2 Payment Systems Options
- Merit-based Incentive Payment System MIPS
- Advanced Alternative Payment Models (APMs)
First Performance Period Reporting Options
In order to ensure the implementation of the Quality Payment Program is successful for as many physicians and other Medicare providers as possible, CMS has created 4 reporting options for the first performance period. Choosing one of these options will ensure that physicians do not receive penalties during the first payment period.
Option 1: Physicians can submit some data to the Quality Payment Program, even if it is after January 1, 2017, in order to avoid negative payment adjustments in MIPS.
Option 2: Physicians can choose to submit data for a reduced number of days, rather than the full year. Physicians who select this option may receive a small positive payment adjustment.
Option 3: For practices that are ready to go on January 1, 2017, physicians can opt to submit data for the entire year-long performance period. Physicians who select this option may receive a modest positive payment adjustment.
Option 4: Instead of reporting through MIPS, physicians can participate in an Advanced APM. If they see enough Medicare patients or receive enough Medicare payments through the Advanced APM during the performance period, they can receive a 5 percent bonus.
MIPS payments are tied to reporting and performance
Ob-gyns who see a low volume of Medicare patients are exempt from MIPS.
*Negotiations are underway to determine this low-volume threshold, which will take into account both the number of Medicare Part B patients an ob-gyn sees and the amount of Medicare charges during the performance period.
Ob-gyns who are new to Medicare and do not have a full year of claims history are also exempt.
Physicians who participate in an Advanced APM
ACOG estimates that up to 50 percent of ob-gyns will meet the low-volume threshold and will be exempt from MIPS. CMS estimates that 60% of ob-gyns may not be subject to MIPS.
Less Red Tape
MIPS combines three existing Medicare reporting programs -- the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM) program, and the Medicare Electronic Health Record (EHR) Incentive (meaningful use) program -- into one single program.
MIPS requires reporting on four categories:
- Resource use
- Advancing care information (meaningful use), and
- Clinical practice improvement activities, a new category.
- You may be able to report through claims, registries, Qualified Clinical Data Registries, health information technology developers, and certified survey vendors.
Payment Incentives for High Performing Physicians
- Beginning January 2019, individual ob-gyns will see their Medicare payments increased or reduced on a sliding scale basis based on their reporting and performance.
- Ob-gyns can choose to report as an individual or as a group.
- You can also report on care delivered to non-Medicare patients, although the payment adjustments will only apply to your Part B payments.
- Under the law, MIPS payment adjustments must be budget neutral. In the first year, depending on the variation of MIPS scores, adjustments are calculated so that negative adjustments can be no more than 4 percent, and positive adjustments are generally up to 4 percent.
- To reward high performers and incentivize others toward performance improvements, the positive adjustments can be scaled up to 3 times the positive adjustment – 12% -- to achieve budget neutrality.
- Positive and negative adjustments will increase to +/- 9 percent by 2022, with a potential 27 percent upward adjustment to Part B payments.
- There is no scaling factor for negative adjustments, cuts are capped.
2019 – 2024: $500 million in additional performance bonus dollars –-- for exceptional performers, not subject to budget neutrality.
Performance Reporting Categories
This category will account for 50 percent of a physician’s MIPS score in the first payment year, 2019.
You’ll choose 6 quality measures that best match your practice.
You’ll choose one cross-cutting measure and one outcomes measure (if available) or another high-priority quality measure. High-priority quality measures relate to patient outcomes, appropriate use, patient safety, efficiency, patient experience, or care coordination. In addition, for individual physicians and small groups (2-9 clinicians), CMS calculates two population measures for acute and chronic conditions based on claims data. For groups with 10 clinicians or more, CMS calculates three population measures – the composite measures and all-cause hospital readmission. This means there are no additional reporting requirements for physicians for population measures.
Access the list of quality measures that CMS proposes ob-gyns can report.
Access an additional list of measures that may be appropriate for ob-gyns to report.
2. Advancing Care Information (EHR Meaningful Use)
This category will account for 25 percent of your MIPS score in the first year.
Using a certified EHR technology, you’ll report a set of measures that reflects how you use EHR technology in your practice, with an emphasis on interoperability, information exchange, and patient privacy. Your overall Advancing Care Information score will be made up of a base score and a performance score for a maximum score of 100 points.
The base score accounts for 50 points of the total Advancing Care Information category score. To receive the base score, you’ll provide the numerator/denominator or yes/no for each objective and measure. *CMS is proposing these 6 objectives and associated measures.
