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On April 27th, CMS issued a proposed rule for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which replaced the Sustainable Growth Rate (SGR) with a payment system that rewards value and the quality of care provided. The proposed rule lays out CMS’ unified framework for value and quality, called the Quality Payment Program (QPP). The QPP has two pathways: (1) the Merit-Based Incentive Payment System (MIPS) and (2) Advanced Alternative Payment Models (APMs).

MIPS

MIPS replaces Medicare’s current quality programs: (1) the Physician Quality Reporting System (PQRS), (2) the Value Modifier Program, and (3) the Electronic Health Record (EHR) Incentive Program/Meaningful Use with four performance categories.

Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MIPS-NPRM-Slides.pdf

Each performance category is weighted and points determined towards an overall Composite Performance Score (CPS).

Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MIPS-NPRM-Slides.pdf

Clinicians’ MIPs scores are used to compute a positive, negative, or neutral adjustment to their Medicare payments. In the first year, depending on the variation of MIPS scores and budget neutrality, adjustments are calculated so that negative adjustments can be no more than 4 percent, and positive adjustments are generally up to 4 percent, with additional bonuses for the highest performers. The maximum negative adjustment in 2020 is 5 percent, 7 percent in 2021, and 9 percent in 2022 and thereafter.

CMS would begin measuring performance for doctors and other clinicians through MIPS in January 2017, with payments based on those measures beginning in January 2019. MIPS does not apply to hospitals or facilities. In the rule, CMS has proposed some flexibility in how radiologists can meet the performance categories given the general non-patient facing nature of radiology practice and limitations on their access to certified EHR technology.

APMs

Advanced APMs are the CMS Innovation Center models, Shared Savings Program tracks, or statutorily-required demonstrations where clinicians accept both risk and reward for providing coordinated, high-quality, and efficient care. These models must also meet criteria for payment based on quality measurement and for the use of EHRs. From 2019 through 2024, Qualifying APM Professionals (QPs) would receive a lump sum payment equal to 5 percent of the estimated aggregate payment amounts for Part B services. Clinicians participating in APMs are excluded from MIPS.

For more information about Medicare’s Quality Payment Program, go to https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program.html