Ringing in the New Year with MACRA and MIPS

by | Dec 20, 2016

If you are a healthcare provider and have not yet familiarized yourself with the meaning of these acronyms, this article will provide a basic overview and also give direction on how to implement these systems in 2017.   Non-participation is no longer an option, as MIPS will impact your pocketbook and has the ability to create a potentially negative public perception of your practice.

MACRA is an acronym for the Medicare Access and CHIP Reauthorization Act, which is a payment system replacing the Sustainable Growth Rate (SGR) formula.  The Centers for Medicare & Medicaid Services (CMS) has released its final ruling, dated October 14, 2016, that lays out the parameters for its Quality Payment Program (QPP.)  The QPP has two reporting frameworks: MIPS and advanced APMs (Alternative Payment Models).  This article will focus exclusively on MIPS, as this will be the primary reporting method for most practices.  In essence, MACRA (via its QPP and the MIPS system) will attempt to place an increased focus on quality and value of care while minimizing the burden on eligible clinicians.

With the implementation of the MIPS system, PQRS, VBM and MU are all being retired. While you may feel that this news must be the aforementioned minimization of burden, understand that after these quality reporting systems end on December 31, 2016, they will be consolidated into a new series of acronyms and rules called the Merit Based Incentive Payment Systems (MIPS).   As many practices were finally understanding and becoming comfortable with the terminology of PQRS and the associated rules pertaining to quality reporting, it is now time to learn a new process to ensure readiness for the 2017 reporting framework of MIPS.

In 2017, MIPS will have three components:  Quality,  ACI (Advancing Care Information) and Improvement Activities.

These components will carry the following weightings (see below) to develop a 100-point composite score. A practice’s composite score will be compared to a floor and the score of your peer group to determine the payment adjustment.

The 2017 MIPS components and weights are as follows:

Quality (replaces PQRS)

60-85% (Depending on specialty)

Advancing Care Information (replaces MU)

0-25%  (Depending on specialty)

Improvement Activities (new)


Cost (replaces VBPM)

0% – Begins 2018

DPI recommends the following courses of action to comply with 2017 MIPS reporting rules:

1. Appoint a MIPS team lead or champion.

  • Every organization that falls under the eligibility umbrella should have a subject matter expert (SME) on MIPS.

2. Your MIPS SME should determine who is eligible or exempt within the organization.

3. Report Clinical Quality Measures (CQMs).

  • From a quality perspective, these measures are similar or identical to the PQRS measures (if you have already reported these, this should be an easy transition.) To fully participate, you will need to report six CQMs or one specialty-specific measure set. Generally, all the PQRS rules still apply for individual and group reporting options.

4. Report Clinical Practice Improvement Activities (CPIAs).

  • These activities will be different from practice to practice, but contain 93 activities with different priority levels. These will be scored on an all-or-none basis. You can selectively report on activities already being performed within your organization. Full participation requires reporting on four CPIAs.

5. Determine if your specialty is eligible for the Advancing Care Information (ACI) piece.

  • Your specialty may or may not be an eligible provider for ACI. Since ACI is optional for some specialties in 2017, this quality category will be reweighted to 85%. To fully participate, you must report on five ACI measures.

6. Your MIPS team lead should develop a MIPS submission plan that identifies your reporting mechanism and captures enough measures across the three dimensions to meet full participation requirements. You can choose the level or pace of participation for the first year of MIPS, which is considered a transition year. We recommend full participation, if possible, but the minimum requirements should at least be met to avoid the -4% adjustment. The levels of participation and payment adjustments will range from:

  • minimal reporting to avoid a 4% negative payment adjustment in 2019
  • full reporting to qualify for an exceptional performance bonus and up to a potential (but) unlikely) 22% positive adjustment.

As the program progresses year after year, so do the positive and negative adjustments. By 2022, the adjustments (for the 2020 reporting year) will range from -9% to potential (but unlikely) +37%. With these extreme levels of payment adjustments, no one will be able to afford ignoring these measures. As an added repercussion, results will be readily available online for public view. Not only will your checkbook take a beating for non-participation, but your reputation will be at stake, too.

If these rules are overwhelming, or you lack the time or resources to implement these new reporting measures, DPI can assist in developing and implementing a successful MIPS submission plan.  While we specialize in anesthesia and pain management, we do have the expertise and resources necessary to implement plans for other specialties, as well.