1. Physician Practice Roundtable
Understanding the Merit-Based Incentive Payment System Reporting Requirements Under MACRA
A Detailed Look at the MIPS Performance Categories, Performance Scoring, and the Available Reporting Mechanisms
Board Update from the Physician Practice Roundtable
July 2016
The focus of today’s presentation is on CMS’ proposed reporting requirements under the Merit-Based Incentive Payment System (MIPS) of MACRA (The Medicare Access and CHIP Re-Authorization Act of 2015).

2. Physician Practice Roundtable
Understanding the Merit-Based Incentive Payment System Reporting Requirements Under MACRA
A Detailed Look at the MIPS Performance Categories, Performance Scoring, and the Available Reporting Mechanisms

3. 8% 92% MACRA1: The Law That Repealed The SGR
Most Clinicians Expected to Fall into MIPS Track in 2019 8%
92%
Advanced Alternative Payment Models (APM)
Requires significant share of revenue in contracts with two-sided risk, quality measurement and EHR requirements
APM track participants would be exempt from MIPS payment adjustments and would qualify for a 5 percent Medicare Part B incentive payment in
Merit-Based Incentive Payment System (MIPS)
Rolls existing quality programs2 into one budget-neutral pay-for-performance program, in which providers will be scored on quality, resource use, clinical practice improvement, and EHR3 use, and assigned payment adjustment accordingly
Refresher: MACRA in Brief
Legislation passed in April 2015 repealing the Sustainable Growth Rate (SGR)
Locks provider reimbursement rates at near-zero growth, stipulates the development of two new payment tracks: The Merit-Based Incentive Payment System and the Advanced Alternative Payment Models tracks
On April 27, 2016 CMS released proposed rule outlining plans to implement the two tracks
Payment adjustments will impact clinician MPFS payment starting Jan 1, 2019
Medicare Access and CHIP Reauthorization Act.
Meaningful Use, Value-Based Payment Modifier, and Physician Quality Reporting System.
Electronic Health Record.
Source: CMS, “CY 2016 Physician Fee Schedule Final Rule,” Oct 30, 2016, Advisory Board interviews and analysis.
At this point, I’m sure we are all familiar with MACRA, which is the law that repealed the Sustainable Growth Rate formula or SGR.
The law does two key things: It locks clinician payment rates at near zero growth. And it creates two new payment tracks—the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APM). Starting in 2019, provider Medicare payment adjustments each year will depend on which track our medical group falls into.
These two tracks, as shown here, are the Advanced Alternative Payment Model or APM track, which offers incentives for providers to move into downside risk models and the Merit-Based Incentive Payment System, or MIPS track. In this option, Medicare will consolidate and expand upon all three of providers’ pay-for-performance programs—Meaningful Use, the Value-Based Payment Modifier, and the Physician Quality Reporting System—into a single model. Starting in 2019, physicians in this track will face a range of payment adjustments, from payment reductions as much as 9% and increases of up to 27%.
Due to the stringent requirements for qualifying for the APM track set forth in both the legislation itself and CMS’s proposal, CMS projects that very few clinicians, in fact only 8% of clinicians, will likely qualify for the APM track. The vast majority (approximately 92%) of eligible clinicians will be subject to the MIPS payment adjustments in 2019.
Additionally, because this is a brand new program and there is a lot of uncertainty as to how CMS will calculate APM qualification, the Advisory Board and CMS both encourage all clinicians—regardless of payment model participation—to report under the MIPS track in 2017—the first year of the program.
The goal of this presentation is to walk through the details of the MIPS reporting requirements for each MIPS category and discuss the accepted reporting mechanisms medical groups can use to report under MIPS. Let’s start with a quick overview of the four MIPS categories.

