• Updated Dec. 22, 2016

    The Academy’s health policy experts are answering your questions on the Centers for Medicare & Medicaid Services forthcoming Medicare physician payment system. If you have a question you would like added to this document, email healthpolicy@aao.org.

    MACRA and MIPS Overview Q&A

    What is the Medicare Access and CHIP Reauthorization Act (MACRA)?

    MACRA is legislation passed in 2015 by Congress. It is a massive overhaul of how the federal government pays physicians who see Medicare patients. MACRA eliminated the sustainable growth rate, but preserves fee-for-service payments. The policy consolidates several quality-reporting programs into a single, system, the Quality Payment Program (QPP). This system has two tracks:

    1. the Merit-Based Incentive Payment System (MIPS) and 
    2. the Advanced Alternative Payment Model (APM). 

    Under MACRA, physicians can choose from either of the two tracks in which to participate. The vast majority of physicians, including ophthalmologists will be in MIPS initially.

    Based on their 2017 performance in MIPS or an APM, physicians will receive positive or negative Medicare payment adjustments beginning in 2019.

    How will MACRA impact my Medicare payments?

    Under MACRA, all physicians will receive a 0.5 percent update to the annual conversion factor (before sequestration or adjustments due to impacts from budget neutrality factors) from 2016 through 2019. For 2020 to 2025, no update is guaranteed. Physician updates will be based on performance in in either the MIPS or the APM track. Physicians will then receive that track’s associated bonus or penalties.

    When and how can I begin my MACRA preparations?

    Academy members should start preparing their practices for MIPS now. The Centers for Medicare & Medicaid Services intends to launch the program Jan. 1, 2017. 

    You can start your preparations by taking the following steps:

    • Designate a physician to oversee MACRA planning. 
    • Review the Academy’s MACRA and MIPS webpages. 
    • Sign up for the Academy’s IRIS Registry and consider EHR adoption. 

    Additionally, if you haven’t yet integrated your EHR system with the IRIS Registry (aao.org/irisregistry), you should look into doing so in 2017. The proposed policy promotes the use of Qualified Clinical Data Registries (QCDRs), which include the IRIS Registry. This enables electronic reporting on three of the four MIPS performance categories. Additionally, CMS has made it clear that it plans to expand the role of these clinical data registries in MIPS as the policy evolves.

    What is the Merit-Based Incentive Payment System (MIPS)?

    MIPS is the consolidation of several, current federal quality reporting programs into a single entity. In the same way it rolled out other quality-payment programs, CMS will enact a two-year lag before payments are impacted. This means the impact to physician Medicare payments will be felt starting in 2019.

    Of MACRA’s two tracks (the other being Advanced APM), MIPS is the fee-for-service option. MIPS is the program in which most Medicare physicians will initially participate under MACRA. For the foreseeable future, it is the path for the majority of ophthalmologists.

    MIPS will measure physicians’ and groups’ performance in four categories. These categories and their proposed initial weights are outlined below:

    • Quality (replaces the current Physician Quality Reporting System), 50 percent weight;
    • Resource use (replaces the current Value-based Modifier), 10 percent weight;
    • Clinical practice improvement (a new category), 15 percent weight; and
    • Advancing care information (replaces current meaningful use of electronic health records program), 25 percent weight.

    How will MIPS impact my Medicare payments?

    Under MIPS, physicians and groups will be eligible to earn a positive or negative payment adjustment to their Medicare fee for service payments. This adjustment is based on performance.

    In 2019, the plus/minus payment adjustment is 4 percent, based on 2017 performance. The positive adjustment could be positively scaled to three times that percentage. CMS predicts an even split between positive and negative payment adjustments. For comparison sake, this is an improvement from 2017 and 2018, during which time physicians are expecting penalties as high as 9-11 percent, based on existing quality and value-based payment programs. CMS also estimates that approximately 55 percent of ophthalmologists will receive a bonus under MIPS. This prediction is based on how our profession performed in 2014 under previous programs.

    MIPS participants will receive a composite score based on how they perform in each of the program’s four categories. This score will be compared against a national benchmark. How much the payment is adjusted will be determined by CMS. The agency will base its determination on where a provider’s score falls compared to the national benchmark. Physicians can get partial credit for some activities.

