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MIPS Requirements for Physicians Under Proposed MACRA Rule

MIPS requirements span four performance categories: quality, resource use, and new programs Advancing Care Information and Clinical Practice Improvement Activity.

By Kyle Murphy, PhD

- The proposed rule for MACRA implementation brings with a whole new methodology for promoting appropriate health IT use and quality reporting as part of the Merit-Based Incentive Payment System (MIPS).

CMS releases proposed rule for MACRA

In yesterday's announcement of the notice of proposed rulemaking, the Department of Health & Human Services (HHS) revealed that a new program, Advancing Care Information, will take the place of the EHR Incentive Programs as one of four scores used to measure a provider's performance in MIPS.

“We’re proposing today to replace meaningful use in the physician office with a new effort that moves the emphasis away from the use of information technology to one that support patient care supported by better and more connected technology,” the Centers for Medicare & Medicaid Services Acting Administrator Andy Slavitt said during a media call Wednesday evening.

The composite performance score (CPS) breaks down as follows: quality (50%), resource use (10%), advancing care information (25%), and clinical practice improvement activity (15%).

To calculate the CPS, the Centers for Medicare & Medicaid Services (CMS) will use this formula:

READ MORE: Understanding Meaningful Use to Facilitate Success in MIPS?

CPS = [(quality performance category score x quality performance category weight) + (resource use performance category score x resource use performance category weight) + (CPIA performance category score x CPIA performance category weight) + (advancing care information performance category score x advancing care information performance category weight)] x 100.

Factoring significantly into this scoring system is the application of a performance threshold, "the level of performance that is established for a performance period at the CPS level," states the MACRA proposed rule.

"CPSs above the performance threshold receive a positive MIPS adjustment factor and CPSs below the performance threshold receive a negative MIPS adjustment factor," the rule continues. "CPSs that are equal to or greater than 0, but not greater than one-fourth of the performance threshold receive the maximum negative MIPS adjustment factor for the MIPS payment year. CPSs at the performance threshold receive a neutral MIPS adjustment factor."

To establish the performance threshold, CMS will review myriad data from previous 2014 and 2015:

  • Part B allowed charges
  • PQRS data submissions
  • QRUR and sQRUR feedback data
  • 2014 and 2015 meaningful use data

"For the 2019 MIPS payment year, we propose to set the performance threshold at a level where approximately half of the eligible clinicians would be below the performance threshold and half would be above the performance threshold," the rule states.

READ MORE: 3 Things to Know about MACRA Implementation, MIPS

MIPS weighting of performance categories under MACRA

Quality

This measure spans the full 12-month calendar year performance period beginning in 2017. The magic number to receive full credit in this performance category is 6:

We propose that for the applicable 12-month performance period, the MIPS eligible clinician or group would report at least six measures including one cross-cutting measure (if patient-facing) found in Table C and including at least one outcome measure. If an applicable outcome measure is not available, we propose that the MIPS eligible clinician or group would be required to report one other high priority measure (appropriate use, patient safety, efficiency, patient experience, and care coordination measures) in lieu of an outcome measure. If fewer than six measures apply to the individual MIPS eligible clinician or group, then we propose the MIPS eligible clinician or group would be required to report on each measure that is applicable.

The proposed rule includes details on how quality measures will be evaluated and selected year over year.

READ MORE: Proposed MACRA Rule to End Meaningful Use for Physicians

Resource use

Similar to quality performance, the scoring for resource use is based on a full 12-month calendar year performance period and "performance in the resource use performance category would be  assessed using measures based on administrative Medicare claims data. At this time, we are not proposing any additional data submissions for the resource use performance category," the rule states.

Specifically, federal officials will use the total per capita cost measure, the Medicare Spending per Beneficiary (MSPB) measure, and several episode-based measures. For the latter, the proposed rule includes a list of 41 episode-based measures; however, CMS has not yet committed to a specific number of these measures to be included under MIPS.

The proposed rule indicates that the total per capita cost measures from the Value-based Payment Modifier for four conditions ((chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, and diabetes mellitus) will not be included in the final list.

Advancing care information

This is the program slated to replace meaningful use for physicians and require a full year's worth of reporting.

Details about satisfying this requirement are extensive. For 2017, there are numerous paths for physicians to take:

● A MIPS eligible clinician who only has technology certified to the 2015 Edition may choose to report: (1) on the objectives and measures specified for the advancing care information performance category in section II.E.5.g.7 of this proposed rule, which correlate to Stage 3 requirements; or (2) on the alternate objectives and measures specified for the advancing care information performance category in section II.E.5.g.7 of this proposed rule, which correlate to modified Stage 2 requirements.

● A MIPS eligible clinician who has technology certified to a combination of 2015 Edition and 2014 Edition may choose to report: (1) on the objectives and measures specified for the advancing care information performance category in section II.E.5.g.7 of this proposed rule, which correlate to Stage 3; or (2) on the alternate objectives and measures specified for the advancing care information performance category as described in section II.E.5.g.7 of this proposed rule, which correlate to modified Stage 2, if they have the appropriate mix of technologies to support each measure selected.

● A MIPS eligible clinician who only has technology certified to the 2014 Edition would not be able to report on any of the measures specified for the advancing care information performance category described in section II.E.5.g.7 of this proposed rule that correlate to a Stage 3 measure that requires the support of technology certified to the 2015 Edition. These MIPS eligible clinicians would be required to report on the alternate objectives and measures specified for the advancing care information performance category as described in section II.E.5.g.7. of this proposed rule, which correlate to modified Stage 2 objectives and measures.

Beginning in 2018, achieving optimal performance in the category is simplified:

● Must only use technology certified to the 2015 Edition to meet the objectives and measures specified for the advancing care information performance category in section II.E.5.g.7. of this proposed rule, which correlate to Stage 3.

Calculating a provider's performance in this category requires three figures, a base score, performance score, and the potential Public Health and Clinical Data Registry Reporting bonus point. Physicians have the ability to exceed 100 percent.

The proposed rule includes a few ways for providers to achieve their 50 percent base score.

There is the primary proposal:

Primary model for Advancing Care Information base score

An alternate proposal:

Alternative model for Advancing Care Information base score

And lastly a modified primary and alternate proposal:

Primary/alternate model for Advancing Care Information base score

Worthy of noting about primary proposal, clinical decision support and computerized physician order entry are off the table.

The performance score comprises a provider's satisfying of measures for patient electronic access, coordination of care through patient engagement, and health information exchange.

The proposed rule includes a sample score for a provider:

Sample score for Advancing Care Information performance category

Clinical practice improvement activity

The last performance category factoring into the CPS is clinical practice improvement activity (CPIA) which has as its goal "to use a patient-centered approach to program development that leads to better, smarter, and healthier care."

This category is not a concern for providers working as part of certified patient-centered medical homes who will receive full credit. For the remaining physicians, the magic numbers are 60 and 90.

"We propose at §414.1380 to set the CPIA submission criteria under MIPS, in order to achieve the highest potential score of 100 percent, at three high-weighted CPIAs (20 points each) or six medium-weighted CPIAs (10 points each), or some combination of high and medium-weighted," the rule reads.

Put more simply, MIPS physicians will be required to choose an appropriate number of CPIAs to reach 60 points and receive full credit (100%) for at least 90 days. CMS has proposed more than 90 CPIAs. Certain measures are weighted more heavily and carry more points — that is, high-weighted CPIAs count for 20 points while medium-weighted CPIAs count for 10.

The public has 60 days to comment on the proposed rule, so these MIPS requirements are still subject to change.

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