4. Four MIPS1 Categories Make up Total Performance Score
Category
Description
Relative Difficulty
Quality
Clinicians must select 6 measures of the over 200+ available to report to CMS; score in this category not just awarded for reporting, but for high performance
Resource Use
Points awarded for cost savings; clinician scores based on Medicare claims, no reporting required
Clinical Practice Improvement
New category that rewards clinicians for clinical practice improvement activities; over 90 activities to choose from
Advancing Care Information
Tracks clinicians EHR2 use offering partial credit, can report as individual or group
Relative Weight of Each MIPS Category Over Time
Score based on peer performance benchmarks
Score based on Eligible Clinicians’3 own performance
Merit-Based Incentive Payment System.
Electronic Health Records.
Eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians.
Source: CMS, “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models,” May 9, 2016, available at: Advisory Board research and analysis. ;
Under the MIPS track, clinicians are scored on their performance across four categories: quality, cost/resource use, clinical practice improvement, and advancing care information. As shown on the right, a provider’s quality performance will determine 50% of their performance score in the first year, outweighing performance in each the other three categories. However, over time the relative weights of each of these categories will begin to even out and the resource us category will grow from 10% to 30%.
Given the unique scoring standards for each category, let’s take a look at the relative difficulty of achieving high performance in each.
The Quality and Resource Use categories are relatively difficult. That’s because there are many complex requirements to learn. And, how well clinicians perform will be based on peer benchmarks. So providers will be competing with all other MIPS participants to get the highest possible score. Of these two, Quality is where most groups should focus because it makes up 50% of the performance score in 2017 and we have more opportunity to inflect our performance by selecting the measures that make our group look good.
The Clinical Practice Improvement Activities category on the other hand, is relatively easier to achieve high performance. The requirements are more straightforward to understand, and the score is based a clinician’s own performance. Meaning, how they score depends on whether they perform certain activities or not.
The Advancing Care Information category is moderately difficult. The EHR use measures can be challenging, but since MU has been around for several years, many providers will have experience already. And similar to CPIA, how well clinicians do is based on their own performance on the measures, not their relative performance according to a benchmark.
Now that we have a high-level understanding of the relative ease or complexity of performing well under these categories, let’s take a closer look each category and the new reporting requirements clinicians and groups will be expected to meet.
Let’s start with the quality category since it will be the highest weighted category in 2019.

5. MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures; Generous Bonus Points
PQRS
MIPS Quality
Quality Measures
Report 9 measures across 3 National Quality Strategy Domains
Groups of 100+ EPs reporting via GPRO are required to also report all Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey measures
Report 6 measures,1 including at least 1 outcome measure and 1 cross-cutting2 measure
CAHPS measure is an optional quality measure for groups of 2 or more ECs
3 additional population-based measures3 based on claims data
Data Submission
Use 1 of the allowed reporting mechanisms
Use 1 of the allowed reporting mechanisms
MSSP/Next Gen ACO entities do not separately report
Data Completeness
Varies by type of reporting mechanism (e.g., 50% of the EP’s Medicare Part B fee-for-service patients for individual claim-based and qualified registry-based reporting)
90% of all applicable patients regardless of payer, if using QCDR,4 qualified registry, or is EHR-based
80% for individual EC’s applicable Medicare Part B patients, if using claims-based
Scoring
Measures are equally weighted for a maximum of 10 points each
A measure is included in the scoring only if minimum case requirement5 is met, so the total possible points can vary between ECs
Performance points assigned for a measure based on benchmark decile range created from the baseline year6
If more than the required six measures are reported, CMS will use highest scoring measures to determine adjustment
Special Considerations
Non-patient-facing ECs do not need to report cross-cutting measure
Generous bonus points7 awarded for:
Reporting extra outcome or high-priority measures8
End-to-end electronic reporting
Exceptions for certain specialty measure sets, ECs without 6 applicable measures and/or without applicable outcome measures, and CMS Web Interface reporting.
“Cross-cutting” measures are broadly available to all clinicians with patient-facing encounters regardless of specialty.
