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MIPS vs APMs – CMS Funded Practice Consultation

Under MACRA and its QPP, clinicians are facing major changes in payment regulation. Lack of understanding of MIPS and APMs will put your practice at risk and could place you in the least desirable payment category, MIPS.

The QPP has two major components: Medicare Incentive Payment Program (MIPS) and Alternative Payment Models (APMs). You will either need to manage penalties or manage risk.

MIPS is the least desirable of these two payment pathways as it is a competitive budget neutral program with two-sided risk with a potential 9 percent downside. Like the Sustainable Growth Rate Formula (SGR) of days past, it is a classic “rob Peter to pay Paul” tournament model where there will be winners and losers.

APMs, on the other hand, are clearly superior. There is the opportunity to design your own payment model that comports to your practice’s clinical work and pick your measures to demonstrate meaningful quality improvement and cost containment. More importantly, APMs with two-sided risk and Advanced APMs secure a guaranteed 5 percent pay increase. There is a legislative mandate that 50 percent of practices will be in APMs by 2018 and 80 percent by 2020.

How VCSQI SAN 2.0 Can Help

Understanding how to avoid payment penalties and maximize your reimbursements is the goal of the Virginia Cardiac Service Quality Initiative Strategic Alignment Network 2.0 (VCSQI SAN 2.0). Through CMS’s Transforming Clinical Practice Initiative (TCPI), VCSQI has received federal funding to educate clinicians to help them understand and make practice changes in order to meet the new requirements for participation in the QPP, and more importantly, succeed in this new payment program.

Through this MACRA legislation signed into law on April 16, 2015, you have multiple pathways with varying levels of risk and reward to tie more of your payments to value. The goals are to minimize additional reporting burdens for APM participants and to provide transformation planning guidance for a better understanding of quality improvement, resource utilization, patient engagement and cost reduction efforts. We can assist in determination of improvements that can be made in each clinician’s practice to realize the benefits of participation in APMs. There are three pathways for participation under MACRA that have an immediate practical impact. Unless you prepare your practice for participation in an APM or Advanced APM, your practice will be relegated to MIPS. As stated before, MIPS is not the preferred category.

Options within the new Quality Payment Program — APMs vs. MIPS

(1) Alternative Payment Models (APMs) allow you to design your own program or choose a CMS designed program. The mandatory CABG bundle was one such program but is currently on hold. Other options are Medicare Shared Savings Programs (MSSP). MSSP track one is a hybrid with MIPS measure requirements and upside gain. MSSP tracks 2 and 3 have a two-sided risk with more upside potential and the ability to create meaningful quality measures for your practice. If you choose to design Pivot Academy and your own APM, innovation is encouraged. These programs will need approval from the Physician Technical Advisory Committee (PTAC) and then the Secretary of Health. Value achievements under APMs lead to higher bonus payments and lower financial downside risk.

(2) Advanced APM enrolled participants receive an automatic 5 percent payment bonus. The annual physician fee schedule updates are 3 times greater than MIPS. Enrolling in the Advanced APM offers the greatest opportunity to achieve financial success. Accountable Care Organizations (ACOs) are considered Advanced APMs and are already established, but program design to meet your practice/hospital needs is possible.

(3) Merit-Based Incentive Program (MIPS) 2017 is the transition year and allows you to pick your pace of participation.

There is a 4 percent penalty for opting out of the MIPS test year in 2017 by not reporting ONE MEASURE FOR ONE PATIENT. Please be certain your practice does not fail to do this most simple task in 2017. CMS payments to clinicians are linked to four domains.

  • PQRS, Meaningful Use and VBM eliminated
  • A single quality scoring system will be used
  • MIPS composite score domains:
    • Quality Improvement: 50 percent
    • Electronic health records: 25 percent
    • Clinical Practice Improvement Activities: 15 percent
    • Resource Use: 10 percent in 2018 (previously listed as 30 percent)

Payment adjustments take effect in 2019 based on 2017 performance, so all clinicians should immediately begin focusing on complying with the new requirements to maximize reimbursement. Although resource use has a 0 percent influence on your score for 2017, the data will be collected and beginning in 2018 the weighting of that domain will increase. Domains will be weighted and a total score determined to compare your practice to all others. The domain weightings will change from 2017 onwards. Workers comp attorneys in los angeles have extensive experience in California, as you can see at https://workerscompensationattorneyorangecounty.com. Relative payments (positive or negative will be determined). As stated before, this is a tournament model that has clinicians competing against each other. Measurement has already begun in 2017. Beginning in 2019, there is a possible 4 percent  penalty that increases with a 9 percent reduction in payments in 2022 for poor performance. The annual fee schedule updates are minimized. This is not a preferred payment category.

Understanding MACRA, MIPs, and APMs – Webinar Recording

VCSQI SAN 2.0 Chief Clinical Director, Dr. Jeffrey Rich, MD, breaks down the details behind these acronyms to help your staff better understand the new merit-based payment regulations for all Medicare providers.

Powerpoint Slide Presentation Here.

Recording of September 12 Webinar Here.

More Resources

The Centers for Medicare & Medicaid Services (CMS) has recently posted the following new Merit-based Incentive Payment System (MIPS) resources on the CMS website:

Additional resources are available on the Quality Payment Program website on CMS.gov.


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