2. MACRA: Medicare’s Shift to Value-based Delivery & Payment Models
Current as of 11/1/2016

3. Current State Over Utilization Silos of Care Volume over Value
This is the current fee for service state we are all familiar with… because we live in it every day. It is not set up to reward value or quality and, in many cases;… it promotes over utilization and fragmented care.
Fee for Service

4. Push Toward Value & Quality
Medicare payments tied to quality or value by end of 2016
Of those through alternative payment models (APMs) by end of 2016
Private payer business through value-based arrangements by 2020
In January 2015, the Secretary of the Department of Health and Human Services announced payment goals that will work to change the current state.
The first goal is to tie 85% of Medicare fee-for-service payments to quality or value by the end of 2016, with 90% of payments tied to quality or value by the end of 2018.
The second goal is to have 30% of those quality and value payments made through alternative payment models by the end of 2016.
On March 3rd two thousand sixteen, President Obama announced Medicare had already met the 30% goal, almost a full year ahead of schedule.
Private payers have gotten on board as well. Soon after the Secretary made her announcement, private payers committed to having 75% of their business tied to value-based arrangements by 2020.
This reinforced the commitment of the entire healthcare delivery system to payment reform that emphasizes …value…over… volume.
75%

5. The Medicare Access and CHIP reauthorization Act (MACRA) is the key legislative piece that moves the healthcare system closer to meeting the goals laid out by the Secretary.
The first line in the legislation is spelled out here, and it states clearly what the law is intended to do…To repeal the Medicare Sustainable Growth Rate (the SGR) and strengthen Medicare access by improving physician payments
If only the law were this simple!

6. MACRA Legislative Timeline
MACRA enacted
Request for Information
Proposed Rule released
Final Rule w/ comment
April 16, 2015
October 1, 2015
April 27, 2016
October 14, 2016
This is what the legislative timeline looks like.
The MACRA law was passed in April 2015, in October 2015 CMS asked any and all interested stakeholders to submit answers to roughly 220 questions to determine how to make the law actionable.
The AAFP submitted a lengthy response to this request for information. CMS took our response and the responses from all of the stakeholders and created the proposed rule.
A 962 page draft was CMS’s first attempt to define the rules of what will be the Quality Payment Program going forward. The AAFP has reviewed the full document page by page and submitted over 100 pages of comments and suggestions to CMS.
The final rule was released on October 14th. It includes a comment period in which AAFP will reply in order to help inform their decisions for the coming rules.
*Medicare physician fee schedule published separately

7. What Does MACRA Do? Merit-Based Incentive Payment System (MIPS)
Consolidates quality programs
Advanced Alternative Payment Models (AAPM)
Potential for bonus payment for participation
As we mentioned previously, MACRA introduces two new payment tracks:
One that consolidates quality programs –the Merit Based Incentive Payment System (MIPS)
And Alternative Payment Models (APMs) - which have the potential for bonus payments for participation
We anticipate many of our members will move through MIPS into the alternative payment model track.

8. Here is a graphical representation of the MACRA path you will be venturing on.

9. Clinical Nurse Specialist Certified Registered Nurse Anesthetist
QPP Participants
MACRA defines eligible clinicians as:
Physicians
(MD/DO)
Physician Assistant
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse Anesthetist
The final rule defines eligible clinicians physicians (MD/DO), Physician Assistants, Nurse Practicioners, Clinical Nurse Specialists and Certified Registered Nurse Anesthetist. Other providers will added
*You are not required, as a condition of participating in the Medicare program, to participate in either of the QPP pathways. You may elect to provide care to Medicare patients and not participate in the QPP. However, if this is your decision, you will face maximum negative payment updates as established by the law.

10. Merit-Based Incentive Payment System
(MIPS)
Lets take a look at MIPS in more detail

11. MIPS Highlights Consolidates existing quality and value programs
Adds a category for Improvement Activities
Establishes a Final Score
Weighted scoring by category
Provides opportunity for payment adjustments
Both positive and negative
Highlights of MIPS include the consolidation of existing quality and value programs to reduce administrative burden; establishment of a performance score; and sliding scale payment adjustments.

