CMS Releases Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Proposed Rule

This evening, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule for the implementation of the MIPS Program and APMs, as required under the Medicare Access and CHIP Reauthorization Act (MACRA), signed into law last year to repeal and replace the flawed Sustainable Growth Rate (SGR). The proposed rule lays out CMS' proposals for how eligible clinicians will begin complying with the law beginning in 2017. This proposed rule incorporates some of the flexibility and reduced reporting burdens that ASCRS has been advocating over the past few years. 

MIPS-Merit-Based Incentive Payment Program

Payment adjustments will begin in 2019, based on 2017 performance. As required by MACRA, CMS proposes to streamline the current quality reporting programs--PQRS, the Value-Based Payment Modifier (VBPM), and EHR Meaningful Use--into one program and add a new category, clinical practice improvement activities (CPIA). CMS has also renamed the EHR Meaningful Use component to "Advancing Care Information."

In addition to combining the programs, CMS proposes to modify certain program requirements and provide relative weights for each component. Eligible clinicians' performance in each of the components is calculated into a composite score, which determines whether the eligible clinician receives a bonus payment, is held harmless, or is penalized.

Specifically, CMS proposes the following program modifications and weights for each of the four components:

  • Quality (50% of total score in year 1): Clinicians would choose to report a minimum of six measures, with at least one cross-cutting measure and an outcome measure, if available. If an outcome measure is not available, the provider would report one additional "high priority" measure.
  • Resource Use (10% of total score in year 1): The resource use category will include two of the three cost measures previously used in the VBPM program: total per cost capita for all attributed beneficiaries and Medicare spending per beneficiary. CMS proposes to maintain a similar two-step attribution method to the one currently used by the VBPM, and ASCRS will comment again on how this attribution method could hold providers responsible for the cost of services they did not provide. In addition, episode-based measures will also be used to evaluate resource use, as applicable. CMS proposed one episode, Lens and Cataract Procedures, that ASCRS has provided comments on previously and will do so as well in comments on this proposed rule. 
  • Advancing Care Information (25% of total score in year 1): For this category, providers must submit data for a full calendar year reporting period. This performance category would be comprised of a score for participation and reporting (base score) and a score for reporting at various levels above the base score (performance score). To meet the base score requirements, CMS proposes two base score alternatives, wherein providers would have to report on either six or eight objectives, with different measures included in each alternative. Under the performance score, a clinician has the potential to earn a performance score of up to 80% in the objectives and measures for patient electronic access, coordination of care through patient engagement, and health information exchange. 
  • Clinical Practice Improvement Activities (CPIAs) (15% of total score in year 1): CMS is proposing clinicians work toward achieving a total of 60 points by selecting a number of CPIAs. Clinicians may select activities from a list of more than 90 options, such as activities focused on care coordination, beneficiary engagement, and patient safety. There are medium-level activities worth 10 points, and high-level activities worth 20 points. CMS is proposing that a CPIA be performed for at least 90 days during the performance period.

APMs-Alternative Payment Models

Clinicians opting to participate in an APM and meeting certain thresholds, will be exempt from MIPS and will receive a 5% bonus payment for six years.

There are two types of APMs, Advanced APMs and Other Payer Advanced APMs. Advanced APMs include Accountable Care Organizations (ACOs), medical homes, and episode payment models. Other Payer APMs include payment arrangements under any payer other than traditional Medicare. Medicare Advantage and other Medicare-funded private plans are included as Other Payer APMs.  For year 1, clinicians participating in APMs must derive at least 25% of payment amounts or include 20% of patients from the APM to receive the bonus payment for qualified participation. The threshold for revenue percentages increases in the following years. CMS anticipates that many clinicians will participate to some extent in an APM, but not meet the law's requirements for sufficient participation in the most advanced models. The proposed rule contains proposals to provide financial rewards within MIPS, and proposes to allow clinicians to be able to switch between components of MIPS, based on what works for their practice and patients.

Additional information on the proposed rule is available in CMS's press release.

Information Available at the ASCRS•ASOA Symposium and Congress

Attendees at the 2016 ASCRS•ASOA Symposium and Congress in New Orleans, May 6-10, will have exclusive opportunities to gain detailed information about this proposed rule. ASCRS Government Relations experts will be conducting several sessions, leading ASOA roundtables, and providing one-on-one information at the ASCRS•ASOA Gateway Booth in the Exhibit Hall. Download the Government Relations Programming-at-a-Glance Guide to ensure you do not miss valuable opportunities to learn about the new proposed program and get your questions answered.

ASCRS will be submitting comments on this proposed rule and will provide additional information in upcoming editions of Washington Watch Weekly. If you need additional assistance, please contact Ashley McGlone, manager of regulatory affairs, at 703-591-2220.