MACRA – MIPS and APMS
Pawan Goyal, MD, MHA, PMP, MS, FHIMSS, CPHIMS
Associate Executive Director, Quality
American College of Emergency Physicians
The Medicare and CHIP Reauthorization Act of 2015 (MACRA) was a landmark piece of legislation that put into law various cost-containment schemes that have been swirling around CMS for years. It ended the dreaded SGR policy of pushing down the road each year draconian pay reductions, replacing it with the “volume-to-value” mantra chanted throughout the new legislation. It also adds a great deal to the reimbursement lexicon of acronyms. The two that will affect emergency physician reimbursement the most in coming years are MIPS and APMs.
Pay for Production Moves toward Incentives for Outcomes
CMS is phasing in the full implementation of MACRA/MIPS through 2020 but penalties and incentives will be applied from 2017 reporting. Groups who delay reporting until late 2017 will not likely win additional incentives this year but penalties are easily avoided.
MIPS is replacing the PQRS system. The Merit-Based Incentive Payment System (MIPS) rates clinicians each year on a 100-point performance scale, where providers compete with each other over positive or negative adjustments to their payments with the aggregate effect of Medicare budget neutrality. The Alternative Payment Models (APMs) include other measurement schemes that set requirements for the use of certified EHR technology, quality measurement, and financial risk. A practice that participates in a qualified APM is exempt from MIPS, while some participants in Advanced APMS have the option to participate in MIPS, as well.
The MIPS and APM programs are two paths to the same destination – cost reduction with a nod toward quality improvement. The paths cross occasionally but are essentially different incentive plans for changes in certain practice performance measures.
When physicians read “Merit-Based”, the conditioned response sometimes is – they are taking away payments. That is both true and false in many regards but, for the near future emergency practices can win some additional reimbursement. MIPS is, in the aggregate, a zero-sum game, some will win what others will lose. It will not be as easy for other specialties to win as it will be for emergency medicine.
Under MIPS most providers will score points on quality, resource use, practice improvement activities and, EHR use. In 2017, emergency medicine will only be scored on quality and improvement activities with payments adjusted according to your score compared to everyone else’s scores.
The MIPS measures
Under the quality portion of the MIPS program, physicians are able to select measures that best fit their practice. To receive a positive payment adjustment in 2017, physicians are required to report on six measures, including one outcome measure. Physicians who report their quality portion of MIPS through a Qualified Clinical Data Registry (QCDR) are able to report on additional non-MIPS measure that are built into the registry. These additional measures are EM specialty-specific, for the Clinical Emergency Data Registry (CEDR).
Investigate participating in the ACEP developed CEDR. CEDR is a QCDR which includes the most common QPP measures for emergency medicine as well as specialized measures focused on the emergency department. This allows the opportunity to higher MIPS scores by reporting with measures tailor made for emergency medicine. Participation in a registry counts toward Improvement Activities as well.
All of these changes did affect the practice of emergency medicine significantly, and not all for the better, but we learned how to accommodate and even to thrive as the true value of emergency physicians became clearer – we were really good at keeping patients out of the hospital, doing great workups far beyond what the primary care providers had the resources to do and we were flexible enough to accommodate documentation hoop-jumping.
The Role of Registry in MIPS Reporting
Pawan Goyal, MD, Associate Executive Director, Quality, ACEP
With more than 30 years of experience in healthcare delivery and management for large federal, state and local government contexts, Dr. Pawan Goyal is currently leading the Quality line of business for ACEP. The quality portfolio includes Clinical Emergency Data Registry (CEDR), Emergency Quality Network (E-QUAL), Quality Policy, Health Information Technology, Emergency Medicine Informatics, Patient Safety, and Performance Measures.