12. What’s it called? Proposed Rule – April 2016 Final Rule– October 2016
MACRA (consolidated existing programs)– April 2015
Proposed Rule – April 2016
Final Rule– October 2016 MU
Advancing
Care Information
Advancing
Care Information
Value
Modifier
PQRS
Resource Use
Quality
Cost
Quality
CPIA
CPIACPIA IA
Advancing
Care Information
CPIA

13. MIPS Final Score Quality Cost Advancing Care Information (ACI)
In addition to the more familiar programs that will be used to calculate a MIPS composite score, a new category of clinical practice improvement activities has been introduced.
Physicians will be assessed, and receive payment adjustments, based on a composite score comprised of these four categories.
You will see that many primary care providers are already doing something (if not a lot) in each of these categories.
Quality – Physicians will need to report on 6 measures of their choosing- one being an outcome measure. Those that have been reporting PQRS will be familiar with this process.
Resource Use- Similar to value-based payment modifier, there will be no data submitted by physicians to CMS for this category. CMS will use claims data to calculate the score.
Advancing Care Information- which is the old Meaningful Use, is reported very much the same as the previous program.
Then, there is the new category of Clinical Practice Improvement Activities
Quality
Cost
Advancing Care Information (ACI)
Improvement Activities

14. Improvement Activities – New!
Expanded Practice Access
Population Management
Care Coordination
Beneficiary Engagement
Patient Safety and Practice Assessment
Achieving Health Equity
Emergency Response and Preparedness
Integrated Behavioral and Mental Health
New but not really! - While the Clinical Practice Improvement Activities category is new, the functions identified are not.
These functions are the overarching categories for the roughly 90 activities named in the proposed rule as clinical practice improvement activities. Many of these activities you may have already done if you’ve worked toward PMCH recognition, either through an accrediting body, a payer, or a state based program.

15. Weighting by Category - 2017
This is a breakdown of year 1 scoring. The four categories above contribute points, in a weighted fashion, to make up the performance score. The total number of points scored will range from 0-100, with each category weighted as established in statue.
Quality 60%
Cost 0%
IA 15
ACI 25
This is a breakdown of year 1 scoring. The four categories above contribute points, in a weighted fashion, to make up the MIPS Composite Performance Score. The total number of points scored will range from 0-100, with each category weighted as established in statue.
You will notice there is a footnote for CPIA. Specifically, a “Certified” patient centered medical home will receive the full 15 points for this category. Those in alternative payment models who do not qualify for the alternative payment model bonus, will get half the credit for the CPIA category. We will discuss this more in the alternative payment model section.
“Certified” patient centered medical home is defined in the proposed rule as those recognized by NCQA, the Joint Commission, URAC, and AAAHC. The AAFP is advocating for state-based and payer programs to be included in this definition as well.

16. Weighting Progression
2017/19
2018/20
2020/21
Quality
60%
50%
30%
Cost 0%
10%
Advancing Care Information
25%
Improvement Activities
15%

17. ‘Pick your Pace’ Options for 2017
Test
Submit some data to QPP
No negative adjustment
Partial Participation
Report minimum 90 days
Small positive adjustment
Full Participation
Report 90 days up to full year
Modest positive adjustment
Advanced APM
Qualifying Program & Qualified Participant
5% incentive payment
Use Executive Summary Notes Here
NO NEGATIVE PAYMENT ADJUSTMENTS

18. “Pick Your Pace” Reporting
Test
Report one quality measure, one improvement activity, or all four of the required measures within the advancing care information (ACI) category
Partial Participation
Report a minimum of 90 days for more than one quality measure, more than one improvement activity, or more than four of the measures within the ACI category.
Full Participation
Report to MIPS for a full 90-day period or full year

19. Annual Performance Threshold
Established by Secretary years 1 and 2
For transition year 2017, threshold is 3
Below = negative payment adjustments
Above = positive payment adjustments
When MIPS begins in 2019, there is no historical “look back” period of previous MIPS scores to use to set a performance threshold. The law gives authority to the Secretary of Health & Human Services to establish the performance threshold in years one and two.
After that, the performance threshold will be based on the mean or median of the previous year’s MIPS scores.
MIPS scores will then be compared to the threshold. Scores above the threshold will yield positive payment adjustments and scores below the threshold negative adjustments.

