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MACRA/MIPS demystified


Doctors may not agree with MACRA, however, refusing to comply will result in financial penalties. The best course of action is to get educated.

On April 16, 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law thereby abolishing the fatally flawed Sustainable Growth Rate (SGR). The goals of this law are multiple: reimburse physicians for quality versus quantity, merge several quality programs into the new Merit Based Incentive Payments System (MIPS), and pay out bonuses for providers who participate in alternative payment models (APMs).

While the roll-out of this new law was met with much confusion, the implementation is perhaps even more mind-boggling for many physicians. Most of us know of bonuses and quality initiatives, but this program promises either positive or negative adjustments based on specific quality measures. Depending on a MIPS composite performance score, a provider will receive positive, negative, or neutral adjustments on their base pay. Even the usual language has changed.

When even the data experts seem to struggle on the implications of MIPS, how are busy providers supposed to understand? Many providers are employed by hospitals or large groups who have departments dedicated to the task. Doctors in small practices don’t have anyone but themselves to do it. Yet, it is imperative to learn to avoid being financially penalized (the true meaning of the phrase “negative adjustment”).

What doctors need to know about MACRA/MIPS?

  • Doctors who refuse to submit requested data will have their base pay from Medicare negatively adjusted by 4 percent right off the bat. This penalty stands to become larger over the years. Do doctors need to participate in MIPS reporting? No, but expect to be paid less.
  • There are some doctors who are exempt from MIPS reporting. These include doctors who are newly enrolled for the first time during the reporting period, those who significantly participate in APMs, and those who are below volume threshold (submitted charges less than $90,000 in a given year or saw fewer than 200 Medicare patients). 
  • There are three performance categories where providers may submit data: Quality, Advancing Care Information, and Improvement Activities. 
  • Under the Quality category, providers are required to submit data regarding patient outcomes, appropriate use of medical resources, patient safety, efficiency, patient experience, and care coordination.
  • Providers must choose six measures to report that best reflects their practice. One of these measures must be an outcomes measure and one a cross-cutting measure. 
  • Advancing Care Information replaces prior EHR Meaningful Use reporting and comprises 25 percent of the composite score.
  • Clinicians will submit data based on interoperability and information exchange.
  • Improvement Activities comprises 15 percent of the score and includes activities that improve clinical practice, including shared decision making, patient safety, coordinating care, and increasing access.
  • Clinicians have 90 measures to choose from. For those providers participating in a Certified Medical Home, they receive full credit for this category.
  • A fourth category, comprising 10 percent of the score, is Resource Use. This is not a category that requires the clinician to submit any data. CMS calculates this measure based on claims. 
  • Measures by individual providers can be reported through claims, qualified clinical data registries (QCDRs), qualified registries, and EHRs. Measure by large groups can be submitted through QCDRs, qualified registries, EHRs, and the CMS web interface. 
  • An eligible physician may chose to participate in an APM if they meet the eligibility requirements. APMs include Medicare Shared Saving Program ACOs, all CMS Innovation Center initiatives excluding Health Care Innovation Awards, and certain demonstration programs. Physicians participating in patient-centered medical homes also qualify for bonuses. An advisory board is now in place to review proposed models. 

While many doctors opposed the passage of MACRA, it appears that it is here to stay. We may not agree with its provisions, however, if we refuse to comply, we will be hit with financial penalties. The best course is to get educated and get paid the money we deserve. 

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