Protect patient health information - THIS IS REQUIRED
Patient electronic access
Coordination of care through patient engagement[BL2] , such as secure messaging to patients
Health information exchange
Public health and clinical data registry reporting, specifically immunization registry reporting
The performance score accounts for up to 80 points towards the total Advancing Care Information category score (Even if your total ACI score exceeds 100 points, you won’t receive more than the maximum 25 points towards your MIPS score). You’ll be asked to select the measures that best fit your practice from the following:
Patient electronic access
Coordination of care through patient engagement
Health information exchange
If you choose to report on more than one public health registry, you’ll receive one bonus point for reporting beyond the immunization registry category.
Your base score, performance score, and bonus point (if applicable) are added together for a total of up to 131 points. Ob-gyns earning 100 points or more will receive the full 25 points in the Advancing Care Information category. If you earn fewer than 100 points, your overall performance category score declines proportionately.
3. Resource Use
This category accounts for 10 percent of your MIPS score in the first year, and uses over 40 episode-specific measures to account for differences among specialties.
Your score will be automatically calculated based on your Medicare claims; you don’t have any reporting or other requirements to receive your score.
Each measure will be worth up to 10 points. You’ll need to see a sufficient number of patients in each cost measure to be scored, generally a minimum of a 20-patient sample. Your performance category score will be based on the average score of all the cost measures attributed to you.
4. Clinical Practical Improvement Activities
The clinical practice improvement activities category accounts for 15 percent of the MIPS score in the first year.
Physicians will be rewarded for implementing practice activities that focus on care coordination, beneficiary engagement, and patient safety. You’ll have more than 90 options from which to choose under the following categories:
Expanded practice access
Achieving health equity
Patient safety and practice assessment
Emergency preparedness and response
Participation in an APM, including a medical home model
Integrated behavioral and mental health
The full list of improvement activities that CMS has proposed.The maximum total points in this category will be 60 points.
*CMS proposes weighting the activities in this category. Highly weighted activities – those that support the patient-centered medical home, as well as activities that support the transformation of clinical practice or a public health priority -- would be worth 20 points. Other activities would be worth 10 points.
You can also receive credit in this category for participating in Alternative Payment Models and Patient-Centered Medical Homes (PCMH). Physicians participating in an accredited PCMH will get full credit under this category and do not have to report on any other activities.
Physicians who participate in Advanced APMs are exempt from MIPS reporting requirements.
Physicians practicing within a qualifying APM will receive a 5% bonus between 2019 and 2024. For 2026 and beyond, clinicians will receive a 0.75% increase in the Physician Fee Schedule.
You can choose to participate in several different APMs, including Accountable Care Organizations and demonstrations under the Medicare Health Care Quality Demonstration Program.
Advanced APMs must meet a number of additional requirements:
Physicians accept financial risk for providing coordinated, high-quality care. CMS may withhold payments, reduce rates, or require the APM to pay CMS back if the APM’s actual expenditures exceed expected expenditures. The amount of risk must meet these requirements:
The maximum amount of losses possible under the Advanced APM must be at least 4 percent of the APM spending target
Marginal risk -- the percent of spending above the APM benchmark (or target price for bundles) for which the Advanced APM is responsible -- must be at least 30 percent.
Minimum loss rate – the amount by which spending can exceed the APM benchmark (or bundle target price) before the Advanced APM Entity has responsibility for losses -- must be no greater than 4 percent.
Payments must be based on quality measures that are evidence-based, reliable, and valid; and must include an outcome measure on the MIPS list, if applicable.
At least 50% of the Advanced APM participants must use certified EHR technology (CEHRT) to document and communicate clinical care information in the first performance year. This requirement increases to 75 percent in the second performance year.
Medical home models developed under the CMS Innovation Center authority qualify as Advanced APMs regardless of whether they meet the financial risk criteria. These medical homes must focus on primary care and accountability for empaneled patients across the continuum of care. Because medical homes tend to have less experience with financial risk than larger organizations and limited capability to sustain substantial losses, CMS proposes unique Advanced APM financial risk standards to accommodate medical homes that are part of organizations with 50 or fewer clinicians.
Currently, there are several existing models that CMS believes meet the definitions of Advanced APMs regardless of whether these models achieve savings or perform well:
• Comprehensive Primary Care Plus
• Medicare Shared Savings Program – Track 2 and Track 3
• Next Generation ACO Model
• Oncology Care Model with 2-sided Risk (available in 2018)
• ModelComprehensive Care for Joint Replacement
• Cardiac Episode Payment Model
To qualify for bonus payments, you’ll need to receive a minimum amount of payments or see enough patients through the Advanced APM. You can choose to be assessed as a group to increase your chance of meeting these minimum requirements.
In 2019 and 2020, the participation requirements for Advanced APMs are only for Medicare payments or patients. Starting in 2021, the participation requirements for Advanced APMs may include non-Medicare payers and patients, including those with Medicare Advantage plans.