MACRA and MIPS: A Resident Primer

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As residents, attending physicians often insulate our learning environment from the political whirlpool of insurance reimbursements. However, the education and awareness of the financial climate affecting our daily practice is crucial to our training as radiologists. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is frequently reported on in medical news and literature.

Let me briefly define the basics of MACRA from the resident perspective.

MACRA reforms the former physician reimbursement model from volume-based to value-based. This vision is implemented through the Quality Payment Program (QPP), one of many provisions outlined in the 2,398-page document.

Prior to MACRA, payers reimbursed physicians with a fee-for-service structure. Medicare sought to cap the rising costs through the Sustainable Growth Rate (SGR), enacted by Congress in 1997. Colloquially referred as the “doc fix,” the SGR avoided cuts to physician reimbursements by rolling over the cuts to the following year, annually, thereby continually deferring cuts to reimbursements.

Through the passage of MACRA, the SGR became obsolete. The QPP intends to reward physicians and practitioners for quality over quantity, shifting the payment model to focus on population health. Under the QPP umbrella, two tracks exist: the Merit-based Incentive Program (MIPS) and the Advanced Alternative Payment Models (APMs). QPP outlines six goals:

  1. Improve beneficiary outcomes
  2. Maximize clinician participation
  3. Enhance clinician experience
  4. Improve data and information sharing
  5. Increase Advanced APM accessibility
  6. Ensure operational excellence

Most physicians are MIPS-eligible. Transitioning from volume- to value-based reimbursement requires the consolidation of three previously implemented individual quality-based programs: the Physician Quality Reporting System (PQRS); the Value-based Payment Modifier (VPM); and the Medicare Electronic Health Records Incentive Program (MEHRIP).

The MIPS program gauges physician performance through four categories:

  1. Quality, replacing PQRS
  2. Advancing Care Information, replacing MEHRIP
  3. Improvement Activities, a new metric
  4. Cost, replacing VPM

This new category of Clinical Practice Improvement Activities (CPIAs) intends to reward clinicians and practices that devise strategic programs aimed at patient care coordination; shared decision-making; beneficiary engagement; and patient safety. To receive credit, you must submit at least 90 days of CPIA reporting during the performance period (one year). CMS approves 90 types of qualifying CPIAs for physicians to use. With some exceptions, the CPIA component of QPP constitutes 15 percent of the final QPP score.

Medicine no longer adheres to fee-for-service. Payers, patients, and health systems require demonstrable outcome measures designed around improving the delivery of health care. The first performance period for MIPS began January 1, 2017. All measured data must be reported to CMS by March 31, 2018. Practices opting not to participate in MIPS will see a negative four-percent adjustment in payment next year.

As radiologists, we are poised to significantly improve patient care through quality initiatives. As residents, our training affords us the position to design, test, and deploy novel methods to improve patient care. As a follow up to this article, radiology-focused quality initiatives will be highlighted here on the ACR-RFS Bulletin blog, along with the continued reporting of significant news on MACRA.

MichaelCHeadshotBy Michael A. Chorney, MD, Resident at University of Pennsylvania Health System, Philadelphia

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