As we highlighted in our last blog post on MACRA, the goal as stated by the Department of Health and Human Services back in January of 2015 is to tie 95 percent of Medicare payments to quality or value through a combination of two tracks.

There are two main paths through which to participate in the new Quality Payment Program: the Merit-based Incentive payment System (MIPS) and the incentive-based Advanced Alternative Payment Model (APMs). Initially, the majority of physicians won’t be able to transition to the APM model and will therefore land on the MIPS path, which will adjust traditional fee-for-service payments upward or downward based on the new reporting program.

Changes coming yellow highway road sign against summer blue sky with clouds


MIPS will streamline PQRS, Value-based Modifier and Meaningful Use into its one program, broken out into four performance categories (the last adjustments for these three programs will take place in 2018 while the new MIPS adjustments will take their place in 2019). The MIPS composite performance score (CPS) will be based on four performance categories. Each performance category is weighted differently and add up to be one single composite performance score. An EC’s total score will be compared against a performance benchmark and the adjustments will be associated with that score.

The four performance categories under MIPS are:

  1. Quality
  2. Resource Use
  3. Clinical Practice Improvement Activities (new) (participation in an APM counts for
  4. Advancing Care Information (EHR Incentive)


MACRA creates extra incentives for participation in an advance APM. CMS states that MACRA does not change how any particular APM functions or rewards value; APMs are supported by their own payment rules. In order to become a qualifying APM participant (QP), providers must participate in an advanced APM for at least one year, and an APM must meet certain criteria to become an advanced APM. According to MACRA, an advanced APM must:

  • Require 50% of its eligible clinicians to use certified EHR technology
  • Base payments on quality measures comparable to those under MIPS
  • Either require APM Entities to bear more than nominal financial risk for monetary losses or be a medical home model that has been expanded under the CMS innovation center authority (this is a future goal; these expanded medical home models don’t exist yet)

Stay tuned as we dive deeper into the components and timeline of MIPS and MACRA. Next we will go over who is subject to MIPS. The comment period for MACRA closed on June 27, 2016 and we’re currently still in the rulemaking stage. The 2017 Physician Fee Schedule Proposed Rule, MACRA Final Rule for the 2017 performance period and 2019 MIPS payment adjustment period, and annual list of MIPS quality measures for the 2017 performance period are expected this fall.