MACRA and the Quality Payment Program  

Modifications to MIPS by the “Bipartisan Budget Act Of 2018”


The recently-enacted Bipartisan Budget Act of 2018 (Budget Act) added much-needed flexibility to the Merit-based Incentive Payment System (MIPS), Medicare’s physician payment system established by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The Further Extension of Continuing Appropriations Act, 2018 (HR1892) (officially renamed the “Bipartisan Budget Act of 2018”) enacted by the United States Congress and President Trump on February 9, 2018 extends the transition years for MIPS to include 2019, 2020 and 2021. This goes beyond the 2017 and 2018 transition years stated in the original MACRA legislation. There are also some changes included in the Act that apply to the 2018 MIPS performance year.

What Changes

  • Post-transition now begins in 2022, not 2019 and includes key requirements.
    • In 2022 the MIPS performance threshold must be the mean or median of national historical MIPS scores
    • The MIPS cost category must be weighted at 30% of the score
  • During the extended transition years of 2019 – 2021, the Health and Human Services (HHS) Secretary shall:
    • annually increase the MIPS performance threshold in a “gradual and incremental transition” towards the value mandated for 2022 (the first post-transition year),
    • set the MIPS Cost category weight to be between 10% and 30%, and
    • not factor year-to-year MIPS Cost improvement into the MIPS score for 2018 and extended transition years.

·         Beginning with the 2018 performance year, the MIPS payment adjustment percentage will be applied only to Medicare Part B “covered professional services”. That means, most prominently, no MIPS payment adjustment for Part B drugs. Hence, MIPS financial incentives and penalties in absolute dollars will be reduced somewhat by this change.

·         Similarly, beginning with the 2018 performance year, the low-volume exclusion for MIPS will now only be based on “covered professional services”, rather than items as well, such as Part B drugs. Hence, the low-volume exclusion will exclude somewhat more clinicians than before. This assumes that the dollar amount and patient count thresholds of the exclusion set by CMS remain as they are ($90k and 200 patients, respectively) in the 2018 QPP Final Rule.

What Remains the Same

  • The schedule of maximum MIPS penalties for low performance or non-participation without a MIPS exclusion does not change
    • -5% for the 2018 performance year
    • -7% for 2019
    • -9% for 2020 and beyond
  • CMS will still publicize MIPS scores, category scores, and 5-star performance ratings of quality measures. More than half-a-million clinicians’ scores will be publicly reported during 4Q 2018 for the 2017 performance year.
  • The compliance and reporting requirements for Quality, advancing care information (ACI) and improvement activities (IA) do not change, although Quality benchmarks will likely continue to rise.

Key Takeaways

  • Drive to value-based care. This Act reinforces CMS’ position that MIPS is a catalyst to move from FFS to value-based care. It further entrenches the MIPS program.
  • Clinicians may stay in MIPS longer. Easing the ramp up of the MIPS program may result in more clinicians and organizations deciding to remain in MIPS longer rather than entering an Advanced Alternative Payment Model (APM). MIPS becomes a safer “training ground” for clinicians to develop and practice value-based care improvement strategies before moving to more aggressive programs such as APMs.
  • CMS continues to drive continuous MIPS performance improvement. The Act requires CMS to continue to increase the MIPS performance threshold year-over-year to reach the required national mean or median by 2022. In the 2018 QPP Final Rule, CMS predicts that 74% of eligible clinicians will have scores of greater than 70 for 2018. For the 2022 performance threshold, if the historical national mean or median were to be, say, 75 points, then the average annual increase in the threshold from 2019 to 2022 would be 15 points per year, enough to encourage continuous improvement.
  • MIPS compliance and complexity persist. As the growing MIPS penalty remains, MIPS compliance will remain important. MIPS regulations and requirements will continue to be updated annually and semi-annually, making it essential for organizations stay on top of the program.
  • MIPS Cost will grow in importance. MIPS Cost remains at least at 10% until it must be 30% in 2022. This confirms CMS’ commitment to making cost performance part of MIPS.

·         MIPS public reporting is on track. As CMS projected, more than half-a-million clinicians’ 2017 MIPS scores and quality measures will continue to be publicly-reported in 2018 through the Physician Compare website or through a freely downloadable file. The reputational impacts of MIPS remain intact and are even more important as providers stay in MIPS for a longer period of time.

Under the original MACRA policy, the Centers for Medicare & Medicaid Services (CMS) would have been required to establish the performance threshold for avoiding a penalty under MIPS at the mean or median performance of all participants beginning in 2019. MACRA includes a special rule for 2017 and 2018 giving CMS the authority to establish different threshold for success. CMS did so, setting a threshold of three points for 2017 and 15 points for 2018. 

In the Budget Act, Congress extended the flexibility for CMS to establish a threshold other than the mean or median for an additional three years as physician practices adapt to the new value-based payment program and CMS reduces administrative burden and provides feedback.   

CMS Releases Final Rule for the Quality Payment Program, Year 2


The most significant change impacting the chiropractic profession is the increase in the low volume threshold (LVT).  For 2017, providers were exempted from participation in MIPS if their Part B allowables were less than or equal to $30,000 or if they had 100 or fewer Medicare beneficiaries as patients.  For 2018, CMS has increased the LVT.  Providers are now exempted from MIPS if their Part B allowables are less than or equal to $90,000 or if they have 200 or fewer Medicare beneficiaries.  This reduces the number of chiropractors who are eligible to participate in MIPS by almost 1000 - for 2018 just under 600 chiropractors will be eligible.

For additional details on what has changed in Year 2 of the Quality Payment Program, please see the following resources:

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law in April 2015, fundamentally changes how physicians and other clinicians are reimbursed under the Medicare Physician Fee Schedule (PFS). The MACRA law permanently repealed the fatally flawed Medicare Sustainable Growth Rate (SGR) methodology for updates to the PFS, and replaced it with a payment structure that creates incentives for the delivery of value-based, high-quality, efficient patient care versus volume-based care.

MACRA was designed to offer providers two new Medicare payment model pathways. On Oct. 14, 2016, the Centers for Medicare and Medicaid Services (CMS) released a final rule that detailed the regulations for creation and implementation of these new payment system pathways, collectively referred to as the Quality Payment Program (QPP). As of Jan. 1, 2017, doctors of chiropractic are eligible to participate in one of the pathways. Learn more by clicking the links below.

An Introduction to MACRA

Overview of the Merit-Based Incentive Payment System (MIPS)

MIPS Eligibility and Participation

MIPS Performance Categories

MIPS Performance Scoring and Payment Adjustments

Where Do I Begin? 

MACRA and QPP Resources

MACRA Education Videos (available to all)