Incudes all-cause hospital readmission; acute conditions composite; and chronic conditions composite.
Qualified clinical data registry.
Minimum 20 cases for all quality measures, except 200 for all-cause hospital readmission for group reporting
Baseline year is 2 years before the performance year. For example, 2015 is the baseline for the 2017 performance year.
Each type of bonus point is capped at 5% of total possible points.
High-priority domains are appropriate use, patient safety, efficiency, patient experience, and care coordination.
Sources: CMS, “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models,” 81 FR , Federal Register, May 9, 2016, Advisory Board research and analysis.
The Quality category builds upon the existing Physician Quality Reporting System or PQRS program with a few changes. While the PQRS program pays clinicians for simply reporting, the MIPS quality category rewards clinicians according to their quality performance relative to a benchmark.
The quality category of the MIPS track is different from the PQRS program in four key ways:
Fewer measures to report: Under PQRS, clinicians have to report nine quality measures and only one of which must be a cross-cutting measure. However, under MIPS clinicians will be required to report only six quality measures, that include one cross-cutting measure and one outcomes-based measure. However, non-patient facing clinicians such as diagnostic radiologists don’t have to report cross-cutting measures. Under MIPS CMS will also assess three additional population-based measures that are based on claims data. Additionally, clinicians that participate in MIPS APMs such as the Medicare Shared Savings Program (MSSP) track 1 do not have to submit quality measures separately from their APM entity to meet the reporting requirements under this category.
Greater focus on specialist measures: Following complaints over the lack of specialist measures, CMS prioritized increasing the number of measures available for specialists to report. 80% of the 200+ measures available for reporting are now specialist measures.
More data necessary to meet data completeness requirements: Under PQRS, physicians are required to report quality measure data on at least 50% of applicable Medicare Part B patients, if they choose to report via quality registry or claim-based. Under MIPS, however, CMS proposes to significantly increase the data completeness requirements. Physicians would have to report quality measure data that covers either 90% of all applicable patients, regardless of payer, for those using QCDR, qualified registry, or EHR-based reporting or 80% of an individual Eligible Clinicians applicable Medicare Part B patients if using claims-based reporting. Thus, CMS is requiring clinicians and groups to report much more data than they’ve traditionally been used to in the past and in some cases even report on non-Medicare patient data.
Bonus points are possible: Clinicians can get bonus points in the Quality category for reporting additional high-priority measures, or for reporting measures electronically under MIPS—a luxury that is not available under PQRS.
The scoring for the Quality category can get fairly complicated. Each measure is generally worth up to 10 points. But there are exceptions, and we might not get scored on every measure we report because the minimum case requirements are not met. Thus the total possible points clinicians are assessed against can vary.
Finally, it is important to know how CMS will determine the benchmark for each measure. According to the proposed rule, 2017 serves as the performance year for 2019—the first MIPS payment year. However, the baseline year that CMS will use to determine the quality measure benchmarks is actually two years prior. Thus 2015 data will be used to create the measure benchmarks in 2017, which will determine clinician payment adjustments in 2019.

6. MIPS Resource Use Performance Category
New Cost Measures; Performance Assessment Based on Claims
VBPM
MIPS Resource Use
Cost Measures
6 measures
Total Per Capita
Medicare Spending Per Beneficiary (MSPB)
Four Per Capita Costs for beneficiaries with four specific conditions (DM,1 CPOD,2 CAD,3 CHF4)
Total number of measures assessed depend on applicable episode-based measures
MSPB
New! 41 clinical condition and treatment episode-based measures
Data Submission
ECs/groups do not need to separately report data for this category. CMS uses the data submitted through administrative claims to assess cost performance.