20. *Adjustment to provider’s base rate of Medicare Part B payment
Adjust Payments
-4%
-5%
-7%
-9% 4% 5% 7% 9%
onward
*Potential for 3X
adjustment
Beyond the baseline adjustments, written into the law are higher adjustments for the highest performers. These can be up to 3 times the maximum adjustment for that year.
But the positive and negative adjustments must still be budget neutral.
Also, positive and negative adjustments will be made on a sliding scale, which is important. People will likely get a wide range of adjustments between 0 and the maximum for the year, not necessarily in whole numbers. We may be seeing adjustments carried out several decimal points. At this time, we don’t know.
It is important to note, the adjustments are not cumulative, whether positive or negative. Every year, your baseline resets to zero.
Outside the budget neutral adjustments, for years , there is $500M set aside for additional positive payment adjustments of up to 10% for “exceptional performers”. As the proposed rule is written, exceptional performers will be those that score in the top 25% of MIPS scores.
Before leaving this slide, an important note for lower performers who score in the lowest quartile of MIPS scores: These providers will automatically be adjusted down to the maximum penalty for that year
*Adjustment to provider’s base rate of Medicare Part B payment

21. Adjustment Summary Performance Score Payment Adjustment
Exceptional Performers
(Final Score over 70) =
Eligible for up to 10% positive adjustment in 2019
25th Percentile or below
Maximum negative adjustment
At threshold
Stable Payment
Here are some key points to remember: If you score in the lowest quartile of MIPS scores, you will automatically be adjusted down to the maximum payment adjustment for the performance year.
If you score at threshold, you receive no adjustment
Exceptional performers are eligible for a potential positive payment adjustment up to 10%. This incentive will be paid based on a sliding scale and is outside the budget neutrality. $500M has been set aside to cover this incentive payment. Exceptional has been proposed to be the top 25% of MIPS scores.
And it is important to remember, this program is budget neutral, so the total negative adjustments must equal the total positive adjustments.

22. MIPS Exemptions Year 1 Medicare
Eligible Advanced Alternative Payment Model with Bonus
Below low volume threshold
Less than or equal to $30,000 Medicare payments; or less than or equal to 100 Medicare beneficiaries
There are 4 groups of physicians and practitioners who will not be subject to MIPS –Those who are in their first year of Medicare participation.
Participants in eligible Alternative Payment Models who qualify for the bonus payment .
Those who have a patient volume below the low volume threshold- this number has not been defined.
And most likely, federally qualified health centers and Rural health clinics.

23. Advanced Alternative Payment Models
(AAPMs)
Let’s move on to APMs

24. Definitions Qualifying AAPM Participant Advanced APM Qualifying APM
Based on existing payment models
Advanced APM
Based on criteria of the payment model
Qualifying AAPM Participant
Based on individual physician payment or patient volume
As we’ve mentioned, most providers will move through MIPS as they prepare to enter the Alternative Payment Model track.
At the highest level, MIPS is based on existing activities with few entry requirements or exceptions making it easy to become a participant.
Conversely, in the APM track, you must meet specific qualification and eligibility criteria. Let’s talk about what each of these mean.

25. Qualifying APMs MSSP (Medicare Shares Savings Program)
Expanded under CMS Innovation Center Model*
Demonstration under Medicare Healthcare Quality Demonstrations (MHCQ) or Acute Care Episode Demonstration
“Demonstration required by Federal Law”
Qualifying APMs
The goal is for you to be a Qualifying APM Participant.
The first step to get there is to be practicing in a “qualifying” payment model defined in the law. MACRA is very specific about which models qualify, and they are listed here.
Although this is a wide net cast for qualification it does get smaller as we move through the next steps of eligibility and further qualification.

26. Advanced APM Eligibility
Qualifying APMs
Advanced APMs
Quality measures comparable to MIPS
Use of certified EHR technology
More than nominal risk OR Medical Home model expanded under CMMI authority
Step two in the process is for qualified APMs to meet eligibility criteria, listed here. Let’s take a closer look.
First, Advanced APMs must report measures comparable to those in MIPS.
Second, they must use certified EHR technology
And, this last bullet is interesting. The APM needs to either 1) bear more than nominal financial risk for monetary losses, OR 2) be a medical home model expanded under CMMI authority.
Nominal financial risk has been defined in the proposed rule and it is very complicated. The AAFP is advocating the definition be simplified.

27. Primary Care Advanced APMs
Shared Savings Program (Tracks 2 & 3)
Next Generation ACO Model
Comprehensive Primary Care Plus (CPC+)
In the proposed rule, CMS defined those programs that met the criteria necessary to be considered an Advanced APM. They have said they will release an updated list of Advanced APMs annually.

