The Merit-based Incentive Payment System for small and rural practices

The Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015 called for major changes in the physician payment system. The first reporting requirements related to these MACRA provisions began in January 2017. This new Centers for Medicare & Medicaid Services (CMS) payment system, the Quality Payment Program (QPP), continues the transition to payment methodologies based on value and performance rather than volume. The two options surgeons have to participate in the QPP are the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (A-APMs) incentive payment.

Small and rural practices transitioning to the QPP may face additional challenges due to limitations on staffing, technology, or other factors. This column serves as a guide to educate small and rural practices about their reporting requirements and resources available to help them succeed in MIPS.

What components of MIPS are being implemented in the 2017 transition year?

In the early years of the QPP, most surgeons will participate in the MIPS program, which comprises four components: Quality, which is based on the former CMS Physician Quality Reporting System; Advancing Care Information (ACI), based on the previous Electronic Health Record Incentive Payment Program–Meaningful Use; Improvement Activities (IA), a new category; and Cost, which is derived from the previous Physician Value-Based Payment Modifier program. In the first year of the program, referred to as the 2017 transition year, Quality accounts for 60 percent of the MIPS final composite score, and ACI and IA account for 25 and 15 percent, respectively. Due to ongoing development, the Cost component has no weight in the MIPS final score for the transition year.

What is “Pick Your Pace?”

In the 2017 transition year, CMS is allowing providers flexibility in how they participate in MIPS by creating Pick Your Pace participation thresholds. Pick Your Pace allows participants to submit minimal data to avoid a penalty, as well as the opportunity to fully report to potentially qualify for a small incentive payment. The 2017 transition year MIPS Pick Your Pace options are as follows:

• Option 1: Submit no data under any component and receive a 4 percent Medicare Part B penalty in payment year 2019.
• Option 2: Test the MIPS program by submitting a minimum amount of 2017 data to CMS to avoid the 4 percent Medicare Part B penalty in 2019. CMS defines a minimum amount of data as: one Quality measure, one IA, or required Base Score ACI measures.
• Option 3: Participate in MIPS for part of the year by submitting data for at least a continuous 90-day period in 2017 to avoid the 4 percent penalty and possibly earn a small incentive payment based on performance. Partial participation in MIPS means that surgeons should meet at least the following reporting criteria:
  • Six Quality measures for at least 90 consecutive days for 50 percent of all-payor applicable patients (or 50 percent of applicable Medicare patients for claims reporting), and/or
  • Four medium-weighted or two high-weighted IA for 90 consecutive days, and/or
  • ACI measures for at least 90 consecutive days
• Option 4: Fully participate in MIPS by submitting 2017 data to be eligible for a positive payment adjustment, based on performance. Full participation in MIPS means that surgeons should meet at least the following reporting criteria:
  • Six Quality measures for up to a full year on 50 percent of all-payor applicable patients (or 50 percent of applicable Medicare patients for claims reporting), and
  • Four medium-weighted or two high-weighted IA for up to a full year, and
  • ACI measures for up to a full year

How does CMS define a small or rural practice?

CMS defines a small practice as one with 15 or fewer MIPS-eligible clinicians. CMS defines a rural practice as individual MIPS-eligible clinicians and groups in rural areas (for example, zip codes designated as rural, using the most recent Health Resources and Services Administration Area Health Resources File data set available) or health professional shortage areas (HPSAs). For 2017, CMS considers an individual MIPS-eligible clinician or a group with at least one practice site under its tax identification number in a zip code designated as a rural area or HPSA to be a rural area or HPSA practice.

Are clinicians in a small or rural practice required to report for MIPS?

CMS bases its requirements to report on the Medicare Part B charges a physician receives or the number of Medicare patients a provider sees. Physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists who bill more than $30,000 in Medicare Part B allowed charges and who provide care to more than 100 Medicare patients annually must participate in the QPP. Similarly, if these providers have less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare Part B patients, they will not have to participate in MIPS.

Clinicians in their first year of Medicare participation and qualified participants in an A-APM may also be exempt from MIPS.

Clinicians can verify their MIPS participation status by inputting their National Provider Identifier on the CMS QPP web page.

Does the program have any scoring advantages for small and rural practices who are subject to MIPS?

Small practices are subject to different scoring rules for the IA component of MIPS. The IA component comprises medium- and high-weighted activities that are reported to achieve the total score of 40 points. Regularly, the medium activities are worth 10 points and the high activities are worth 20 points. However, for small practices, the medium activities count for 20 points and the high count for 40 points, ensuring that these providers only need to attest to two medium-weighted activities or one high-weighted activity to reach 40 points.

What local resources are available to help small and rural practices succeed in MIPS?

CMS allotted approximately $20 million to 11 community-based organizations (CBOs) in February 2017 to help small practices comply with MIPS. These CBOs will help clinicians in small and rural practices select and report on appropriate measures and activities to satisfy the requirements of each performance category under MIPS, engage in continuous quality improvement, and optimize their health information technology. They will also help clinicians evaluate their options for joining an A-APM.

The CBOs use various mechanisms, including in-person consults, online meetings, and telephone/e-mail correspondence, to help surgeons in small and rural practices comply with the MIPS reporting requirements. These CBOs help surgeons reach their Pick Your Pace goals by identifying measures and activities that are appropriate for their specialty and practice. The CBOs help determine the best data submission mechanism, walk practices through the entire data submission process, and work with practices to improve performance scores.

How do clinicians locate their respective CBO?

The 11 participating CBOs and their geographic coverage are detailed in the map (Figure 1). Contact information for the 11 participating CBOs can be found in the sidebar on this page. General information or help to get connected is also available by sending an e-mail to qppsurs@impaqint.com.

Figure 1. Geographic CBO Coverage by Organization

Where else can small and rural practices go for help?

In addition to the local resources, CMS recently launched a web page to highlight support and available options for small, underserved, and rural practices, including a version of the map in Figure 1. Surgeons also can visit the ACS QPP web page and the CMS QPP website for more information.

If you have questions regarding the QPP, contact CMS at QPP@cms.hhs.gov, or the ACS Division of Advocacy and Health Policy at QualityDC@facs.org.