Minimum Case Required
20 cases for Total Per Capita and 4 Per Capita Costs with specific conditions
125 cases for MSPB
20 cases for all measures
Attribution /Level of Analysis
Cost measures are evaluated at a TIN level
Individual reporting: TIN/NPI5 level
Group reporting: TIN level
Scoring
Measures are equally weighted for a maximum of 10 points each
A measure is included in the scoring only if minimum case requirement is met, so the total possible points can vary between Eligible Clinicians
Performance points assigned for a measure based on benchmark decile range from the performance year
Special Considerations
Resource use reweighted to “0” for
Non-patient-facing Eligible Clinicians
MIPS APM preferential scoring standard
Diabetes mellitus.
Chronic obstructive pulmonary disease.
Coronary artery disease.
Congestive heart failure.
National Provider Identifier.
Sources: CMS, “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models,” 81 FR , Federal Register, May 9, 2016, Advisory Board research and analysis.
Next, the Resource Use category incorporates the cost component of the Value-Based Payment Modifier or VBPM program. Importantly, under this category we don’t need to separately report data to CMS. CMS will base performance on our claims data.
The Resource Use category introduces three key changes from the VBPM program:
New episode-based measures: CMS is carrying over two of the cost measures from the VBPM program and adding new episode-based cost measures for specialists.
Re-setting minimum case numbers: Under VBPM and MIPS in order for a metric to be considered it has to have a minimum number of cases. Under VBPM that minimum number of cases ranged from as low as 4 cases to as high as 125 cases. However, the Resource Use category of the MIPS streamlines this requirement by mandating that all measures only have to have 20 cases.
Individual clinician-level assessment now available: Under VBPM, all cost measures are evaluated at the Tax ID number level. However, under MIPS clinicians that choose to report as individual clinicians can have their cost data assessed at the National Provider Identifier number.
Critically, clinicians and groups that participate in Alternative Payment Models such as the MSSP track 1 are not given a score under the Resource Use category of the MIPS track. Instead, for those clinicians and groups the Resource Use category is re-weighted to zero and the category weight is re-distributed to the Clinical Practice Improvement Activities category, increasing the weight from 15% to 20%, and the Advancing Care Information category, increasing the weight from 25% to 30%.
As with the quality category, the scoring for the Resource Use category can be fairly complicated. Each Resource Use measure is generally worth up to 10 points. However, the total possible points can vary because not every measure might apply to us.
Unlike the Quality category, the benchmark for the Resource Use category is not based on data from two years prior. Instead, CMS has proposed that for this category the benchmark will be determined using performance data from the performance year itself.

7. MIPS CPIA Performance Category
Brand New Requirement; More Than 90 Activities to Choose From
Two measure types
Nine Activity Groups H
High-weighted activity: 20 points
Expanded Practice Access
Care Coordination
Population Management
Patient Safety and Practice Assessment
Participation in an APM2
Achieving Health Equity
Emergency Preparedness and Response
Beneficiary Engagement
Integrated Behavioral and Mental Health M
Medium-weighted activity: 10 points
Reporting Requirements
The activity must be performed for at least 90 days during the performance period
Yes/no response for CPIA activities included in the CPIA inventory
Special Considerations
Scoring
Maximum score of 60 points
Any combination of high-weighted or medium-weighted activities
Reporting Flexibility: The following types of ECs and groups may report any 2 activities to receive full credit; each activity is worth 30 points.
Small groups (15 ECs or less)
Groups located in rural areas or HPSAs1
Non-patient-facing ECs
Example
Reported Activities
Points Earned 1 50 2 60 3 M H M H
Scoring Flexibility: Certain participants get preferential scoring.
MIPS APM: Automatic 30 points
Certified PCMH: Automatic 60 points M H
Health Professional Shortage Areas.
including a medical home model.
Sources: CMS, “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models,” 81 FR 28161, Federal Register, May 9, 2016, Advisory Board research and analysis.
The Clinical Practice Improvement Activities or CPIA category is a brand new category with a new set of reporting requirements that clinicians and groups have not had to report on before. In this category CMS is looking for evidence of practices seeking to enhance certain practice transformation activities such as care coordination, beneficiary engagement, and patient safety.
