The Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015 repealed the flawed sustainable growth rate formula used to adjust physician reimbursement for services provided to Medicare beneficiaries and called for the establishment of a new payment system that emphasizes value over volume. In response to this charge, the Centers for Medicare & Medicaid Services (CMS) developed the Quality Payment Program (QPP), which offers two tracks for provider participation: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (A-APMs). In the early years of the QPP, most surgeons will participate via the MIPS pathway.
The second year of the program, 2018, brings about many noteworthy changes to the QPP. The penalty for nonparticipation in the 2018 reporting period has increased from 4 percent to 5 percent, and, over time, the penalty for nonparticipation or poor performance will continue to increase. Therefore, it remains critically important that all surgeons make a plan for how they can best participate and succeed in the QPP.
This article outlines simple steps to determine if MIPS applies to you, provides background information on MIPS, offers information on various reporting options, details the four MIPS performance categories, breaks down the MIPS Final Score and payment adjustments, offers examples of ways to avoid a Medicare payment penalty, and highlights accommodations for small and rural practices. It also includes information about APMs and describes resources that the American College of Surgeons (ACS) has developed to help Fellows succeed in the QPP.
Does MIPS apply to your practice in 2018?
For various reasons, surgeons may be exempt from the requirement to submit data for MIPS, or they may be ineligible to do so. To determine whether MIPS applies to you, follow these steps:
- Determine if you are a participant in an A-APM. If you are unsure, you can input your National Provider Identifier (NPI) number to determine your status. If you are a participant in an A-APM, you are not only exempt from reporting MIPS data, but you could also receive a 5 percent bonus in 2020 based on your participation in 2018.
- Determine if your institution, employer, or group is reporting your MIPS data. If you have confirmed that these entities are reporting your data on your behalf, then you need not take further action.
- Determine if you are exempt from participating in MIPS based on the low volume threshold exemption. For 2018, the low volume threshold excludes providers or group practices that have Medicare Part B allowed charges less than or equal to $90,000 or that provide care to 200 or fewer Part B enrolled Medicare beneficiaries. To confirm you are exempt based on the low volume threshold, input your NPI number.
If you do not meet the above criteria, then you are required to submit data in 2018 to avoid a 5 percent negative payment adjustment in 2020.
MIPS took the Physician Quality Reporting System, the Value-Based Modifier, and the electronic health record (EHR) Incentive Program, commonly referred to as Meaningful Use, added the new component called Improvement Activities, and combined them to derive a composite MIPS Final Score. The new names of the components of the Final Score are as follows, respectively: Quality, Cost, Advancing Care Information (ACI), and Improvement Activities (IA). The weights for the individual components of the Final Score for the 2018 MIPS program performance year (assuming each category is reported on and/or scored), based on percentage, are as follows and as represented in Figure 1:
- Quality: 50 percent
- ACI: 25 percent
- IA: 15 percent
- Cost: 10 percent
Figure 1. 2018 MIPS performance category weights
2018 reporting options
In 2018, providers may participate in MIPS as an individual, a group, or as part of a virtual group. Surgeons who choose to report as individuals will receive a payment adjustment based on individual performance. Groups, including virtual groups, will receive a single MIPS Final Score that has a corresponding payment adjustment for all individual members of the group.
Beginning in 2018, providers will be allowed to form virtual groups to be assessed collectively under MIPS. A virtual group is a combination of two or more tax identification numbers (TINs) assigned to one or more solo practitioners, one or more groups of 10 or fewer eligible clinicians, or both, which elect to form a virtual group for a performance period of a year. Participating in a virtual group allows certain providers with different TINs to report data together and share the burden of meeting the reporting requirements.
The 2018 data submission mechanisms available for each performance category for individuals and groups are listed in Table 1.
Table 1. Data submission mechanisms for 2018 MIPS
MIPS performance category: Quality
Assuming that a clinician or group is scored under all four performance categories, the Quality component is worth 50 percent of the MIPS Final Score. For 2018, surgeons are expected to report on at least six measures, including one outcome measure (a high-priority measure may be substituted if an outcome measure is unavailable). Surgeons may choose from numerous MIPS measures, including the CMS general surgery specialty measure set or Qualified Clinical Data Registry (QCDR) measures, such as the ACS Surgeon Specific Registry (SSR) quality measures.
A noteworthy change for 2018 is the data completeness criteria. In 2018, providers who report via claims must submit data on 60 percent of Medicare patients to whom they provide care to meet the data completeness criteria. Providers who report via other mechanisms need to report on 60 percent of all patients, regardless of payor (including uncompensated care patients). Measures that do not meet these data completeness thresholds will only earn one out of 10 potential points (three out of 10 points for small practices).
