MIPS and APMs Lecture Review

This set covers vocabulary and key concepts related to MIPS and APMs as established by MACRA, including scoring components, penalties, and alternative payment models.

MACRA

The Medicare Access and CHIP Reauthorization Act of 2015, which replaced the Sustainable Growth Rate ($SGR$) and established MIPS and APMs.

Sustainable Growth Rate ($SGR$)

The previous system replaced by MACRA that had an almost $30\%$ pay cut for doctors which was patched by Congress each year.

Merit-Based Incentive Payment System (MIPS)

A program that uses Medicare payment adjustments based on a composite performance score to achieve cost and quality goals.

Eligible Clinicians (ECs)

The healthcare providers in the MIPS program who can receive payment bonuses, penalties (up to $-7\%$), or no adjustment to Medicare Part B payments.

MIPS Composite Performance Score Elements

A four-part scoring system consisting of Quality ($30\%$), Improvement Activities ($15\%$), Promoting Interoperability ($25\%$), and Cost ($30\%$).

MIPS Quality Component

A category worth $30\%$ of the MIPS score where ECs report on at least 6 Quality Measures, including one outcome measure.

MIPS Improvement Activities (IA)

A category worth $15\%$ of the MIPS score requiring ECs to attest to completing 4 activities (2 for some rural practices) for at least $90$ days each.

MIPS Promoting Interoperability (PI)

A category worth $25\%$ of the MIPS score requiring the use of a CMS-certified EHR and reporting measures such as ePrescribing and clinical data registries.

MIPS Cost Component

A category worth $30\%$ of the MIPS score that replaces the Medicare Value Modifier Program and calculations like MSPB and TPCC.

Medicare Spending per Beneficiary (MSPB)

A cost metric including Medicare Part A and B costs surrounding an admission, covering $3$ days before, during, and $30$ days after admission.

Total per capita Cost (TPCC)

A cost calculation of all Part A and Part B costs for a Medicare beneficiary over the span of a year.

MIPS Non-Participation Penalty

A penalty of $-9\%$ applied to Medicare Part B payments for clinicians who do not participate in MIPS.

Maintenance of Certification (MOC)

Specialty Board programs for members that can qualify for MIPS IA activities if they are practice-wide and last at least $90$ days.

Alternative Payment Method (APM)

A narrow network payment approach formed to target specific issues like clinical conditions or populations while providing high-quality, cost-efficient care.

Qualified Providers (QPs)

Clinicians in APMs who can receive up to a $5\%$ bonus on Medicare Part B payments, typically if $> 50\%$ of their income is through Medicare Part B.

Advanced APMs

A type of APM that offers advantages such as higher incentives and exclusion from MIPS reporting requirements.