There are nine types of measures within this category and a total of over 90 activities to choose from. CMS requires that the activity must have been performed for at least 90 days during the performance period in order for a medical group to report it.
The scoring for this category is fairly straightforward. High weighted activities are worth 20 points, and medium weighted activities are worth 10 points. The maximum category score is 60 points, and clinicians can get full credit by reporting any combination of high or medium weighted activities.
The CPIA category offers a lot of flexibility for many clinician types, including preferential scoring for some. For example those that participate in MIPS APMs (i.e. MSSP track 1) automatically get 30 points in this category and those that participate in a certified patient centered medical homes automatically receive 60 points. Additionally, small or rural groups and non-patient facing clinicians get full credit for reporting only two activities under CPIA.

8. MIPS ACI Performance Category
New Name for MU; Rewards Participation and Performance
How Three Key Tenets of MU Change Under ACI MU
ACI
Changes
Year
2017
2018+
Objectives and Measures
Modified Stage 2  OR
Stage 3 (optional)
Stage 3
ACI measures correlating to Modified Stage 2; OR ACI measures correlating to Stage 3
ACI measures correlating to Stage 3
Slight changes, a few measures easier
CEHRT Allowed
2014 and/or 2015 Edition
2015 Edition only
No change
CQM Reporting
9 measures
No longer required as it is combined with the quality category
Aligned
Scoring
Special Considerations
Hospital-based3, advanced practitioners, and those qualifying for hardship are not scored (i.e., ACI category reweighted to zero)
First-time participants do not have a shorter reporting period in ACI, unlike MU
New data submission mechanisms allow for reporting alignment
Type
Possible Points
Base 50
Performance1
Modified Stage 2: 60 Stage 3: 80
Bonus2 1
Total
Capped at 100
Measures are equally weighted for a maximum of 10 points each. Points are awarded based on numerator/denominator performance rate, e.g., 95% performance equals 9.5 points.
Up to one bonus point total is awarded for reporting any public health measure in addition to Immunization Registry.
A MIPS eligible clinician who furnishes 90 percent or more of his or her covered professional services in sites of service identified by the codes used in the HIPAA standard transaction as an inpatient hospital or emergency room setting in the year preceding the performance period.
Sources: CMS, “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models,” 81 FR , Federal Register, May 9, 2016, Advisory Board research and analysis. ;
Finally the Advancing Care Information or ACI category is the rebranding and restructuring of the Medicare Meaningful Use (MU) program.
The ACI category introduces three key changes from the MU program:
Partial credit now allowed: Meaningful Use is an all or nothing program, meaning physicians would either get full or no credit fore each measure. ACI on the other hand offers partial credit, and offers a baseline number of points for participation.
Non-physician clinicians will be included after first performance period: Unlike the current MU rules, non-physician advanced practitioners such as physician assistants, and nurse practitioners will not be exempt from ACI requirements. However, as proposed, CMS has made an exception to this rule for the first year of the program, meaning that Advanced Practitioners will not be held accountable for performance under the ACI category until 2018.
Reporting can be at the individual or group level: ACI also allows clinicians to report as an individual or group, while MU does not. Additionally, unlike MU, first time participants do not have a shorter reporting period under ACI.
In terms of scoring, the ACI category credits providers 50 base points for minimum participation across all the ACI measures. Clinician can also get additional credit of up to 10 points each for performance on certain measures, and up to 1 bonus point if they report an optional public health measure in addition to the base score requirements. Clinicians or groups that score 100 or more points get full credit for this category.
Now that we have walked through the specific new reporting requirements under each of the MIPS categories, let’s turn to the reporting mechanisms we can use to report this data to CMS.