In addition to the points earned through the clinical quality measures, providers may earn bonus points for reporting additional outcome and high-priority measures, as well as a bonus for end-to-end electronic reporting of quality measures via certified electronic health record technology (CEHRT).
MIPS performance category: ACI
The ACI component is worth 25 percent of the MIPS Final Score. The primary assessment for ACI is a composite score composed of three parts: a Base score, a Performance score, and a Bonus score. To receive credit for the ACI component in 2018, providers must have either 2014 or 2015 edition CEHRT and report their performance for at least a continuous 90-day period. Additionally, providers are required to attest to the Prevention of Information Blocking Attestation. More information on the Prevention of Information Blocking Attestation can be found on the CMS website.
The Base score accounts for 50 percent of the ACI score and must be achieved to earn a performance score, which accounts for 90 percent of the ACI or a bonus score, which is up to 25 percent. When combined, the total achievable percentage points is 165 percent, but the ACI component is capped at 100 percent, meaning there are multiple opportunities to earn “extra credit” and achieve a “perfect” score.
Clinicians also have several opportunities to earn bonus points (up to 25 percent) for the ACI performance category. Specifics are as follows:
- 10 percent bonus for submitting data for ACI measures using 2015 edition CEHRT exclusively
- 10 percent bonus for reporting certain IAs via CEHRT
- 5 percent bonus for reporting to an additional public health agency or clinical data registry not reported under the Performance score
In 2018, certain providers are not required to comply with the ACI requirements. Surgeons who are hospital-based or ambulatory surgery center-based will receive an automatic reweighting so that ACI is 0 percent and Quality is 75 percent of their MIPS Final Score. Surgeons in small practices or who have decertified EHR must apply for a hardship exception to have ACI reweighted to 0 percent and Quality to 75 percent.
MIPS performance category: IA
The IA component is worth 15 percent of the MIPS Final Score. Within the IA category, each activity is assigned either a high (20 points) or medium (10 points) weight.
- To receive full credit, most surgeons must select and attest to having completed between two and four activities for a total of 40 points.
- For small or rural practices to achieve full credit, only one high-value activity (weighted at 40 points) or two medium-value activities (each weighted at 20 points) are required. CMS defines small practices as those practices composed of 15 or fewer eligible clinicians. CMS defines rural practices as those practices in which more than 75 percent of the NPIs billing under the individual MIPS eligible clinician or group’s TIN are designated in a ZIP (zone improvement plan) code as a rural area or Health Professional Shortage Area (HPSA) based on the most recent Health Resources and Services Administration Area Health Resource File data set.
While IA is a new requirement introduced in 2017, surgeons are likely already familiar with many of the activities included, such as Maintenance of Certification Part IV, use of the ACS National Surgical Quality Improvement Program Surgical Risk Calculator, participation in a QCDR, and registration with their state’s prescription drug monitoring program. Surgeons who fulfill all of the requirements for the IA category will receive the maximum score and full credit towards their MIPS final score (15 points).
MIPS performance category: Cost
The Cost component is worth 10 percent of the MIPS Final Score. CMS will calculate cost for the 2018 performance period, which means that although Cost will be a weighted performance category in 2018, surgeons will not need to take any action with respect to reporting for Cost. In other words, there are no reporting requirements for Cost. For 2018, CMS will base the Cost score on two measures: the Total Per Capita Costs for All Attributed Medicare Beneficiaries measure and the Medicare Spending Per Beneficiary measure.
MIPS Final Score and payment updates
In 2018, MIPS participants will report data that will result in payment updates (positive, negative, or neutral) starting in 2020. Payments are applied two years after the performance year. The information reported to CMS in various categories (Quality, ACI, IA, and Cost) will be combined into a single MIPS Final Score, which will be compared with a threshold to determine each provider’s update. For 2018, the performance threshold is set at 15 points. Surgeon performance in the four categories will be adjusted based upon that category’s weight and combined into a final score between 0 and 100. This final score will then be benchmarked against a performance threshold, as follows:
- If the score is above the threshold, the provider will be eligible for a positive update.
- If the score is equal to the threshold, the update will be neutral.
- If the score is below the threshold, payments will be reduced.
In general, the maximum positive and negative updates are 5 percent for the 2020 payment year (based on 2018 performance) and will grow annually until they reach +/–9 percent for 2022 and future years.
Achieving the 2018 performance threshold
In 2018, surgeons will need to earn 15 points to avoid a negative payment adjustment in 2020. Following are examples of ways surgeons can achieve 15 points:
- The simplest way to achieve a score equal to the performance threshold is to earn the full points in the IA category.
