Q. What is MACRA and how is it related to MIPS, APMs?

A. Medicare Access and CHIP Reauthorization Act of 2015 or MACRA is the name of the legislation that Congress passed in 2015 making major changes to the physician payment reimbursement system in Medicare. Among other things, the law instructed CMS to create two new quality payment programs, MIPS and APM, to replace and synthesize existing programs, including parts of the EHR Incentive Program (i.e., Meaningful Use).
While referenced in the law, MIPS and APM are defined in the regulations by CMS. In October 2016, CMS released their Final Rule with comment providing details on MIPS and APM.

Q. What is APM?

A. APM and Advanced APM are programs where provider groups work together to more efficiently manage costs and provide more coordinated patient care. In doing so, they accept a great amount of risk in terms of potentially not being fully reimbursed for their costs in exchange for gaining additional money from Medicare through the care coordination efficiency. It is more of the model CMS wants providers and clinicians to move toward although initially most will be in the MIPS category.

Q. What is MIPS?

A. MIPS replaces a previous Medicare payment system (sustainable growth rate or SGR), and in doing so it consolidates some existing CMS programs under one program. The programs being consolidated include the Physicians Quality Reporting System (PQRS), the Physicians Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals. CMS is using MIPS to improve clinical care via payment adjustments based on the categories.

Q. Does MIPS replace Meaningful Use?

A. MIPS replaces Meaningful Use for providers only (hospitals are not impacted) and just for providers in their Medicare billing (Medicaid is not impacted). It is better to say that MIPS “absorbs” the Medicare aspect of the EHR Incentive Program into its program and uses it along with some other programs to create a single quality payment model.
In MIPS, CMS has renamed the Medicare EHR Incentive Program to Advancing Care Information.

Q. Can an eligible clinician participate in both MIPS and Medicaid EHR Incentive Program, and if so how do they report for both?

A. Yes that can be done assuming the clinician meets the necessary eligibility requirements to participate in both programs. However, they are two separate programs with separate reporting requirements. For example, Medicaid EHR Incentive Program has specific measure thresholds which must be met while the Advancing Care Information category does not. While there is similarity with the use of common measures and CEHRT, each program must be followed according to its own rules.

Q. When does MIPS begin?

A. The first MIPS Performance Period is scheduled for CY 2017. In CY 2018, the results of the Performance Period are to be submitted to CMS to factor into payment adjustments. In CY 2019, the payment adjustments from the CY 2017 Performance Period will be applied. CY 2019 would be considered the Payment Year of the CY 2017 Performance Period. This same 3-year cycle follows each year (e.g., CY 2020 payment adjustments based on CY 2018 Performance Period, etc.).

Q. How does MIPS do its payment adjustment?

A. MIPS use formulas from four different categories to create a single MIPS Composite Performance Score (CPS). This CPS of each clinician is compared with all other submitted MIPS CPS and ranked in a percentile grouping (e.g., 65%-74%, etc.). Based on the ranking, an adjustment of positive, neutral or negative will be assigned to Medicare payments for the given MIPS Payment Year.

Q. What are the four categories which make up the MIPS Composite Performance Score?

A. The four parts of the MIPS CPS (Composite Performance Score) are:

1. Quality
2. Cost
3. Improvement Activities
4. Advancing Care Information

Each category has its own method for achieving its score. The scores of each category are given an assigned weight and then added together to obtain the MIPS CPS.

Q. At a high level, what does each category focus on and record?

A. Key points to understand these categories at a high level are:

1. Quality
   • Quality measures clinical performance across a wide spectrum of specialties and activities.
   • Quality measures are reported through different means, including eCQMs from EHRs as well as Medicare Part B Claims, qualified registries, and CMS web interfaces.
   • Unlike PQRS, which was pay-for-reporting (i.e., just had to turn something in regardless of results), MIPS compares eligible clinicians against benchmarks for scoring.
2. Cost
   • Examines total per capita cost for patients, the Medicare Spending per Beneficiary (MSPB) measure, and episode-based measures.
   It takes into account and makes necessary adjustments for geographic payment rate and beneficiary risk factors.
   • Cost is reported through Medicare claims submission.
3. Improvement Activities
   • Focuses on creating patient-centered approach for improving health care.
   • Improvement Activities are activities that eligible clinicians would implement to improve their clinical practice or care delivery.
     • Examples would be utilizing CEHRT and health IT to create 24/7 care team access to emergency requests from patients or that participate in research projects for identifying new processes for engaging minority patients in health care.
4. Advancing Care Information
   • Similar to Meaningful Use, eligible clinicians use certified EHR technology to perform various activities that are measured.
   • Allows for flexible scoring on measures rather than all or nothing. Utilizes Base Measures and Performance Measures.
   • Bonus points are achieved through public health reporting as well as utilizing CEHRT in meeting some Improvement Activities measures.

Q. What is the minimum reporting period for the activities for each category to quality?

A. In general, it is as follows…

There are some caveats. For eligible clinician groups to utilize the CMS Web Interface for quality reporting, or to report the CAHPS for MIPS survey, these submission mechanisms utilize certain assignment and sampling methodologies that are based on a 12-month period. Also, administrative claims-based measures are based on 12-month performance periods. There are also a few special (but not common) circumstances where an eligible clinician can submit data for a period less than 90 days and avoid a negative payment adjustment.

Also, the performance categories can utilize different 90-day periods. For example, March 1, 2017 through May 30, 2017 for quality reporting, and May 15, 2017 through August 13, 2017 for advancing care information.

Q. Where can we find the list of CQMs (Clinical Quality Measures) for MIPS?

A. The list of measures is in the appendix of the MIPS/APM Final Rule. They are broken down by individual listing as well as grouped by specialty. There are over 270 different measures. Some eMeasures can be supported by an EHR and tested using Cypress, but others utilize claim data or qualified registries.

