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MACRA: Medicare’s Shift to
Value-based Delivery &
Payment Models
Shawn Martin
AAFP Senior Vice President
Advocacy, Practice Advancement, & Policy
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What Does MACRA Do?
• Consolidates quality programs
Merit-Based Incentive Payment System (MIPS)
• Potential for bonus payment for participation
Advanced Alternative Payment Models (AAPM)
4
5
2017/2018 QPP Participants
Physicians
(MD/DO)Physician
Assistant
Nurse
Practitioner
Clinical
Nurse
Specialist
Certified
Registered
Nurse
Anesthetist
MACRA defines eligible clinicians as:
MIPS Exemptions
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• Year 1 Medicare
• Eligible Advance Alternative Payment
Model with Bonus
• Below the Low Volume Threshold
• 2017: < $30,000 Medicare Part B
allowed charges; or cares for < 100
Medicare beneficiaries • 2018: < $90,000 Medicare Part B allowed
charges; or < 200 Medicare beneficiaries
Merit-Based Incentive Payment System
(MIPS)
MIPS Highlights
Consolidates existing quality and value programs
• Adds a category for Improvement Activities
Establishes a Final Score
• Weighted scoring by category
Provides opportunity for payment adjustments
• Both positive and negative
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MIPS Performance Categories
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Quality Cost Improvement
Activities
Advancing
Care
Information
(ACI)
Weighting by Category - 2017
Quality, 60%
Cost, 0%
Improvement Activities1, 15%
Advancing Care Information,
25%
1 - “Certified” PCMH receives
the full credit for IA; APM
Participants receive half credit
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Weighting Progression
**Proposed for 2018
Individual vs. Group
• If you choose to report as a group, all
performance categories must be reported as
a group
• Groups will be scored as a group and will
receive one MIPS score
• Groups must report the same measures for
all ECs
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Quality Measures
• Must report on measures
• May report more; only the highest scores will be used
to calculate the quality score
• Most measures need a 20 patient case minimum
• One must be an measure
– Controlling high blood pressure; A1C Poor Control
Cost Category Weight- 2017
Advancing Care Information
• ACI replaced Meaningful Use
• Must use certified EHR technology (CEHRT) to report for
the ACI performance category
• In 2017 and 2018, the CEHRT may be the 2014 edition,
2015 edition, or a combination of both (you might change)
• Physicians without an EHR are eligible to participate in
MIPS, but will not be able to receive any points in the ACI
category
Improvement Activities
There are 92 improvement activities available within the following overarching categories:
Expanded Practice Access
Population Management
Care Coordination
Beneficiary Engagement
Patient Safety and Practice Assessment
Achieving Health Equity
Emergency Response and Preparedness
Integrated Behavioral and Mental Health
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PCMH
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• Practices recognized or certified by:
NCQA, AAAHC, TJC, URAC; and
Accrediting bodies that have
certified 500 or more practices
– 2017: One member of the TIN
could have PCMH “recognition”
for 100% IA credit
– 2018: 50% of TIN members need
PCMH “recognition” for the TIN
to receive full IA credit**
Annual Performance Threshold
• Established by Secretary years 1 and 2
– For transition year 2017, threshold is 3
– Proposed for 2018, threshold increases to 15
• Below = negative payment adjustments
• Above = positive payment adjustments
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Adjust Payments
-4% -5% -7% -9%
4%
5%7%
9%
2019 2020 2021 2022 onward
*Adjustment to provider’s base rate of Medicare Part B payment
*Potential for
3Xadjustment
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Adjustment Summary
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Performance Score Payment Adjustment
Exceptional Performers
(Final Score over 70)=
Eligible for up to 10%
positive adjustment in
2019
25th Percentile or below =Maximum negative
adjustment
At threshold = Stable Payment
“Pick Your Pace” Reporting
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• Report one quality measure, one improvement activity, or all four of the required measures within the advancing care information (ACI) category
Test
• Report a minimum of 90 days for more than one quality measure, more than one improvement activity, or the measures within the ACI category.
Partial Participation
• Report to MIPS for a full 90-day period or full year
Full Participation
Advanced Alternative Payment Models
(AAPMs)
DefinitionsQualifying APM
• Based on existing payment models
Advanced APM
• Based on criteria of the payment model
Qualifying AAPM Participant
• Based on individual physician payment or patient volume
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Qualifying APMs
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• MSSP (Medicare Shares Savings
Program)
• Expanded under CMS Innovation
Center Model*
• Demonstration under Medicare
Healthcare Quality Demonstrations
(MHCQ) or Acute Care Episode
Demonstration
• “Demonstration required by Federal
Law”
Qualifying APMs
Advanced APM Eligibility
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• Quality measures comparable to MIPS
• Use of certified EHR technology
• More than nominal risk OR Medical Home model expanded under CMMI authority
Qualifying APMs
Advanced APMs
2017 Primary Care Advanced APMs
• Shared Savings Program (Tracks 2 & 3)
• Next Generation ACO Model
• Comprehensive Primary Care Plus (CPC+)
• Vermont Medicare ACO Initiative (as part of the
Vermont All-Payer ACO Model)
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Qualifying AAPM Participant
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• Percentage of patients or
payments thru eligible APM
• In 2019, the threshold is 25%
of Medicare payments or 20%
of beneficiaries
• QP status will be determined at
the group level
Qualifying APMs
Advanced APMs
Qualifying
AAPM
Participant
Additional Rewards for
Qualifying Participants
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• Not subject to MIPS
• 5% bonus 2019-2024
• Higher fee schedule update to 0.75% 2026
MACRA Timeline2017 2018 2019 2020 2021 2022-2024 2025 2026
Medicare Part B Baseline Payment Updates
+0.5% +0.5% +0.5% 0% 0% 0%+0.25%*
+0.75%**
*Non-qualifying APM Conversion Factor
**Qualifying APM Conversion Factor
Merit-Based Incentive Payment System (MIPS)
PQRS, Value-based
Modifier, & Meaningful UseQuality, Cost, Advancing Care Information, & Improvement Activities
-9% -9%? 0 or +/-4%*“Pick Your Pace”
+/-5% +/-7%
Qualifying AAPM Participant
5% Incentive payment
Excluded from MIPS
+0%
+/-9%
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What Can I Do Right Now?
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No Participation
TestPartial
ParticipationFull
Participation
‘Pick Your Pace’
Employed Physicians and Residents
• MIPS scores follow
you
• MIPS scores are
publicly available
• Consider a practices’
MIPS score as you
evaluate employment
contracts
*Check out the FPM Employed Physician Supplement
R. Shawn MartinSenior Vice President
Advocacy, Practice Advancement, & Policy
@rshawnm
