By Julia Kettlewell, MPH, BSN, RNP and Eldrina Easterly, BS

To achieve the triple aim of improving quality and outcomes and controlling costs, Medicare had made changes, mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

MACRA reforms Medicare payments and ends the Sustainable Growth Rate (SGR) formula, which threatened participating clinicians with cuts for 13 years. Physicians regularly exceeded Medicare’s expenditure targets, forcing Congress to pass a SGR “fix” each year to avert physician payment cuts.

MACRA legislation created the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). The Centers for Medicare and Medicaid Services’ (CMS) created the Quality Payment Program (QPP) to make a “fresh start” and “pay for what works” to stabilize, strengthen and improve Medicare.

The QPP shifts Medicare payments from a fee-for-service model to a pay-for-performance, value-based model. The QPP effects more than 600,000 clinicians nationwide and streamlines reporting, standardizes evidence-based measures and eliminates duplication. It promotes industry alignment through multipayer models and incentivizes cost-effective, quality care. The QPP brings patients increased access to care, better outcomes and enhanced care coordination through a patient-centered focus.

The QPP creates a single system by consolidating Physician Quality Reporting System (PQRS), Physician Value-based Payment Modifier (VM), and Medicare’s Electronic Health Record (EHR) Incentive Program.

QPP features two participation tracks: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Clinicians who chose not to participate in either QPP track in 2018 will receive a 5 percent reduction in Medicare payments beginning in 2019.

For the 2018 MIPS performance period, Medicare Part B clinicians will participate in MIPS if they bill more than $90,000 a year and provide care to more than 200 Medicare patients. These clinicians include:

  • Physicians who are doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine and optometry and chiropractors
  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Registered Nurse Anesthetists

MIPS-excluded clinicians include those newly enrolled in Medicare, below the low-volume threshold (fewer than 200 Medicare Part B patients and billing Medicare Part B allowed charges less than $90,000 a year), or participants in Advanced APMs at a significant level.

Advanced APMs include accountable care organizations (ACOs), bundled-payment models, patient-centered medical homes and risk-bearing models. For the 2018 performance year, significant Advanced APM participation means involvement in the following:

  • Comprehensive End-stage Renal Disease Care Model
  • Comprehensive Primary Care Plus (CPC+)
  • Shared Savings Program Tracks 2 and 3
  • Next Generation ACO Model
  • Oncology Care Model
  • Comprehensive Care for Joint Replacement

Participating in an Advanced APM provides three benefits: no participation in MIPS, eligible for a 5 percent lump-sum bonus and a higher Physician Fee Schedule update starting in 2026.

Clinicians who choose the MIPS track have four performance categories:

  • Quality (replaces PQRS) includes familiar quality measures such as health screenings and medication lists
  • Cost (replaces value-based modifier) is based on claims; no reporting in 2018
  • Improvement Activities include care coordination, shared decision-making and safety checklists
  • Advancing Care Information (replaces EHR incentive program) includes e-prescribing, sending/accepting a summary of care and others

MIPS lets clinicians choose activities or measures that align with their practice. Each category is weighted on a 100-point scale. For 2018, Quality is 50 percent, Improvement Activities are 15 percent, Advancing Care Information is 25 percent and Cost is 10 percent. The total MIPS score translates into a neutral, positive or negative payment adjustment.

The performance period opens Jan. 1 and closes Dec. 31. MIPS does not apply to hospitals or facilities but does apply to eligible clinicians within these facilities who bill charges to Medicare Part B.

In 2019, the first year of payments, the maximum adjustment is plus or minus 4 percent, increasing annually to plus or minus 9 percent by 2022 and beyond.

MACRA is a complex program. CMS has established a support network to provide direct, no-cost technical assistance to enhance successful QPP participation. The support network serves all eligible clinicians, regardless of practice size or specialty.

The Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) provide support for large groups of 16 or more clinicians. The QPP-Small, Underserved and Rural Support (SURS) contractors serve small (15 or fewer eligible clinicians), rural and underserved clinicians, especially those in medically underserved or health-professional-shortage areas. The QPP-SURS contractors assist practices with MIPS education, workflows, EHR technology optimization, program structure information, requirements and timelines.

In Arkansas, TMF Health Quality Institute serves as both the QIN-QIO and the QPP-SURS contractor, with AFMC serving as an integral subcontractor to TMF for both QIN-QIO and QPP-SURS assistance. AFMC can provide free, one-on-one technical assistance to MIPS-eligible clinicians, tailored to the needs of individual practices.

For more information about educational resources and technical support, visit https://tmfqin.org/qpp or https://qpp.cms.gov/, or contact TMF directly by emailing QPP-SURS@tmf.org, or phoning 1-844-317-7609. For eligibility questions, visit https://qpp.cms.gov/participation-lookup

Ms. Kettlewell is director of quality with AFMC’s Outreach Quality department and Ms. Easterly is AFMC’s manager HealthIT and HIT lead for QPP-SURS.