    The maximum plus-or-minus payment adjustment amount will increase to 5 percent in 2019, followed by a 7-percent increase in 2020, and 9 percent in 2021. It will be capped at 9 percent thereafter. Physicians that do not successfully participate in MIPS or an advanced APM will earn the highest penalty amount.

    What is the Alternative Payment Model? What are my APM options under MACRA to qualify for the 5 percent bonus?

    Alternative Payment Models are voluntary models that change the way the CMS pays physicians. Some examples may include: accountable care organizations; patient-centered medical homes; and bundled payment models.

    Physicians can elect to participate in an advanced APM instead of the Quality Payment Program’s MIPS track. CMS has proposed that physicians who sufficiently participate in an Advanced APM qualify for a 5 percent Medicare Part B incentive payment. These physicians would also be exempt from MIPS payment adjustments for years 2019-2024.

    Are all APMs considered advanced APMs?

    Not all APMs are considered “advanced.” At MACRA’s onset, there are only a few CMS-proposed models that qualify as advanced APMs. Advanced APMs require the following of participants:

    • bear financial risk, 
    • base payments on quality measures, and 
    • require participants to use certified EHR technology. 

    In its proposed rule, CMS listed only six models that would qualify as an advanced APMs:

    1. Comprehensive End Stage Renal Disease Care Model; 
    2. Comprehensive Primary Care Plus; 
    3. Medicare Shared Savings Program—Track 2 and Track 3; 
    4. Next Generation ACO Model; and 
    5. Oncology Care Model Two-Sided Risk Arrangement. 

    APMs that do not qualify as an Advanced APM may count as APMs under the Merit-Based Incentive Payment System, which can enable participating providers to earn some credit under the MIPS program.

    If I am in an alternative payment model (such as an ACO), do I still have to participate in MIPS?

    Only APM participants who successfully participate in an advanced APM, assuming they meet the required thresholds, will be exempt from MIPS. The majority of physicians will only be eligible for MIPS. This includes many APM participants.

    At MACRA’s onset, there are only a few CMS-proposed models that qualify as advanced APMs. This is due to the requirement of two-sided financial risk. In addition, advanced APM participants must see enough of their payments or patients through that mode. Initially, that will be 25 percent of payments, or 20 percent of patients.

    You must participate in MIPS if your APM does not qualify as an advanced APM. You must participate in MIPS if you cannot meet the thresholds for advanced APM participation. However, participation in an APM may help you meet some of the MIPS reporting requirements. These requirements include quality reporting and clinical practice improvement.

    I am choosing to ignore MACRA, MIPS and APMs. Can I still see Medicare patients and get paid?

    Some physicians — for example, those planning to retire in the near future — may choose not to participate in MIPS or an APM. These physicians can continue to see Medicare patients. They will receive fee-for-service-based payment for treating these patients. However, they will also experience reduction in their Medicare payments two years later. These payments will be reduced by the amount of the maximum MIPS penalty. In 2019, the maximum penalty will be 4 percent. It will increase to 9 percent in 2021.

    How does the Academy’s IRIS Registry help with MIPS?

    We expect that the IRIS® Registry will play a big role in helping you meet federal quality-reporting requirements.

    As with PQRS, the IRIS Registry will support our members’ participation in the MIPS quality category. Participating physicians — with and without EHR systems — will continue to have multiple ways to meet the requirements of quality reporting.

    We also expect the IRIS Registry will help you meet the requirements of the new clinical practice improvement category. This is a new category, for which CMS outlined a number of activities in which a physician could choose to perform. Physicians will earn points in each activity, which will count toward their overall category performance. Several of those proposed activities will give credit to physicians who use the IRIS Registry or another clinical data registry.

    The IRIS Registry will also enable physicians to earn some credit in the advancing care information category. CMS is also proposing a new registry-centric reporting option in which data submission to CMS on behalf of physicians is permitted. This would be an alternative to using CMS’ attestation system. The Academy is exploring the feasibility of offering this service for our members in the future. We will decide after the final rule’s release.

    Who do I contact for help with my MACRA planning?

    The Academy is your best resources for all things related to MACRA. We will provide more information on this program over the next few months, including how the IRIS Registry will support your success. Visit AAO.org for more information. You can also contact the Academy at healthpolicy@aao.org.

    'Implementing MIPS in Your Practice' Webinar Q&A

    On Nov. 18, Academy experts presented a live webinar, “Implementing MIPS in Your Practice.” View these and other questions submitted to mips@aao.org: