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MACRA and MIPS

On October 14, 2016, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA was officially signed into law on April 16, 2015 in order to make significant adjustments to how Medicare pays for physician services. Importantly for our purposes at Managing eLearning, these changes directly tie reimbursement to performance, and even to participation in performance improvement activities—that is, learning.

Some of the major changes to occur are:

  • Shifting from rewarding healthcare providers by volume-based performance to value-based performance
  • Stopping the use of the Sustainable Growth Rate (SGR) formula (what was used to determine Medicare payments for healthcare providers)
  • Combining existing quality reporting programs into one new system
    • Meaningful Use
    • Physician Quality Reporting System
    • Value-Based Payment Modifier

The Quality Payment Program is the result of these changes created by the Centers for Medicare & Medicaid Services. The program can be broken down into two different tracks: Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). MIPS will combine the existing quality reporting programs, whereas APMs will cover physicians who receive a “significant share” of their revenue through APMs.   The goal of MIPS will be to reduce the level of financial penalties physicians could have faced, and also to provide a greater potential for bonus payments.

Payment adjustments under MIPS will be based on performance. The composite performance score (CPS) will be made up of four measurements: Quality, Advancing Care Information, Improvement Activities, and Cost. These categories were created to consolidate existing quality reporting programs and create one merit-based formula. The CMS will create a cumulative score by weighing the four performance categories, and then determine a reimbursement amount for physicians. The following weights have been applied to the performance categories:

MACRA and MIPS

 

The old quality reporting programs’ replacements are shown below:

  • Quality – Replaces current Physician Quality Reporting System (PQRS) program
  • Advancing Care Information – Replaces Meaningful Use (MU) program
  • Clinical Practice Improvement Activities – New category
  • Cost– Replaces current Value-Based Modifier (VBM) program

Cost will not require data submission from physicians. CMS will calculate it from adjudicated claims.

Education & MIPS

Education and Performance Improvement will play a large role under MIPS. Physicians looking to qualify for a positive payment adjustment (i.e, bonus pay) under MIPS will need to participate in performance improvement (PI) activities. A proposed rules list defines what will qualify as a Clinical Practice Improvement Activity (CPIA). More information on reporting under MIPS can be found on the American Medical Association’s Medicare Payment Reform page.

A comprehensive list of what is defined as a CPIA can be found at the Centers for Medicare & Medicaid Services’ Quality Payment Program website. A few examples of improvement activities:

  • Expanded practice access
  • Population management (Learn more about Population Health and management in our two part blog series. Part I – Intro to Population Health, Part II – Population Health and CME)
  • Care coordination
  • Patient engagement (care plans, shared decision making)
  • Patient safety and practice assessments (checklists, MOC)

In order to track and report on CPIAs, we suggest an innovative learning technology such as a performance improvement platform.  A performance improvement platform will enhance the tracking of physician activity and suggest learning activities for improvement.  Over time, the PI activities suggested will ideally be incorporated into the physician’s practice and increase their Quality CPS measurement.

Association Managers & MIPS

Managers of associations can leverage MACRA & MIPS by providing CPIAs, which members can participate in, potentially qualifying for payment adjustments.  In the case of Clinical Practice Improvement Activities, medical association managers should explore LMSes that offer performance improvement capabilities. Not only will a PI platform and LMS track and report activities for MIPS, but it will provide valuable feedback for physicians seeking to make meaningful improvements in quality of care. A beneficial PI platform should be able to provide statistical evidence that PI activities are making an impact on quality of care. Performance Improvement measures can be linked to the physician’s improvement in the quality of their practice. Performance Improvement platforms can be utilized to improve physician’s patient outcomes, and in turn, achieve better results under the Quality component of MIPS. If a physician performs well in both the Quality and Clinical Practice Improvement categories, they will receive larger reimbursements from Medicare. By providing both reporting for PI activities and improvement in quality of patient care and outcomes, medical associations can provide more value to their members.


We are excited to learn more on Quality and Performance Improvement initiatives in healthcare at IHI’s upcoming Annual National Conference! Come see us at booth 101.

IHI Annual National Forum