MACRA repealed the flawed Sustainable Growth Rate (SGR) and facilitates a movement toward paying clinicians for value rather than volume. Under MACRA, clinicians will receive payment under either the Merit-Based Incentive Payment System (MIPS) or incentives for participation in an Advanced Alternative Payment Model. The Centers for Medicare and Medicaid Services (CMS) estimate that most clinicians will be subject to MIPS, at least in 2019, the first year of the payment program.

MIPS streamlines the current Medicare quality reporting programs — the Physician Quality Reporting System, the Electronic Health Record Incentive and the Value-Based Payment Modifier — into a single program. Under MIPS, CMS proposes that clinicians will receive a Composite Performance Score (CPS) based on the categories of quality, resource use/cost, advancing care information (formerly referred to as Meaningful Use), and a new category — participation in clinical practice improvement activities.

CMS proposes to use 2017 as the first performance year under MIPS, which will be used to assess payment in 2019. For most clinicians, the four categories of the CPS will be weighted at 50 percent quality, 25 percent advancing care information, 15 percent clinical practice improvement activity participation, and 10 percent cost in the first year. CMS proposes that clinicians who participate in an alternative payment model (APM) such as Track 1 of the Medicare Shared Savings Program (MSSP), but are still required to report MIPS, may report based on different weights due to the structures of those models.

CMS proposes to measure clinicians and clinician groups against a maximum number of possible points per performance category according to the table below. The ACC will post additional issue briefs describing each component in more detail.

Each performance year, CMS proposes to issue a MIPS performance threshold score to clinicians. Those clinicians who score below the threshold will receive a negative payment adjustment of up to 4 percent in 2019. Those in the lowest 25th percentile will see the maximum negative adjustment, while those closer to the benchmark may see smaller adjustments. Clinicians who score at or above the threshold will receive either a neutral payment adjustment, or a bonus in 2019. MACRA provides a maximum bonus of 4 percent in 2019; however, because the program is budget-neutral, CMS may apply a scaling factor that could increase the bonus (but not the penalty) up to 12 percent in 2019. In addition, CMS proposes to award an additional bonus of up to 10 percent to clinicians with “exceptional performance,” meaning those who score in the highest 25th quartile of clinicians.

Each performance year, CMS proposes to issue a MIPS performance threshold score to clinicians. Those clinicians who score below the threshold will receive a negative payment adjustment of up to 4 percent in 2019. Those in the lowest 25th percentile will see the maximum negative adjustment, while those closer to the benchmark may see smaller adjustments. Clinicians who score at or above the threshold will receive either a neutral payment adjustment, or a bonus in 2019. MACRA provides a maximum bonus of 4 percent in 2019; however, because the program is budget-neutral, CMS may apply a scaling factor that could increase the bonus (but not the penalty) up to 12 percent in 2019. In addition, CMS proposes to award an additional bonus of up to 10 percent to clinicians with “exceptional performance,” meaning those who score in the highest 25th quartile of clinicians.

Suggested Materials

MACRA Information Hub
Advancing Care Information Proposed Rule Issue Brief