MACRA for Busy Docs: 12 Things to Know

Leigh Page


September 07, 2016

In This Article

What Will Physicians Have to Do?

3. Most Physicians Will Be in MIPS

MIPS requires you to report activities and results in four categories, and each category makes up a percentage of your total score. That score is what determines your payment from Medicare.

Quality performance (50% of your score). This category, which replaces PQRS, starts off as the biggest one in MIPS. It's worth 50% of the MIPS score in 2019, although its share will be reduced to 30% by 2021.

Clinicians must report six quality measures—down from nine in PQRS. The measures include a "cross-cutting" one that is the same for virtually all eligible clinicians, and one outcome measure that is applicable to most clinicians. Clinicians will pick measures from a list that has not been finalized yet.

Advancing care information (ACI) (25% of your score). This is the continuation of MU, and it's worth 25% of your MIPS score. There are still many details that have to be worked out on ACI in the final rule, but in general, it would present a wider array of reporting options than under MU.

ACI is broken down into base measurements and optional measurements. ACI will allow more flexibility than MU on what activities clinicians can report, but it also raises the bar. The new category replaces pass/fail scores under MU with graduated scoring, which means that it will be harder for average performers to get a good score.

Clinical practice improvement (15% of your score). This is the new MIPS category, worth 15% of the total score. The idea is to encourage physicians to adopt such activities as same-day appointments, timely communication of test results, and establishing care plans for patients.

Resource use (10% of your score). Replacing the current value-based payment modifier program, this MIPS category measures cost savings from prudent use of resources. To do well, you've got to reach out to patients and make sure they're not overusing services. This category's share of the MIPS score starts at 10% and grows to 30% by 2021 and beyond. This category doesn't require any reporting; CMS collects the information from Medicare claims data.

4. Advanced APMs Will Be Out of Reach for Most Physicians

The ultimate goal of MACRA is to entice clinicians to get into advanced APMs, where CMS will not need to supervise them as closely as MIPS physicians, because their organizations have assumed financial risk and will presumably manage cost like payers do.

When physicians in APMs assume financial risk, they agree to absorb any losses if the cost of treating patients exceeds an agreed-upon benchmark. But if the cost falls below the benchmark, participants will be able to keep part of the savings.

This arrangement can be very risky if you don't have an infrastructure in place, including use of electronic medical records, generation of performance data, and staff who are coordinating care. Many APMs, such as track 1 ACOs, do not assume sufficient financial risk, so they won't be considered advanced APMs. This means that the vast majority of physicians in ACOs will not be in the advanced pathway. Their ACOs would have to move to a more advanced risk-bearing track to qualify.

Besides the risk-bearing ACOs, the initial list of advanced APMs is paltry. It covers just three other models: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus (CPC+), and the Oncology Care Model.

In CMS-speak, ECs who join advanced APMs will are "qualified providers" (QPs). To incentivize them, CMS will give them a yearly bonus equivalent to 5% of their Medicare Part B revenue beginning in 2019.

But even this ennobled group in the CMS firmament won't be allowed to rest on their laurels. QPs are required to have a certain amount of volume in the advanced APM—initially, at least 25% of Medicare payments and 20% of patients—and that proportion rises starting in 2021. Meeting the higher levels will be easier than you might think. Also starting in 2021, QPs' patient volume in advanced APMs run by private payers will also be counted.


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