Physician Data Analytics and Your EHR – Impact of MACRA, MIPS, and SGRs (Part 2 of 3)


By Richard Howe, PhD, Executive Director, North Texas Regional Extension Center

Last month, I introduced the concept of how the Department of Health and Human Services (HHS) is migrating from fee for service (FFS) to value-based, Alternative Payment Models (APMs), and the basic construct of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation, which repealed the sustainable growth rate (SGR) formula.

This month, I would like to discuss more about how the Merit-Based Incentive Payment System (MIPS) for physicians, Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VBPM) and meaningful use (MU) will become integrated into a single program.

The new MIPS program is designed to shift Medicare reimbursement from fee-for-service to pay-for-performance. Above-par performance could earn a physician a bonus as high as 12% in 2018 and 27% by 2021, according to a summary of the bill prepared by lawmakers. However, physicians also would risk incurring substantial penalties, starting at 4% in 2018 and reaching 9% in 2021, if they fall below par.

In the MIPS program, if all physicians perform at or above the performance threshold, no one will get a penalty. Performance assessment under the MIPS program will be according to a “sliding scale” – versus the current “all or nothing” approaches used in PQRS and Meaningful Use. Credit will be provided to those who partially meet the performance metrics.

As noted last month, the MACRA legislation would replace the SGR with the MIPS program. Performance under MIPS will be based on four categories including: quality, resource use, meaningful use of electronic health records and clinical practice improvement activities. Weights are assigned to each category to create a total composite score of 0-100 for physicians based on their performance in these categories:

Quality Measures: (30%) based on those in existing measurement programs (like PQRS) and other potential measure eligibility pathways;
Resource Use: (30%) Largely based on the current Value-Based Payment Modifier system.
Meaningful Use: (25%) Largely based on the current Meaningful Use Program, and;
Clinical Practice Improvement Activities: (15%) Activity that relevant eligible professional organizations and other relevant stakeholders identify as improving clinical practice or care delivery and that the Secretary of HHS determines is likely to result in improved outcomes.

A provider’s performance in these categories will impact the level of reimbursement. A threshold would be established annually that providers would have to meet or exceed in order to be eligible for enhanced rates. Those who fail to meet the threshold would be at risk of reduced rates.

Next month I will discuss how providers may be exempt from participating in MIPS. This may be an excellent opportunity for your practice to start migrating away from FFS into an equally profitable payment model. Stay tuned!