Understanding MACRA and MIPS: Key Insights and Impacts on Healthcare

Understanding MACRA and MIPS

Introduction to MACRA

In 2016, the Medicare Access and CHIP Reauthorization Act (MACRA) was enacted, replacing the outdated Sustainable Growth Rate (SGR) method. The previous system incentivized healthcare providers based on the volume of Medicare patients treated rather than the quality of care delivered. This approach was not only ineffective for patient outcomes but also created significant challenges in securing financial support for Medicare-related expenses. Providers who treated a higher number of patients, regardless of care quality, received increased payments.

Quality Payment Program (QPP)

MACRA introduced the Quality Payment Program (QPP), designed to encourage providers to focus on delivering high-quality care. Under this program, eligible providers can choose between two pathways: the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). An estimated 500,000 providers are expected to participate in MIPS during its inaugural year, with MACRA allocating up to $3 billion in positive payment adjustments over the next six years.

Exploring MIPS

Eligibility and Requirements

To participate in MIPS, providers must meet specific Medicare billing requirements (Part B). This pathway emphasizes payment adjustments based on data submissions. For the transition year of 2017, MIPS consists of three categories, each with designated weights that help physicians allocate their efforts effectively. Providers can choose to participate as individuals or as part of a group.

MIPS Performance Categories for 2017

Quality

Quality comprises 60% of the total MIPS score, reinforcing the purpose behind the shift from the previous system. Providers can report up to six quality measures from a list of 271, closely related to their specialty. Clinicians are scored based on the duration of data submission, accuracy, and completion of specifications for each measure. The total points earned from the six quality measures, along with any bonus points, determine the final score for this category.

Advancing Care Information

This category accounts for 25% of the total MIPS score, replacing the former Meaningful Use program. Providers must select from two reporting measure sets according to their Electronic Health Record (EHR) edition. Each option consists of different measures, making it crucial to report only those applicable. The score is determined by three subcategories: Base Score, Performance Score, and Bonus Score. Failing to complete all Base Score requirements will lead to a score of zero in the Advancing Care Information category.

Improvement Activities

The Improvement Activities category contributes 15% to the overall MIPS score for 2017. This category assesses whether clinicians are enhancing clinical practices to their fullest potential. Key elements include delivering quality care through patient involvement, ensuring continuous coordination between provider and patient, offering self-management techniques, educating patients and families, providing follow-ups, and utilizing safe technology.

Providers can choose from a variety of activities that best align with their practice for data reporting. Each activity is classified as either high or medium weight, with high-weighted activities earning more points. Individual Medicare providers must submit data on up to four activities for a minimum of 90 days to achieve maximum potential points.

Cost

The final category, Cost, evaluates physicians’ MIPS scores without requiring separate data reporting. The Centers for Medicare & Medicaid Services (CMS) calculates this score based on submitted administrative data. In 2017, the cost category contributed 0% to the overall score, but in 2018, it accounted for the first time for 10%. This score reflects the relationship between lower healthcare costs and high-quality patient services.

Currently, in MIPS 2019, the cost-quality measure represents a significant component, contributing 15% to the final MIPS score. MIPS continues to gain traction, with an increasing number of clinicians participating annually. Its influence on the healthcare industry is substantial, prompting providers to recognize its importance in revenue cycle management and adopt modern, cost-effective healthcare practices.