MACRA, MIPS, and APMs — Are You Ready?

PearlJuly 06, 2016Healthcare ReformPayersPearlsPhysician CompensationPhysician Compensation Survey

Originally published at:

With the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS has proposed a Quality Measure Development Plan that will combine all of the existing quality reporting programs into one new system. To report quality measures, providers will participate in either the Merit-Based Incentive Payment System (MIPS) and/or Alternative Payment Models (APMs).

First, do you qualify?

If you have $10,000 or less in Medicare chargesand 100 or fewer Medicare patients annually, then you are exempt from MIPS participation. Otherwise, you need to participate in a MIPS or APM model.


CMS anticipates most small practices will participate in MIPS. MIPS adjustments are budget neutral, and a scaling factor will be applied based on quality and cost measures to make total upward and downward adjustments equal. If you participate in MIPS, you will need to monitor the various components that are being combined to maximize your potential incentives:

1. Continue to attest for Meaningful Use

If you are already participating, continue to do so to take advantage of incentives and to avoid payment adjustment in 2018 (Medicare adjustments are made looking back 2 years). By 2017, the Medicare Meaningful Use Incentive program will transition into the Advancing Care Information (ACI) component of MIPS.

2. The Advancing Care Information (ACI) component will change several things about Meaningful Use measures:

• Meaningful Use will no longer be a standalone program. ACI will account for 25 percent of your MIPS score (100 points), the total of which will determine payment adjustments (maximum downward adjustment for Year 1 would be negative 4 percent, and the maximum upward adjustment is 12 percent).

• The “all or nothing” approach to Meaningful Use incentives has been abandoned in favor of scaling performance under ACI, so providers don’t need to meet all of the goals. The scoring is split up into two categories: “Participating” and “Performance.”

• Participating providers will receive 50 points of the total possible 100-point ACI category score. But to “participate,” providers need to complete a security risk analysis, be in active engagement with an immunization registry (or qualify for an exclusion), and report a numerator (of at least one) and denominator for all remaining measures. If these baseline measures aren’t provided, then the provider isn’t participating and no points will be awarded.

• The performance score consists of additional points awarded for certain objectives (maximum of 50 points). CMS focuses the performance score on the Stage 3 Patient Electronic Access, Coordination of Care through Patient Engagement, and Health Information Exchange objectives. Here providers can report on the measures in which they perform best.

• Removes the “Clinical Decision Support” and the “Computerized Provider Order” measures since these are consistently above 90 percent and therefore considered widely adopted. It also reduces the number of measures to an all-time low of 11 measures, down from 18 measures, and no longer requires reporting on the “Entry” measure.

• Simplifies reporting requirements for “Health Information Exchange” and “Public Health and Clinical Data Registry” reporting measures to a simple yes/no attestation.

• Eliminates the 90-day reporting period for first-time attestations, instead requiring a full calendar year reporting period for all stages and all providers.

3. Continue to participate in PQRS

This makes you subject to the Value-Based Modifier. Review your practice’s Quality and Resource Use Reports (QRURs) for the 2014 period as well as the first part of 2015. Your QRUR will show you how you are being rated on both cost and quality and where you may need to make adjustments.

4. Monitor your profile on the Physician Compare site

Physician Compare is based on your QRUR data. This information is made readily available to the public as a means for consumers to select providers who meet and exceed CMS’ quality measures. See how you are currently performing and adjust as necessary to optimize your score.

If you are not already participating in a patient clinical data registry, contact your specialty society about participating in theirs, as data registries can streamline reporting and assist with MIPS performance scoring.


If you practice chooses to participate in an Alternative Payment Model (APM) rather than MIPS, here are two key points to consider:

1. Transitioning to a new payment entity

In addition to MIPS, MACRA has created new opportunities for physicians to develop and participate in alternative payment models, or APMs.

If you participate in an Accountable Care Organization (ACO), Clinically Integrated Network (CIN), or other entity that applies and qualifies as an APM, contact your entity’s administrators to ascertain what plans are being made to meet the new model. Even though quality measures and criteria are still being defined by CMS, most organizations are already planning a clear direction.

2. Lump-sum incentive payments

One of the advantages to participating in an APM is that qualifying participants will not be subject to MIPS adjustments and will receive a lump-sum incentive payment equal to 5 percent of the prior year’s estimated aggregate expenditures under the fee schedule. The 5 percent incentive payment is available from 2019 to 2024, but beginning in 2026, the fee schedule growth rate will be higher for qualifying APM participants than for other practitioners. Should you participate in a qualified APM at levels below the MACRA thresholds, don’t worry; it allows physicians to improve their MIPS scores.


Whether you are anticipating participating in an APM or a MIPS model, all providers should review and comment on the proposed Quality Measure Development Plan, and check out the related informational resources provided by CMS. In addition, the American Medical Association has an excellent resource available that provides more detailed information on both programs under MACRA, along with a preparation checklist.