What You Should Know About MACRA

Navigating a complex array of acronyms, this author details how to meet the requirements of the Medicaid Access and CHIP Reauthorization Act (MACRA) and explains how to calculate a Merit-Based Incentive Payment System (MIPS) score through the categories of Quality, Promoting Interoperability, Clinical Practice Improvement Activities, and Cost.

When Congress repealed the flawed Standardized Growth Rate (SGR), the replacement was the Medicaid Access and CHIP Reauthorization Act (MACRA). The MACRA received robust bipartisan support when it passed in the House by a margin of 392–37 and also in the Senate, where it passed by a margin of 92–8. Despite the urging of medical societies and even MedPAC, there has been no announced intent by Congress to replace or eliminate this program at the time of this writing. Therefore, if you want to be a doctor in 2018, you have to deal with MACRA.

The Medicaid Access and CHIP Reauthorization Act has multiple components and the Quality Payment Program (QPP) is the component of MACRA applicable to the content of this article. Every eligible provider in the country will participate in the QPP in 2018 via either the Merit Based Incentive Payment System (MIPS) or an Alternative Payment Model (APM). In order to participate in the QPP via an APM, you must be a “qualified provider” in an “advanced” APM. Since very few or zero podiatrists will qualify for APM participation in 2018, this article will focus on MIPS.

Understanding The Basics Of MIPS

Based on the level of your 2018 participation in the MIPS program, your 2018 MIPS score will be anywhere between 0 and 100. In 2017, the MIPS score necessary to avoid a negative adjustment was 3. For the 2018 reporting period, the bar has been raised. In 2018, a score of 15 MIPS points is necessary to avoid a negative adjustment to your 2020 Medicare Part B Physician Fee Schedule.

Your 2018 MIPS score will be publicly reported. That means anyone who is interested in your score will be able to find it. In addition to the public report of the score, it will also impact your 2020 Medicare Part B Physician Fee Schedule. With some exception, your 2020 fee schedule will be adjusted anywhere from minus 5 percent to plus 5 percent based on your 2018 MIPS score. This is a continuum and your adjustment can fall anywhere within that range.

The exception I referred to above is for those deemed to be “exceptional performers.” You will fall into this category if your MIPS score is over 70. Reaching this exceptional performer level may allow you to earn a positive adjustment of even more than 5 percent. As the program is currently designed, the stakes get higher as the years go on. The adjustment to the 2021 Fee Schedule, based on the 2019 MIPS score, is scheduled to be minus 7 percent to plus 7 percent and the 2022 adjustment, based on the 2020 MIPS score, is scheduled to be minus 9 percent to plus 9 percent.

Essential Considerations In Determining Your Level Of MIPS Participation

Each one of us needs to decide how much of a factor the score being publicly reported plays in our decision to participate and at what level to participate. There are several things to consider.

First, the Centers for Medicaid and Medicare Services (CMS) tells us it is going to publish our score on its Physician Compare website (www.medicare.gov/physiciancompare/). Some may interpret this score as a reflection of the quality of care we provide. Prospective employers may take interest in a healthcare provider’s MIPS score when considering providers for employment. Online physician ranking websites that are more commonly used than CMS’ Physician Compare website could potentially use MIPS scores as part of their ranking algorithms.

Finally, non-Medicare insurance carriers will have access to these publicly reported scores and could potentially choose to adjust fee schedules based upon them. These carriers could even make decisions about copays or whom they allow on their panels based on these scores.

All of the above should be considerations (in addition to the Medicare Fee Schedule) when deciding whether to participate in MIPS and at what level to participate.

Who Is Exempt From MIPS Participation?

Some physicians may be excluded from participation and the exclusion criteria changed for the 2018 MIPS reporting period from what it was in 2017. This change may exclude some providers in 2018 who were included in 2017. If you had less than or equal to $90,000 in Medicare Part B Allowable or you saw fewer than 200 Medicare Part B beneficiaries, then you are excluded from the MIPS program for the 2018 reporting period. This means if you do nothing, you will not receive any adjustment to your 2020 fee schedule. You will not have a publicly reported score because you will be listed as having been exempt from participation in 2018. If you do meet the exclusion criteria and you are exempt, you may still choose to participate if you like. If you do, your score will be publicly reported but you will not have any adjustment to your 2020 fee schedule, positive or negative, regardless of your score.

To check your participation status for the 2018 reporting period, go to www.qpp.cms.gov/participation-lookup and enter your National Provider Identifier.

There are some others who may be exempt from 2018 participation. Anyone who was affected by hurricanes Harvey, Irma, Maria or Nate as well as the Northern California wildfires to such a degree that the disaster(s) impacted their ability to participate in MIPS in 2018 can file a hardship exemption. At the time of this writing, that application is not yet available. The CMS deems those to have been affected as providers in all of Florida, Georgia, Puerto Rico and the U.S. Virgin Islands, and in parts of Louisiana, South Carolina, Texas and California. The CMS Emergency Response and Recovery (www.cms.gov/About-CMS/Agency-Information/Emergency/index.html) website has a full list of those affected.

If you plan to file a participation exception due to the impact of one or more of these disasters on your ability to participate in MIPS in 2018, be on the lookout for the release of that application.

While reporting MIPS measures and activities, you should report on all of your patients regardless of their insurance carrier and even if they do not have medical insurance. This has been a point of confusion for some as we have to report on all of our patients even though the financial penalties and incentives only impact the Medicare Part B Fee Schedule. The one exception to this rule is that you only need to report on Medicare Part B beneficiaries when reporting your quality measures via the claims submission mechanism (more on that later).

A Closer Look At The Four MIPS Categories

For the 2018 reporting period, there are four MIPS reporting categories. These include Quality, Promoting Interoperability (PI) (formerly Advancing Care Information), Clinical Practice Improvement Activities (CPIA), and Cost.

If a practice has greater than 15 eligible clinicians, the Quality category score will count for 50 percent of the overall MIPS score, Promoting Interoperability for 25 percent, CPIA for 15 percent, and Cost for 10 percent. Another change for the 2018 reporting period is that those in practices with 15 or fewer clinicians can apply for an exception from the Promoting Interoperability category. If you choose to take that option, the 25 percent from the PI category shifts to Quality and the Quality category will be reweighted to 75 percent. Continuing with their effort to “ease the burden” on small practices, CMS will add 5 MIPS points to the total of any clinician who is in a practice of 15 or fewer clinicians who submits data in at least one performance category.  

What You Should Know About Your Quality Score

The Quality category score will make up 50 or 75 percent of your total MIPS score depending on the size of your practice and whether or not you choose to claim an exemption from the PI category. There are 271 Quality measures from which to choose. In order to fully participate in the Quality category, you have to choose six quality measures to report on. When you look through the list of Quality measures, you will see that some are deemed to be “outcome” measures while others are not. Of the six measures that you choose, one must be an “outcome” measure. If an outcome measure is not available that is pertinent to your practice, you must report on at least one high priority measure. If you are going to report on multiple Quality measures, you must report performance of all of your measures via the same reporting mechanism.

There are different mechanisms you can use to report the performance of Quality measures. The four reporting mechanisms for Quality measures include claims, registry, EHR and CMS web interface. When you read the specifications of a Quality measure, its available reporting mechanisms will be listed. When selecting your Quality measures, you must first decide the mechanism by which you want to report your Quality measures. Then you need to choose measures to report via that same mechanism. The list of measures is available at www.qpp.cms.gov. The American Podiatric Medical Association (APMA)/MACRA Task Force has gone through these measures and narrowed them down to a much smaller list of podiatry-appropriate measures from which members may choose. Members of the APMA can find this list at www.apma.org/mips2018 .

Once you choose your Quality measures, it then becomes important to know your measures intimately and perform these measures for your patients who qualify for them. If reporting via claims, you must report on 60 percent or more of your Medicare Part B beneficiaries who qualify for your measures in order to earn a perfect score in the Quality category. If you are reporting via registry, electronic health records (EHR) or a CMS web interface, you must report on 60 percent or more of all of your patients who qualify for your measures in order to earn a perfect score in the Quality category.

