Uprise EHR & PM Blog



MACRA, MIPS, and APMs: The Basics

Posted by Janelle Pauli on Jul 23, 2016 11:00:00 AM

Just when you might have thought you had a handle on government regulations and programs, we're throwing some new terms your way. Let's start by defining these three new acronyms so you can better understand how they could affect your eyecare practice. 

  • MACRA (Medicare Access & Chip Reauthorization Act of 2015)
  • MIPS (Merit-Based Incentive Payment System)
  • APMs (Alternate Payment Models)

Most of our information about MACRA we found on the cms.gov website, so if you're looking for more information or additional resources we think that's a great place to start. 

A Quick Overview of MACRA, MIPS, and APMs

According to CMS.gov, the MACRA makes three important changes to
how Medicare pays those who giveMACRA program care to Medicare beneficiaries. These changes create a Quality Payment Program (QPP):

  • Ending the sustainable growth rate formula for determining Medicare payments for health care providers' services.
  • Making a new framework for rewarding health care providers for giving better care, not just more care.
  • Combing the existing quality reporting programs into one new system. 

The proposed changes above will replace a patchwork system of Medicare reporting programs with a more flexible system that allows you to choose from two paths that link quality to payments: MIPS and APMs.

What is MIPS?

MIPS is a new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-Based Payment Modifier), and the Medicare Electronic Health Record (EHR) Incentive Program into one single program that Eligible Professionals (EPs) will be measured on.

EPs are measured on:

  • Quality
  • Resource Use
  • Clinical Practice Improvement
  • Meaningful Use of Certified EHR Technology

The MIPS program is scheduled to launch on January 1, 2017.

  • April 27, 2016: CMS released proposed MACRA rules
  • November 1, 2016: MACRA final rule to be published
  • January 1, 2017: First MIPS performance year begins

Depending on an EP's performance, they may receive a payment adjustment in the form of an increase or decrease in payment, or no payment at all. These payment adjustments will start in 2019 at 4%, and progress to 9% by 2022.

What is APMs?

APMs establishes alternative, incentivized ways for physicians to receive payment, including:

  • A Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO)
  • An expanded, innovative payment model
  • A Medicare Acute Care Episode Demonstration Program of Medicare Health Care Quality Demonstration Program
  • Other demonstration programs necessary per the federal law

Participation in APMs makes EPs eligible for certain incentives. For example, if you're labeled as a "qualifying APM participant" you'll get a lump sum incentive payment equal to 5% of the previous year's appropriate combined expenses based on the applicable fee schedule. Incentive payment will begin in 2019 through 2024. Physicians who qualify as APM participants will not be hit with MIPs adjustments. 

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