Medicare physician payment reform — it’s been called MACRA, MIPS, the QPP and a host of other names. Whatever you call it, though, it is at its core a serious shakeup of what you’ve grown accustomed to for Medicare payment.
New system, new vocabulary
With this new system comes an entirely new lexicon for you to learn. This glossary is your way around the labels, terms, acronyms and alphabet soup of the new policy.
Some of these terms you’ll only find in Centers for Medicare and Medicaid Services materials. Some terms become outdated under the new policy, but remain useful for contextual reasons. If you have a term you’d like to see added, email email@example.com.
ACA (Affordable Care Act) - Officially called the Patient Protection and Affordable Care Act of 2010, and also known as “Obamacare.” This massive legislation included many parts that continue to play a role under the new Medicare physician pay system.
ACI (Advancing Care Information) - This is what was formerly known as the Electronic Health Record Incentive Programs, or more commonly, “meaningful use.” It covers the technological aspects of the Merit-based Incentive Payment System.
ACO (Accountable Care Organization) - ACOs are groups of physicians, hospitals, and other health care providers. These practitioners come together voluntarily to give coordinated high quality care to their Medicare patients. Some ACOs participating in CMS programs will qualify as Advanced APMs if they meet certain criteria. Most, however, will not, at least not initially.
APM (Alternative Payment Models) - New approaches to paying for medical care of Medicare patients that incentives quality and value.
Advanced APM - An “Advanced APM” meets the following criteria: it must meet the legislative definition of an APM; participants must use a certified EHR; payment must be based on quality measures comparable to those used in MIPS; and it must bear more than nominal financial risk. Not all APMs will qualify as “advanced.”
MIPS APM - A sub-set of APMs whose participants otherwise would be subject to the full range of MIPS requirements. This is in addition to their APM obligations. Because the criteria for the identification of MIPS APMs are independent of the criteria for Advanced APM determinations, a MIPS APM may or may not also be an Advanced APM. It is possible, therefore, for an APM meets all three proposed criteria to be a MIPS APM, but still fail to meet the Advanced APM criteria. Conversely, it would be possible that an Advanced APM does not meet the criteria because it does not include MIPS-eligible clinicians as participants. MIPS APMs meet the following criteria: (1) the APM entity participates in under an agreement with CMS; (2) the APM Entity includes one or more MIPS eligible clinicians on a participation list; and (3) the APM bases payment incentives on performance (either at the APM entity or eligible clinician level) on cost/utilization and quality measures.\
CAHPS (Consumer Assessment of Healthcare Providers and Systems) - A survey that measures patient experience. Voluntary participating in CAHPS for MIPS surveys would count as a cross-cutting or patient experience measure for quality scoring purposes.
CEHRT (Certified Electronic Health Record Technology) - An EHR product that is certified by the Office of the National Coordinator of Health Information Technology for use under meaningful use and ACI.
CHIP (Children’s Health Insurance Program) - This program provides health coverage to eligible children, both through Medicaid and separate CHIP programs. CHIP is administered by states, according to federal requirements and is funded jointly by states and the federal government.
CPIA (Clinical Practice Improvement Activities) - Clinical practice improvement activities that make up one component of the total MIPS Composite Score. There are over 90 proposed activities from which practices can choose to implement. Some of the categories for the activities include expanded practice access, population management, care coordination, beneficiary engagement, patient safety and practice assessment, emergency preparedness and behavioral health integration.
CPS (Composite Performance Score) - The sum of a MIPS participant’s performance scores for each of the four MIPS categories: Quality + Resource Use + Advanced Care Information + CPIA. It was previously referred to as the MIPS Composite Score. A MIPS participant’s CPS will be used by CMS to determine the MIPS payment adjustment.
CQM (Clinical Quality Measure) - CQMs measure and track quality of services provided by eligible clinicians. These are measures of aspects of patient care. They include health outcomes, clinical processes, patient safety, efficient use of resources, care coordination, patient engagement, population health, and adherence to clinical guidelines. Electronic CQMs (eCQMs) are those that electronically collected and calculated, including through an EHR.
EC (Eligible Clinician, formerly EP or eligible professional) - A new term used to indicate which professionals are qualified to participate in MIPs or an APM. Ophthalmologists and optometrists are considered ECs.
FFS (Fee for Service) - Most Medicare payments are based on services provided. Traditional Medicare (Part B) is based on fee-for-service payments.
MACRA (Medicare Access and CHIP Reauthorization Act of 2015) - This is the law that sunsets the flawed volume-based Sustainable Growth Rate. It replaces the payment system with one that is value-based. MACRA created the MIPS program and encourages participation in APMs. The goal is to create a sustainable payment system for physicians. The new payment system begins in 2019 and will be phased in over several years.
MIPS (Merit-based Incentive Payment System) - MIPS is a federal quality reporting program established by MACRA that provides payment adjustments to participants based on quality, technology, resource use (cost), and practice improvement. MIPS is the primary path for ophthalmologists under the Quality Payment Program. The Physician Quality Reporting System, meaningful use, and the value-based modifier will cease to exist individually. Instead, they will be consolidated into MIPS beginning in 2019.
MIPS Composite Score - Your MIPS score (in Year 1) will be based on performance in four categories: Quality Reporting, Advancing Care Information (formerly known as Meaningful Use), Clinical Practice Improvement Activities, and Resource Use. This is now referred to as the Composite Performance Score (CPS) (see above).
MSSP (Medicare Shared Savings Program) - MSSP was established under the Affordable Care Act to facilitate coordination and cooperation among providers through accountable care organizations. It was intended as a means for improving the quality of care for Medicare Fee-For-Service (FFS) beneficiaries, while reducing unnecessary costs. MSSP aims to improve beneficiary outcomes and increase value of care by providing better care for individuals, better health for populations, and lowering growth in expenditures. The Shared Savings Program will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first.
MU (Meaningful Use) - The American Recovery and Reinvestment Act created the Medicare and Medicaid EHR Inventive Programs, known as meaningful use, to provide incentives for physicians to adopt EHR and use them “meaningfully” in practice. The EHR Incentive Program was set up in 3 stages, and the program will be rolled into MACRA as part of MIPS. The new term for MU is “Advancing Care Information.”
PFPM (Physician Focused Payment Models) - These are Alternative Payment Models wherein Medicare is a payer, which includes physician group practices or individual physicians as APM Entities and targets the quality and costs of physician services.
PTAC (Physician-focused Payment Model Technical Advisory Committee) - The body that will review and provide comments and recommendations on PFPMs submitted by stakeholders. The secretary must establish, through notice and comment rulemaking, criteria for PFPMs, including models for specialist physicians, that could be used by the PTAC for making its comments and recommendations.
PQRS (Physician Quality Reporting System) - PQRS is a quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. PQRS will be consolidated into the new MIPS program.
QCDR (Qualified Clinical Data Registries) - A QCDR is a CMS-approved entity that collects and submits PQRS quality measures data on behalf of eligible professionals. In addition to PQRS measures, QCDRs can report on additional quality measures developed for use through the QCDR. To be considered a QCDR for purposes of PQRS or MIPS, an entity must self-nominate and successfully complete the qualification process. The Academy's IRIS® Registry is a QCDR.
Qualified Registry (QR) - A Qualified Registry is a CMS-approved entity that collects and submits PQRS quality measures data on behalf of eligible professionals. To be considered a Qualified Registry for purposes of PQRS or MIPS, an entity must self-nominate and successfully complete the qualification process. The Academy's IRIS® Registry is a Qualified Registry.
QP (Qualified Professional) - This represents the subset of professionals who participate in Advanced APMs.
QPP (Quality Payment Program) - This is the name of the new payment program to implement MACRA in the proposed rule released on April 27, 2016. The QPP is composed of two paths: Advanced APMs or MIPS. The majority of ophthalmologists will participate in QPP under MIPS, at least initially.
QRUR (Quality and Resource Use Report) - QRURs provide information about the resources used and the quality of care furnished to a group’s or solo practitioner’s Medicare FFS beneficiaries. The 2015 QRURs will be generated for all groups and solo practitioners nationwide, as identified by their Medicare-enrolled TIN, regardless of whether the 2017 Value Modifier will apply to them. They can use their QRURs to see how their TIN compares with other TINs caring for Medicare beneficiaries.
SGR (Sustainable Growth Rate) - This is the formula on which fee-for-service Medicare Part B payments are based through 2017. This payment system is effectively replaced by MACRA (MIPS and APM).
TCPI (Transforming Clinical Practice Initiative) - This is an initiative within CMMI that is designed to help practices implement changes and improvements so that they can participate in APMs. The initiative is designed to support practices over the next four years in sharing, adapting and further developing their comprehensive quality improvement strategies.
TIN (Tax Identification Number) - This the number that identifies the billing entity. The TIN will be used to connect each EC to the entity under which they bill for purposes of calculating MIPS scores or APM participation.
VBM/VBMP/VM (Value-based payment modifier) - This program provides differential payment to a physician or group under the Medicare Physician Fee Schedule based upon the quality of care furnished compared to the cost of care during a performance period. VM will also be consolidated into MIPS.