9. Understanding the Range of MIPS Reporting Mechanisms
Qualified Clinical Data Registry (QCDR)
EHR
Qualified Registry
Meets specific CMS qualifications but scope of registry is not limited to PQRS measures For more: QCDRs available
Office of the National Coordinator- certified EHR submits data directly to CMS For more: certified EHRs available
Meets specific CMS qualifications and scope of registry is limited to PQRS measures For more: registries available
CMS Web Interface
Attestation or Claims
CAHPS1 Vendor
Group practice reporting option via CMS’ QualityNet web site
For more: see QualityNet
CMS certified vendor used for combined CAHPS and PQRS reporting For more: see approved vendors
Attestation: TBD, CMS may utilize existing MU attestation portal
Claims: Coded data inputted through claims
Consumer Assessment of Health Providers and Systems.
Sources: CMS QCDRs; CMS EHR Reporting; CMS Qualified Registries; CMS Web Interface Group Reporting Option; CAHPS Vendor; Advisory Board research and analysis. ;
When it comes to submitting performance across these categories, we have several reporting options to choose from including Qualified Clinical Data Registry or QCDR, EHR direct, Qualified Registry, CMS Web Interface for group reporting, Attestation, Claims, and certified vendors for groups that choose to submit CAHPS measures.
Included below each mechanism are links which provide more detailed information on each reporting mechanism as well as lists of vendors providers can use.
When thinking about the various reporting options, it is important to understand those mechanisms that will allow us to meet all of the new MIPS reporting requirements.

10. MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
MIPS Data Submission Mechanisms: Report Individually or as a Group
Submission Methods
QCDR
EHR
Qualified Registry
CMS Web Interface1
Attestation
Claims2
CAHPS Vendor3
Quality
CPIA
ACI
Reporting Alignment
Quality Bonus Points
Vendor Readiness
Capability to report measures for all MIPS performance categories
Ongoing compliance with CMS vendor audits
End-to-end Electronic Reporting
Record data in CEHRT
Export and transmit data electronically
Option to use third party intermediary with automated software
Note: the red box denotes submission methods that allow reporting alignment opportunity.
Available for groups of 25 or more only.
Available for individual reporting only.
For groups only; must be a CMS-approved survey vendor for MIPS.
Sources: CMS, “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models,” 81 FR , Federal Register, May 9, 2016, Advisory Board research and analysis.
The three categories listed on the left here—Quality, CPIA, and ACI—require clinicians to submit data to CMS. The Resource Use category is not listed because there is no additional data reporting required. Along the top are all of the reporting mechanisms. Certain ones only apply to either individual reporting, or group reporting, as explained in the footnotes. CMS allows MIPS participants to be scored as an individual, or collectively as a group of clinicians within a single Tax ID Number. The black outline box shows the four reporting mechanisms that allow us to submit data across all these performance categories. Taking advantage of these mechanisms can reduce our reporting burden.
However, our ability to align reporting depends heavily on our vendor’s readiness. The three things we should look for in a vendor are:
1. Familiarity with our specific measures. We have to ensure our vendor is able to submit data for all measures we plan to report. Some vendors may already be familiar with data submission requirements for the Quality category, as they’re similar to what’s in place now for PQRS. But the other two CPIA and ACI category measures may be new to vendors.
2. Preparedness for CMS audits. CMS plans to audit vendors on an ongoing basis. If they don’t meet certain requirements, CMS could place them in probation, or even disqualify the vendor from submitting data in the following performance period. That is something we must watch out for as we select and work with vendors.
3. Commitment to ensuring client success under MIPS. It should be clear that the vendor we choose is committed to our success under the program.
One last note on this slide: It is possible for us to get bonus points in the Quality category if we use end-to-end electronic reporting, meaning we would have to use certified EHR technology to collect our data. And that data has to be exported and transmitted electronically to CMS, either directly from our system or through a third party intermediary that uses automated software to manage and submit data. So if our vendor can support end-to-end electronic reporting, that could give us a leg up on our Quality category performance.