28. Qualifying APM Participant
Qualifying APMs
Advanced APMs
Percentage of patients or payments thru eligible APM
In 2019, the threshold is 25% of Medicare payments or 20% of beneficiaries
QP status will be determined at the group level
The last step after the payment model has been identified as an Advanced APM, is for the participants within the model to be qualified.
Qualifying Participants (QPs) are physicians and practitioners who have a certain percentage of their patients or payments coming through an Advanced APM.
In 2019 and 2020, the threshold for claims is 25% of payments made by CMS for part B services to Medicare attributed beneficiaries paid through the Advanced APM.
The patient threshold is 20% of Medicare unique attributed beneficiaries. This is not a total percentage of your patient panel, this is just a percentage of your Medicare attributed patients.
Beginning in 2021, the threshold percentage may be reached through a combination of Medicare and other non-Medicare payer arrangements, such as private payers and Medicaid
Qualifying APM Participant

29. Additional Rewards for Qualifying Participants
Not subject to MIPS
5% bonus
Higher fee schedule update to 0.75% 2026
Qualifying APM participants are excluded from MIPS, and will receive an annual 5% bonus payment from They will also receive a higher Medicare physician fee schedule update (of 0.75%) starting in 2026.
Physicians and practitioners who participate in qualifying APMs that are not an Advanced APM are not a “qualifying participant” and will be subject to MIPS.
However, APM participation is a clinical practice improvement activity, as defined under MIPS. As a result, these APM participants will receive favorable scoring for this performance category. QP
Advanced APM

30. MIPS APM What if ??? My Advanced APM (MSSP Track 1) is not eligible??
SO…what happens if I am a participant in a program that does not qualify as an Advanced APM, like MSSP Track 1 (which does not bear financial risk)? Or, what If I fail the meet the patient or payment thresholds to become a QP? The answer to the question is this…you are in a MIPS APM. This sends you back to the MIPS track, but it gives you a preferential scoring system. Let’s take a closer look at this…
Don’t meet QP threshold??

31. (MIPS) APM Scoring Standard
Quality
Measures report through APM
Cost
0% Indefinitely
ACI
Must report (same requirements as MIPS ECs)
Improvement Activities
Automatic 100% (annual review of model)
*CMS will calculate the final score for MIPS APM at the APM Entity level.
As a MIPS APM you will be scored according to the APM scoring standard.
To be clear, CMS has been explicit on what APMs are MIPS APMs. They are…The Medicare Shared Savings Program Tracks 1, 2, and 3. Next Generation ACO and CPC Plus.
All advanced APMs could be MIPS APMs, but not all MIPS APMs can be advanced APMs
With this scoring system, CMS will use the measure reported to the APM models as the measures for the Quality category; The Cost category is scored at zero percent now and in the future;
Improvement Activities will be given a score by CMS based on the APM Model design and how it compares to Improvement Activities available to report; Advancing Care Information will be the only category requiring data submission under the APM Scoring Standard.
There is more information about MIPS and the categories that make up your MIPS score is the webinar that looks specifically at the MIPS program.

32. MACRA Timeline 2017 2018 2019 2020 2021 2025 2026 +0% +/-9% 2022-2024
Medicare Part B Baseline Payment Updates
+0.5% 0%
+0.25%*
+0.75%**
*Non-qualifying APM Conversion Factor
**Qualifying APM Conversion Factor
Merit-Based Incentive Payment System (MIPS)
PQRS, Value-based Modifier, & Meaningful Use
Quality, Cost, Advancing Care Information, & Improvement Activities
-9%
-9%?
0 or +/-4%*
“Pick Your Pace”
+/-5%
+/-7%
Qualifying AAPM Participant
5% Incentive payment
Excluded from MIPS
+0%
And finally, the full timeline.
The timeline illustrates the payment updates, and the penalties and/or benefits by year for both MIPS and Qualifying APM Participants.
This timeline is available on the AAFP website
+/-9%

33. Partial Participation
What Can I Do Right Now?
‘Pick Your Pace’
Test
Partial Participation
Full Participation
Advanced APM
So, What Can You Do Right Now to take advantage of the payment opportunities?

34. Assistance is Available
Find a PTN
Go to aafp.org/tcpi
Click “Find a PTN” to find a practice transformation network in your area
with any questions.
If you are not already participating in an Advanced APM, take advantage of the technical assistance provided through the Transforming Clinical Practices Initiative (TCPI)
This project is focused on positioning practices to “thrive as a business via pay for value approaches” by providing practice coaches, resources from quality improvement networks and quality improvement offices and other organizations in practice transformation.
For more information go the AAFP website dedicated to this project or

35. For more information, visit our MACRAReady landing page which will be updated as we learn more.
FAQs
Timeline
MIPS/APM Comparison table
Related articles
Related links
Check out Family Practice Management for up to date articles about MACRA, payment reform, and the practice transformation needed to get your practice ready for the new environment.
FPM is a free resource online for members.