Prior to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare payment used a fee-for-service system where clinicians were paid based on volume of services rather than value. To help control costs, the Sustainable Growth Rate (SGR) was established in 1997. MACRA replaces the SGR with a more predictable payment method that incentivizes value instead of volume, called the Quality Payment Program.
The Quality Payment Program consists of two tracks: Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). Most medical practitioners will be subject to MIPS.
MIPS streamlines three independent programs into a single program: Physician Quality Reporting Program (PQRS), Value-Based Payment Modifier (VM), and the Medicare Electronic Health Records (EHR) incentive program. It also adds an additional component to promote ongoing improvement and innovation of clinical activities.
MIPS has four major provisions: Eligibility, Performance Categories and Scoring, Data Submission, and Performance Period and Payment Adjustments.
Affected clinicians are called “MIPS eligible clinicians,” and will participate in MIPS. The types of Medicare Part B eligible clinicians affected by MIPS may expand in future years. In the first two years, Physicians (MD/DO and DMD/DDS), PAs, NPs, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists will be eligible. In later years, the eligible group may broaden to include Physical or Occupational Therapists, Speech-Language Pathologists, Audiologists, Nurse Midwives, Clinical Social Workers, Clinical Psychologists, Dieticians, Nutritional Professionals, and others. Eligible clinicians may participate as an individual or as a group defined by a taxpayer identification number.
MIPS does not apply to hospitals or facilities. Additionally, there are three groups of physicians who will not be subject to MIPS: First year of Medicare Part B participation, below low patient volume threshold, and certain participants in Advanced Alternative Payment Models.
A single MIPS composite performance score will factor in four weighted performance categories on a 0-100 point scale: Quality, Resource Use, Clinical Practice Improvement Activities, and Advancing Care Information. In year 1, Quality accounts for 50% of the MIPS score, Advancing Care Information for 25%, Clinical Practice Improvement Activities for 15%, and Cost for 10%. Clinicians will be able to choose certain measures on which they will be evaluated to ensure that the score is relevant to their medical practice. The weight of each category may change in the future.
Individuals and groups may submit MIPS data for Quality in the following ways: QCDR, Qualified Registry, EHR, and Administrative Claims. Individuals may also submit Claims, and groups may also use the CMS Web Interface (groups of 25+) or CAHPS for MIPS Survey. Individuals and groups may submit Resource Use information via Administrative Claims.
Individuals and groups may submit Advancing care information via Attestation, QCDR, Qualified Registry, or EHR vendor. Groups of 25 or more may use the CMS Web Interface.
Clinical Practice Improvement Activity information may be submitted by Attestation, QCDR, Qualified Registry, or EHR vendor for both individuals and groups. Individuals may also submit via Administrative Claims, and groups of 25 or more may use the CMS Web Interface.
All MIPS performance categories are aligned to a performance period of one full calendar year. The first MIPS performance period is 2017, with data submission in 2018, and payment adjustments and bonuses beginning in 2019.
A MIPS eligible clinician’s payment adjustment percentage is based on the relationship between their CPS and MIPS performance threshold. A CPS below the performance threshold will yield a negative payment adjustment, while a CPS above the performance threshold will yield a neutral or positive payment adjustment. Exceptional performers will receive additional positive adjustment factor.