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Perhaps the most challenging part of understanding healthcare legislation is knowing what all of the acronyms mean.

To ease some of the confusion, we have put together a short glossary of terms and a reference guide to the most recent regulatory alphabet soup.

MACRA – Medicare Access and CHIP Reauthorization Act

This legislation for healthcare quality evaluation and pay-for-performance was passed in 2015.  The Centers for Medicare and Medicaid Services (CMS) released the Proposed Rule describing how the legislation would be implemented in the spring of 2016.  The rules will be finalized by the fall of 2016.  The Proposed Rule would implement the changes required by MACRA through a new system called the Quality Payment Program (QPP). The performance period for the QPP will begin on January 1, 2017 with payments and penalties taking effect in 2019.

QPP – Quality Payment Program

The goal of the QPP is to provide financial rewards for eligible clinicians who provide high-quality care with efficient resource utilization and engagement in quality improvement activities.

The QPP includes two provider reimbursement programs, the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).  Most Medicare clinicians will initially participate in the Quality Payment Program through the MIPS.

Through the MIPS Program, CMS aims to create a quality reporting system that is more flexible than the PQRS, VBM, and MU programs, while at the same time reducing the complexity and burden of reporting requirements on clinicians.

MIPS – Merit-Based Incentive Payment System

MIPS combines the Physician Quality Reporting System (PQRS), Value-based Modifier (VBM), and the EHR Incentive Program (Meaningful Use) into a single program. A fourth component, Clinical Practice Improvement Activities (CPIA), will be added to promote ongoing improvement and innovation in clinical practice

Performance scores in these four categories will be used to calculate a single Composite Performance Score (CPS) on a 0-100 point scale. The CPS will be used by CMS to determine whether a provider will receive an upward, neutral, or downward payment adjustment to their Medicare Part B payments.

MIPS Eligible Clinicians

These individuals were referred to in PQRS and VBM as Eligible Professionals (EPs), but under MIPS these providers will be referred to as MIPS Eligible Clinicians (ECs). Eligible Clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. There is a new category of providers called “non-patient facing” clinicians.  Clinicians who bill for 25 or fewer patient facing encounters, such as office visits, outpatient visits, and surgical procedures, will be designated as non-patient-facing clinicians.  MACRA allows for special consideration to be given to these clinicians under the MIPS.

APM — Alternative Payment Model

The second payment pathway under the QPP umbrella rewards clinicians for participation in Alternative Payment Model (APM) programs in which a significant portion of their care is reimbursed based on quality and costs and where they have a significant risk of financial loss. Most clinicians do not participate in APMs and will fall under the MIPS for QPP participation.

MIPS Performance Categories:

Quality

Performance on quality metrics will account for 50% of the total composite MIPS score in reporting year one (2017) of the program.  This will be similar to existing PQRS reporting but with a few key changes, primarily aimed at reducing the minimum number of measures that must be reported, while significantly increasing the reporting rate threshold. More information on specific changes and reporting requirement can be found via CMS.

Cost

Cost metrics will compose 10% of the MIPS score in 2017.  It will be similar to the Cost Composite Score utilized by CMS under the VBM program and will be based primarily on two metrics: total per capita costs for all attributed Medicare beneficiaries and Medicare Spending per Beneficiary (MSPB). Administrative claims data will be used for assessing performance in the cost category, relieving clinicians of the need to submit additional data.

Advancing Care Information (ACI)

This category will account for 25% of the total score in 2017.  It replaces the EHR Incentive Program (Meaningful Use) and focuses on the use of technology for information exchange and the use of electronic health records to improve the quality of care.  Rather than the all-or-nothing approach employed by the Meaningful Use program, ACI will allow physicians to receive 50% credit for reporting measures (the base score) and 50% for performance on these measures.  ACI will also decrease the number of measures and simplify the reporting requirements.

Clinical Practice Improvement Activities (CPIA)

The CPIA category will count for 15% of the MIPS score and is designed to reward provider groups for practice improvement activities focused on care coordination, expanded practice access, patient engagement, and safety initiatives. A clinician’s score in this category will be determined by weighing the activities on which he or she reports.  Highly weighted CPIAs would be worth more points toward the overall CPIA score than lower weighted activities. Failure to perform and report CPIAs will result in a zero score in this category, while failure to report the indicated number of activities will result in a partial score. This partial score will be included in the overall MIPS composite score.

In the next blog post, we will look at a broader overview of the impact of the MIPS changes.