Key Insights On Meeting Promoting Interoperability Measures

Promoting Interoperability (PI) is the new title for the category that was previously known as Advancing Care Information and before that was known as Meaningful Use. It is the only MIPS category that requires the use of Certified Electronic Health Record Technology (CEHRT). As noted above, if you are in a practice with 15 or fewer clinicians, you can apply for an exception from the Promoting Interoperability category. If you choose to participate in the PI category, you must know whether you are CEHRT 2014 certified or 2015 certified. If you are using 2014 CEHRT, there are four mandatory PI measures you must perform and report in order to score points in the PI category. These measures include Secure Risk Analysis, Electronic Prescribing (eRx), Provide Patient Electronic Access, and Health Information Exchange. If you use 2015 CEHRT exclusively throughout the 2018 reporting period, you can earn 10 bonus PI points for doing so and the number of required PI measures increases to five with the addition of Request/Accept Summary of Care.

Just performing and reporting these required measures alone will not be enough to earn the maximum PI score. If you want to max out the PI category, you will need to choose more PI measures beyond the aforementioned required measures from a list of ten additional measure options. If you choose registry reporting as one of your additional PI measures, you can earn PI bonus points.

Fulfilling Clinical Practice Improvement Activities And Avoiding Penalties

The Clinical Practice Improvement Activities (CPIA) category lists 97 activities that you can perform. The CPIA category counts for 15 percent of your total MIPS score. With the highest possible MIPS score being 100, a perfect CPIA score earns you 15 MIPS points. With the threshold to avoid a penalty in the 2018 reporting period set at 15 MIPS points, this category has attracted more interest this year because a perfect CPIA score of 40 is all you need to avoid a penalty.

Of the 97 CPIA activities listed, each one is labeled as being either “medium weight” or “high weight.” Successful performance and reporting of a medium weight activity is worth 10 CPIA points. Successful performance and reporting of a high weight activity is worth 20 CPIA points. These CPIA point values double if you are in a group of 15 or fewer clinicians. This includes those in solo practice. Therefore, if you are in a group of 15 or fewer, the performance and reporting of just one high weight activity earns you 40 CPIA points, resulting in 15 MIPS points, which is what you need to avoid a penalty for the 2018 reporting period.

Similarly, if you are in a group of 15 or fewer, the performance of two medium weight activities will earn you 40 CPIA points. If you are in a group of more than 15 and you want a perfect CPIA score of 40, you will need four medium weight activities, two high weight activities, or any other combination that gets you 40 CPIA points. The APMA MACRA task force went through this list of 97 activities and narrowed them down to a much more manageable list of 16 that are applicable to most podiatrists. Members can find this list at www.apma.org/mips2018 .

How To Calculate Your Cost Score

The final MIPS category for the 2018 reporting period is Cost. Clinicians can determine their Cost score by Medicare Spending per Beneficiary (MSPB) and Total Per Capita Cost Measures. The MSPB is the sum of standardized, risk-adjusted spending across all eligible episodes divided by the number of episodes. An episode is defined as all Medicare claims between three days prior to a hospital admission and 30 days after hospital discharge. This period of time seems to be critical to Medicare.

The total per capita cost is the total cost of care attributed to your beneficiaries. This is payment standardized, annualized, risk-adjusted and, perhaps most importantly for podiatrists, specialty-adjusted. You do not need to submit anything for the Cost category. The CMS will pull this information out of claims data.

The reporting period for the Quality and Cost categories is 365 days. The reporting period for Promoting Interoperability and Clinical Practice Improvement Activities is 90 days. Since you only need to report on 60 percent or more of your patients who qualify for your quality measures, you can still perform well in the Quality category even if you start later in the year.

Final Thoughts

Based on the adjustment to your Medicare Part B Fee Schedule and your score being publicly reported, you have to choose if you are going to participate in this program and at what level you want to participate. The CMS has given us the “flexibility” to participate in as many of the categories as we like and at different levels within each category. Hopefully, the information here helps you to decide what makes the most sense for your practice and your staff.

Dr. Lehrman is in private practice in Springfield, PA and operates Lehrman Consulting, LLC. He is a consultant to the APMA Health Policy and Practice Department, serves as an expert panelist on Codingline, and is a Fellow of the American Academy of Podiatric Practice Management (AAPPM). Follow him on Twitter @DrLehrman.