- Meet the ACI Base score and submit one Quality measure (must meet data completeness criteria unless small practice provider*)
- Meet the ACI Base score and submit one medium-weighted IA
- Submit six Quality measures (must meet the data completeness criteria unless small practice provider*)
Support for small and rural surgical practices
Surgeons in small or rural practices are eligible for technical assistance and subject to reduced requirements designed to help them succeed in the QPP. CMS defines a small practice as one consisting of 15 or fewer eligible clinicians. CMS defines a rural practice as one in which more than 75 percent of the NPIs billing under the individual MIPS eligible clinician or group’s TIN are designated in a ZIP code as a rural area or HPSA based on the most recent Health Resources and Services Administration Area Health Resource File data set.
The U.S. Department of Health and Human Services (HHS) will award $20 million for each of the first five years of the QPP to organizations tasked with helping small practices succeed. These funds will be allocated nationwide but with priority given to rural areas, designated HPSAs, and medically underserved areas. This money will be allocated to provide direct outreach and technical assistance, such as helping practices decide which quality measures to report, providing advice on EHR selection, and discussing how to improve the practice’s MIPS Final Score by receiving full credit for IAs, which the provider may already be incorporating into his or her practice. Assistance also will be provided to providers interested in exploring participation in A-APMs. Providers can find these resources and more on the CMS Small, Underserved and Rural Practices web page.
Certain scoring advantages for small practices are built into the MIPS scoring criteria. Specifically, small practices—along with rural practices and practices located in geographic HPSAs—can receive full credit in the IA category of MIPS by attesting to a single high-weighted activity or two medium-weighted activities (half the requirement of larger practices). In addition, five bonus points are automatically added to the MIPS Final Score for small practices.
Small practices may be excluded from MIPS altogether under the low volume threshold (described previously) if they do not provide care to many Medicare patients or if they receive a low number of Medicare Part B payments.
Additional relief is provided by being able to form virtual groups and the ACI significant hardship exception, both described earlier.
APMs and Advanced APMs
APMs provide a model for paying physicians that differs from the traditional fee-for-service construct. The goal of APMs is to improve the quality and value of care provided, reduce growth in health care spending, or both. On the QPP website, CMS describes APMs as payment models that create incentives for clinicians to provide high-quality, cost-efficient care for a specific clinical condition, episode of care, or population.
Although the relevance of APMs has grown, models that recognize the importance of surgeon leadership and the team-based nature of surgical care have been lacking, leaving many surgeons without meaningful opportunities for participation. In response, the ACS is in the beginning stages of a multi-year effort with Brandeis University, Waltham, MA, to develop the ACS-Brandeis Advanced-APM. For details, see the September 2017 Bulletin article on Alternative Payment Models.
APM participation in MIPS
Participating in an APM can improve the chances of attaining a higher MIPS score. CMS created a separate scoring standard in MIPS for certain APMs to avoid duplicative data reporting requirements for MIPS-eligible clinicians. The models to which this scoring standard applies are referred to as MIPS APMs. To be considered a MIPS APM, participating entities must maintain a participation list of MIPS-eligible clinicians, base payment incentives on clinicians’ performance with respect to cost and quality measures, and maintain a participation agreement with CMS or otherwise be approved as a model by law or regulation. Participating in an APM also provides credit in the MIPS IA performance category.
MACRA created additional incentives for enrolling in certain qualified APMs that require participating entities to accept more financial risk, use CEHRT, and adjust payments based on quality measures equivalent to those in MIPS. CMS refers to these models, including the ACS-Brandeis model, as A-APMs.
For the 2017 performance year, the following models were available:
- Comprehensive End-Stage Renal Disease Care—Two-Sided Risk
- Comprehensive Primary Care Plus
- Next Generation Accountable Care Organizations
- Medicare Shared Savings Program Tracks 2 and 3
- Oncology Care Model—Two-Sided Risk
- Comprehensive Care for Joint Replacement Payment Model Track 1 with CEHRT requirements
For 2018, this list will likely grow to include a new Accountable Care Organization Track 1 Plus model, and additional models and opportunities to participate in other payor APMs will be added in the future. Go to the CMS website to learn about new opportunities to participate.
To assist Fellows in complying with the QPP, the ACS has created a variety of resources that explain the purpose and structure of the MIPS program and help to guide Fellows in choosing and achieving the goal that is right for their individual practice. Knowing what options are available is vital to navigating the reporting requirements, making an informed value judgment, and ultimately achieving the best possible financial outcomes.
The ACS has created a set of tools to facilitate Fellows’ understanding of MACRA and the QPP. These tools can be found on the ACS website.This site is reviewed and updated as new information becomes available. The College urges Fellows to use these resources and to contact the Division of Advocacy and Health Policy at qualityDC@facs.org with questions.
Additionally, Fellows can visit the CMS QPP website or contact the CMS QPP Service Center at QPP@cms.hhs.gov or 866-288-8292.
*Note that small practices will earn three points (as opposed to non-small practice providers who earn one point) for Quality measures that do not meet the data completeness criteria.