Q. How many measures must be reported?

A. At least six measures including at least one outcome measure. If an applicable outcome measure is not available, report one other high priority measure (appropriate use, patient safety, efficiency, patient experience, and care coordination measures). If fewer than six measures apply to the MIPS eligible clinician or group, report on each measure that is applicable.

Q. Are there any requirements for Cost category affecting EHR developers?

A. Aside from billing related functionality, the Cost category does impact EHR functionality and is generally outside the scope. There are certainly no impacts to the ONC certification program because of this category.

Q. Are there any certification requirements for Improvement Activities?

A. No, not in themselves. Improvement Activities do not explicitly require certification criteria. However, MIPS allows for bonus point scoring in the Advancing Care Information category if the eligible clinician utilizes their CEHRT in achieving one of the Improvement Activities identified as viable for using CEHRT.

Q. How will the results of the Improvement Activities be reported?

A. The data submission mechanisms will be attestation, QCDR, qualified registry, or EHR for flexibility. Per CMS, they will provide technical assistance through sub regulatory guidance to further explain how MIPS eligible clinicians will report on activities within the improvement activities performance category. In that regard, it would be similar to ONC test procedures for criteria which are created after the ruling is made.

Q. Does Advancing Care Information (ACI) require certification and if so what?

A. Yes, ACI requires Certified EHR Technology (CEHRT) just like the EHR Incentive Program did. In fact, its definition is the same and can be best expressed as: Base EHR criteria + Any CMS-specific required criteria + Criteria associated with measure

Base EHR criteria include criteria like CPOE and Demographics; the full list is found in the ONC 2015 Edition Final Rule. CMS-specific required criteria include criteria such as family health history and others CMS deem important for their program, although the exact criteria depend on the CY. Criteria associated with measures include ePrescribing (315.b.3) if the clinician is submitting the ePrescribing measure.

In CY 2017, the CEHRT can be either 2014 Edition Certified, 2015 Edition Certified, or a combination of both. For CY 2018 and beyond, only 2015 Edition CEHRT can be used. In general, MIPS follows basically the same criteria requirements that would have been needed for Meaningful use Modified Stage 2 or Meaningful Use Stage 3.

Q. How is Advancing Care Information similar and different than the EHR Incentive Program (MU)?

A. At a high level, similarities and differences can be explained on a few key points.

They are similar in that:

• Both use measures involving use of CEHRT to determine success.
• Both require certified EHR technology.
• The measures used are basically the same. MIPS does not introduce any new measures.

They are different in that:

• Missing a threshold on a single measure means the EP “fails” MU. ACI allows for a range of different scores based on different results.
• The MU measures are all equal. There is no longer any core or menu but all measures must be equally met. However, ACI introduces the idea of Base Score and Performance Score for different measures and greater flexibility.

Q. Which criteria are required for MIPS?

A. Essentially the same criteria as for Modified Stage 2 or Stage 3. The CEHRT definition in MIPS is almost identical to the one in the MU 2015-2017/Stage 3 Final Rule.

Q. Which MU measures are used for MIPS?

A. Basically the same. Measures reported for Meaningful Use Modified Stage 2 or Stage 3 are the measures you see in MIPS. One difference is there are fewer exclusions in MIPS than in the Meaningful Use program. Security Risk Analysis, e-Prescribing, Provide Patient Access, Patient-Specific Education, View, Download, or Transmit, Secure Messaging, Patient-Generated Health Data, Send a Summary of Care, Request/Accept Summary of Care, Clinical Information Reconciliation, and several Public Health measures.

Q. How is the Advancing Care Information category score calculated?

A. In Meaningful Use, the EP had several measures to meet. Some were yes/no, and others numerator/denominator with a specific threshold to meet. If the EP answered “no” to any measure or did not meet the required threshold for any measure, the EP did not qualify for Meaningful Use. It was all or nothing.

Advancing Care Information scoring allows for “partial credit”. The Advancing Care Information Performance Category Score is basically made up of two parts: Base Score and Performance Score Measure Components. Base Score is either 50% of the total, and it can be achieved by: 1.) completing a Security Risk Analysis measure (marking Yes to that measure), reporting at least 1 in the numerator of all the numerator/denominator values of the other Base Score Measures. For example in CY 2018, these other Base Score Measures are e-Prescribing, Provide Patient Access, Send a Summary of Care, and Request/Accept Summary of Care; 2). reporting at least 1 in the numerator of all the numerator/denominator values of the other Base Score Measures

The Performance Score Measure Components are the measures associated Patient Electronic Access, Coordination of Care, and Health Information Exchange. These results are added together for the Performance Category Score, and then they are added to the Base Score for the final result.

There are also ways to get some extra points through additional public health measures and utilizing CEHRT in achieving Improvement Activities as well.

Q. For CY 2017, is there any disadvantage to having only 2014 Edition Certification in terms of not being able to achieve same amount of ACI points?

A. No, there really is not. CMS considers CY 2017 a transition year because of not only starting MIPS, but also because 2014 Edition and 2015 Edition certification are both permissible. To that end, they developed a special scoring methodology for eligible clinicians using CEHRT based on 2014 Edition Health IT. It is very similar to the CY 2018 version which relies only on 2015 Edition, but it still allows plenty of measures to be included to allow eligible clinicians to achieve the maximum score in the ACI category.

Q: Since Advancing Care Information objectives are separate from Stage 3 objectives, who is expected to report using Stage 3 objectives?

A. Hospitals still need to report in Stage 3 and so will providers who are in the Medicaid program. MIPS only replaces Medicare MU for providers.