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Get to Know MACRA, MIPS and APM

Nancy Swikert, MD
President, KMA

Do you know what MACRA, MIPS and APM mean? If you don’t, you may be in serious trouble with the financial aspect of your medical practice.

The AMA website has lots of information for those of you who are AMA members. The Specialty Societies also have lots of information on their websites.

Most of you know that after 17 years lobbying Congress, the SGR was repealed. Whereas SGR dealt with yearly practice cuts, MACRA (Medicare Access and CHIP Reauthorization Act) hopefully will bring some positives to practices if followed closely. MACRA is a transition from the fee-for-service payment utilized today to different systems paying on value-based care.

All these coming changes can get pretty complicated with new abbreviations for terms that are new to all of us. So, let’s start with some definitions of terms:

  • MIPS – Merit-based Incentive Payment System – definition to follow
  • APM – Alternative Payment Method – definition to follow
  • EP – eligible professionals
  • EHR – electronic health record,
  • QCDR – qualified clinical data registry – collects medical/clinical data of patient/disease tracking to foster improvement in quality of care
  • CPIA – Clinical Practice Improvement Activities – activity to improve clinical care delivery and the Health and Human Secretary determines will likely result in improved outcomes
  • MU – meaningful use
  • Quality Reporting System (old PQRS) – now six quality measures required
  • Resource use category (old VBM) – differential payment to docs based on quality of care furnished compared to cost of care

There are two basic payment types under MACRA, MIPS and APM. About 92 percent of physicians will initially get paid under MACRA using the modified fee-for-service payment called the Merit-based Incentive Payment System (MIPS). The remaining 8 percent will probably use an alternative payment model (APM) specifically approved by CMS.

Where to Start?

  • First, if your medical practice sees less than 100 Medicare patients annually or charges less than $30,000 in Medicare charges annually, your medical practice is EXEMPT from MIPS participation.
  • Secondly, check with your patient clinical data registry to see if you are participating. If you are not in a clinical data registry, contact your specialty society to see if you can join theirs to assist with MIPS performance scoring.
  • Check your Medicare Physician Quality Reporting System (PQRS) feedback reports. Make sure you understand your current quality metrics reporting requirements and how you are scoring.
  • Determine which quality measures you plan to report on; there are individual measures and specialty-specific measure sets.
  • Access and review the 2015 annual PQRS feedback reports to see where improvements can be made.
  • If you participate in a nationally recognized, accredited patient-centered medical home (PCMH), a Medicaid medical home model, a medical home model, or are recognized by the National Committee for Quality Assurance as a patient-centered specialty model, ensure that your certifications and accreditations are current. Physicians participating in these medical homes earn full CPIA credit.

MACRA requires that CMS release an annual list of MIPS quality measures no later than Nov. 1 of the year prior to each performance year. The measurement plan will further clarify what measures and associated technical specifications MIPS clinicians will be required to report or choose from in 2017.

The proposed rule specifies that the performance period for MIPS is the calendar year (Jan. 1 through Dec. 31) two years prior to the payment adjustment year. As such, MIPS payment adjustments in 2019 will be based on performance in 2017. This process continues with a two-year “performance year” review in subsequent calendar years.

CMS announced Sept. 29 that the final MACRA regulation will exempt physicians from any risk of penalties if they choose one of three distinct reporting options starting in 2017:

Option one: Test the program

  • As long as you submit some data to the Quality Payment Program, including data from after Jan. 1, you will avoid a negative payment adjustment. This option is intended to ensure that the system is working and that physicians are prepared for broader participation in the coming years as they learn more.

Option two: Partial-year reporting

  • Physicians can choose to report Quality Payment Program information for a reduced number of days. Your first performance period could begin well after Jan. 1 and your practice could still qualify for an incentive payment.

Option three: Full-year reporting

  • If your practice is ready to start Jan. 1, you can choose to report Quality Payment Program information for the full calendar year. Your first performance period would begin Jan. 1 and if you submit information for the entire year, your practice could qualify for a modest positive payment.

Advanced Alternative Payment Model (APM) option, for later

  • This option is still available and qualified participants in advanced APMs will be eligible for 5 percent incentive payments in 2019.

Choosing any of these options guarantees that you will not receive a negative payment adjustment.

For more information, visit the KMA website at

Next month, we will have more information about MACRA, MIPS and APM.

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