MIPS vs. APM track in 2017? It’s not as simple as you think.

The MACRA Quality Payment Program proposed regulations are a hot topic right now, which means that physicians and provider organizations are starting to ask what will be required of them in the first performance year, which starts January 1, 2017. In the proposed rule released by the Centers for Medicare and Medicaid Services (CMS) earlier this month, the name “Quality Payment Program” was introduced as the umbrella name for the two tracks that people had come to associate with MACRA—the Merit-Based Incentive Payment System (MIPS) track and Advanced Alternative Payment Model (APM) track.

A plain ol’ APM just won’t be enough—but it could make MIPS easier

If you’re confused about the addition of the word “advanced” to the APM track, you’re not alone. The term “Advanced APM” can’t be found anywhere in the original MACRA legislation, but it makes its debut in the new Quality Payment Program NPRM as the payment track alternative to MIPS. But as of today, even CMS still has the name of the second payment track under MACRA listed incorrectly on their website, so if you’re feeling like you’re in a bit of an alphabet soup nightmare, join the club. To help keep some of these puzzles pieces in order, we’ve created a graphic that illustrates the high-level relationship between MIPS and Advanced APMs, and where participants in non-advanced APMs may fall.

MACRA Quality Payment Program

As you can see in the graphic above, generic alternative payment models (APMs) are still a thing—and if you are participating in one, you may be able to reduce some of the reporting requirements for MIPS. The base definition of APM under the proposed rule includes:

  • CMS Innovation Center models (under section 1115A, other than a Health Care Innovation Award)
  • The Medicare Shared Savings Program
  • Demonstrations under the Health Care Quality Demonstration Program
  • Demonstrations required by federal law

CMS acknowledges that most APMs require participants to report data that may be similar to what MIPS requires; therefore, they are proposing to “establish a scoring standard for MIPS eligible clinicians participating in certain types of APMs in order to reduce participant reporting burden by eliminating the need for such APM eligible clinicians to submit data for both MIPS and their respective APMs.” In short, CMS is trying to preserve some of the “report once for multiple programs” mentality that was pushed in previous years by allowing certain APM participants who aren’t excluded from MIPS the ability to meet certain MIPS requirements via the reporting they are already doing for their APM.

The making of a MIPS APM

In order to determine whether you are a MIPS eligible clinician that is also part of an an APM Entity group that is eligible for the MIPS APM scoring standard, it is necessary to first understand what constitutes a MIPS APM according to CMS. According to the proposed rule, MIPS APMs meet the base definition of APMs and meet the following criteria:

  • APM Entities participate in the APM under an agreement with CMS
  • The participating APM Entities include one or more MIPS eligible clinicians on a CMS-maintained Participation List
  • The APM bases payment on cost/utilization and quality measures; and
  • The APM does not have the following characteristics:
    • The first performance year begins after the first day of that MIPS performance period.
    • The APM scoring standard is impracticable, as determined by CMS within 60 days of the start of the MIPS performance period.

Not all APMs are Advanced APMs

The important thing to understand when reviewing the new requirements under MACRA is this – not all APMs will meet the definition of Advanced APMs, and only certain participants in Advanced APMs will be excluded from MIPS reporting requirements and payment adjustments. Advanced APMs are those that meet the base definition of APM and also meet the following criteria:

  • The APM requires participants to use certified EHR technology.
  • The APM bases payment on quality measures comparable to those in the MIPS quality performance category.
  • The APM either:
    • Requires APM Entities to bear more than nominal financial risk for monetary losses; or
    • Is a Medical Home Model expanded under the authority of the Centers for Medicare and Medicaid Innovation (CMMI).

In addition to determining whether your APM is an advanced APM, eligible clinicians participating in those Advanced APMs must meet additional payment and patient count thresholds in order to be a Qualifying APM Participant or Partial Qualifying APM Participant, which requires information that unfortunately may not be available to your organization right now, or even early on in the first MIPS performance year (2017). This means that even if you are participating in an APM right now, and plan to continue in 2017—or if you plan on starting participation in an APM in 2017—when the end of the 2017 performance year arrives, it is possible that whatever payment model you and your organization are participating in may not meet CMS’ definition of an Advanced APM or you may not have achieved the required thresholds to become a Qualifying or Partial Qualifying APM entity.

Bottom line, almost every Medicare provider who is a MIPS Eligible Clinician should start preparing to participate in MIPS starting January 1, 2017, because even if they are participating in an APM (or an Advanced PM), it may be too late to report for MIPS if it turns out later that they are not excluded.

So what now?

The rules from CMS that define the Quality Payment Program are still in a proposed state, so provider organizations that feel strongly that certain components should be modified should submit comments via www.regulations.gov prior to the comment deadline of June 27, 2016. In the meantime, if you are a provider organization that supports providers who meet the definition of MIPS eligible clinicians and you believe that you are participating in a payment model that may meet the definition of APM, now is the time to start reviewing the requirements for determining whether your payment model is an APM or Advanced APM according to CMS.

Able Health will continue to post blogs the dive into various topics under MACRA and the Quality Payment Program. Stay up to date by subscribing to our newsletter.


Further reading:
MIPS Advancing Care Information: Frequently Asked Questions
Comprehensive Primary Care Plus (CPC+) quality measures for 2017

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