both APM-specific rewards and the MIPS payment adjustment. Those APMs that are deemed eligible will be considered qualifying APM participants ("QPs") and will be exempt from MIPS. Additionally, QPs will be eligible for APM-specific rewards, a lump-sum bonus payment for the period 2019-2024 of 5 percent, and, from 2026 on, a higher fee schedule. In order to be a QP, physicians must base payments on quality measures that will be similar to those in MIPS, must use an approved EHR, and either bear more than the nominal financial risk for losses or be an expanded medical home model. A specific percentage of the physician's patients or payments must be made through an eligible APM to qualify, and in 2021, this percentage may be made through a combination of Medicare and non-Medicare payer arrangements, such as private insurers.

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