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Physician Payment Reform

The passage of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the Sustainable Growth Rate (SGR) and replaced it with two new payment update tracks, the Merit-based Incentive Payment System (MIPS) and CMS Alternative Payment Models (APMs). Payment adjustments under the MIPS and APM programs are scheduled to go into effect January 1, 2019.

MACRA created the MIPS to replace
the current CMS Quality Initiative
Programs. MIPS incorporates aspects
of several CMS quality programs into
a component score to determine physician payment.

Learn More about MIPS

APMs are a new approach to paying for medical care
incorporating quality and total cost of care,
instead of a traditional fee-for-service payment structure.

Learn More about APMs

Performance Year 2019: Submission Window is Open until March 31, 2020
Clinicians should visit the CMS website to submit Performance Year (PY) 2019 data. Data can be submitted and updated any time until 8 pm EDT on March 31 when the submission window closes.

Clinicians can also opt-in to participate in MIPS if certain criteria are met. View the CMS QPP toolkit for more details.

Performance Year 2020
Clinicians can use the updated CMS Quality Payment Program Status Lookup Tool to check initial 2020 eligibility for the MIPS program. By entering a National Provider Identifier in the lookup tool, providers can determine eligibility for the 2020 performance period. Eligibility does change during the second half of the year, so it is recommended that clinicians check their status throughout the year. Final eligibility will be available by December 2020.



MIPS Changes in PY 2020


Performance Threshold

The Merit-based Incentive Payment System is raising the performance threshold points from 30 in 2019, to 45 in 2020. This significant jump will make avoiding a negative payment adjustment more difficult.

  • As required by MACRA, the 2020 performance may result in a Medicare payment adjustment of up to +/- 9% in 2022.
  • The exceptional performance threshold will be raised to 85 points.
  • CMS maintained the performance category weights from 2019 for 2020:
    • Quality: 45%
    • Cost: 15%
    • Improvement Activities: 15%
    • Promoting Operability: 25%

Quality Category

Important changes have been made in the Quality category.

  • For 2020, CMS increased the data completeness threshold for this category by 10 percentage points. Clinicians will now need to report each measure for at least 70% of applicable patients (up from 60% in 2019).
  • CMS removed 42 quality measures and added six new specialty-measure sets, including those for endocrinology and pulmonology.

Cost

In the Cost category, 10 new episode-based measure have been added so that more providers will qualify for this category. Also, CMS is revising the Medicare Spending Per Beneficiary Clinician and Total Per Capita Cost measures.

  • CMS kept the weighting of the Cost category at 15%. However, clinicians can expect an increase in the Cost category weight in MIPS year five.
  • CMS will maintain the existing 8 episode-based measures and add 10 new episode-based measures for a total of 18 episode-based Cost measures.

Improvement Activities Category

  • Starting in 2020, groups can only attest to Improvement Activities if at least 50% of the clinicians in the group or virtual group complete the same activity during any continuous 90-day period. Previously, at least one clinician in the group needed to complete the activity for the group to receive credit.
  • The activities may be completed anytime within the calendar year. 
  • CMS added two new Improvement Activities measures, modified seven existing measures, and removed 15 measures. 

Promoting Interoperability Category

  • CMS reduced the threshold for a group to meet the definition of hospital-based and qualify for reweighting of the PI component. In 2019, in order to reweight the PI component, 100% of clinicians in a group had to meet the CMS definition of a hospital-based clinician. In 2020, more than 75% of clinicians in a group must meet the definition of hospital-based, in order for the group to have the category reweighted for the 2020 performance year / 2022 payment year.

For more information and resources, visit the CMS Quality Payment Program Resource Library

For questions regarding 2020 final requirements, contact the Health Policy team at healthpolicy@entnet.org


What You Need to Know about MIPS PY 2019


CMS implemented extensive updates for the third year of the Merit-based Incentive Payment System (MIPS). Key programmatic changes for 2019 address eligible clinicians, technology requirements, performance categories, scoring methodology, measures and objectives, as well as thresholds and bonus points. The items below highlight some of the major changes for Year 3 (Y3) that AAO-HNS members need to know:

  1. More MIPS eligible clinicians - Eligible Clinicians (ECs) represent the same five provider groups from Y2, but now also include additional practitioners such as qualified audiologists, clinical physical therapists, occupational therapists, qualified speech-language pathologists, and registered dieticians or nutrition professionals.
  2. 2015 Certified Electronic Health Records Technology (CEHRT) required - Submission of data in each of the following performance categories now requires 2015 CEHRT: Quality, Improvement Activities, and Promoting Interoperability. 
  3. Modified performance category weights - The weighting of the Quality category decreased from 50 percent to 45 percent of the final MIPS score. while the Cost category increased to 15 percent. Promoting Interoperability and Improvement Activities categories remain the same (25 percent and 15 percent, respectively). 
  4. Restructured Promoting Interoperability performance category - This performance category includes the following new element
    • Base, performance, and bonus scores were eliminated and replaced with a new scoring methodology (100 total category points)
    • Two new e-prescribing objectives are available; and
    • ECs must meet four objectives: e-prescribing, health information exchange, provider to patient exchange, and public health and clinical data exchange, unless an exclusion is granted. ECs are also required to report certain measures associated with the objectives.

5. New Quality measures - CMS added eight new quality measures for 2019 and removed 26 measures that were duplicative or "topped out."
6. Increased thresholds to avoid penalties and obtain bonus points - ECs and groups must earn at least 30 points (an increase from the 15 points required in 2018) to ensure a neutral payment adjustment. ECs and groups seeking a performance bonus must also earn at least 75 MIPs points (an increase from 70 points in 2018).
7. Modified small practice point system - Small practices (<15) will still receive a small practice bonus, but for 2019, the bonus is now reflected in the Quality performance category score instead of a standalone bonus. If ECs submit data on at least one Quality measure, the bonus points will be increased to six points (as compared to five points in 2018).
8. MIPS Opt-In policy - ECs or groups may opt-in to MIPs if they exceed at least one, but not all three, of the low-volume threshold criteria.