MIPS APM SCORING STANDARD: KEY FACTS FOR ACOs 

As currently proposed under the Medicare Access and CHIP Reauthorization Act (MACRA) Notice of Proposed Rulemaking, certain ACOs would be subject to the new Merit-Based Incentive Payment System (MIPS). ACOs that are not participating in what the proposed rule defines as Advanced APMs would be subject to MIPS. This includes Medicare Shared Savings Program (MSSP) Track 1 ACOs. Additionally, those ACOs that participate in Advanced APMs, but do not meet Qualifying APM Participant (QP) thresholds, will be subject to the MIPS. Those that meet Partial QP thresholds will have a choice to report voluntarily and be scored under MIPS. QP and Partial QP thresholds are described in more detail below.

CMS has made certain accommodations for ACOs that fall in these categories and will be considered MIPS APMs; therefore, they will be scored under a separate MIPS APM Scoring Standard to recognize their ongoing work and efforts through the ACO. This resource describes some of the benefits and accommodations for ACOs made through the MIPS APM Scoring Standard as proposed by CMS.

Advanced APMs

As proposed by CMS, the following are the ACO programs which would be considered Advanced APMs:

• MSSP Tracks 2 and 3
• Next Generation ACO Model

Qualifying Participant Thresholds

As specified by MACRA, CMS outlines the required proportion of payments that must be made “through” the APM Entity in order to qualify for the Advanced APM bonus. These payment thresholds are illustrated in Table 4 below, along with CMS’s proposed corresponding thresholds for a patient count approach. The agency proposes to calculate both thresholds for an APM Entity and utilize the one with the more favorable outcome for that APM Entity.

Table 4: Payment and Patient Count Threshold for Meeting QP Determination

CMS proposes to calculate this threshold in the following manner: attributed beneficiaries/attribution-eligible beneficiaries. Read our comment letter for more details on the QP and Partial QP threshold calculations.

MIPS

These are the criteria proposed for the general MIPS program scoring. ACOs that meet the MIPS APM standard will be scored under the MIPS APM Scoring Standard, described in detail below. For the general MIPS scoring, each provider will receive a composite performance score (CPS) between zero and 100 based on performance in the following categories:

1. Quality (50 percent)
2. Resource Use/Cost (10 percent)
3. Advancing Care Information- formerly Meaningful Use (25 percent)
4. Clinical Practice Improvement Activities (15 percent)

If the clinician scores above the threshold for a given year, a bonus will be provided. A penalty will be applied if the score is below the threshold for a given year. CPSs at the performance threshold receive a neutral MIPS adjustment factor. The threshold will be the mean or median of all MIPS-eligible clinician CPSs for a period of time prior to the performance year (CMS has not yet determined what this timeframe will be).

Payment Adjustment Details

For the 2019 payment year, the maximum penalty that could be applied to a clinician’s payment is -4 percent. Clinicians who fall in the bottom 25 percent of all MIPS eligible clinician performance will receive the maximum penalty amount. The amount of upward adjustments or bonuses provided is unknown due to budget neutrality requirements of the MIPS program. CMS must first collect penalties assessed then determine the amount of bonuses that may be provided, and these two amounts must be equal. This will cause CMS to create a scaling factor to determine bonus amounts. CMS notes that bonus amounts cannot exceed 12 percent for the 2019 payment year. However, from 2019 through 2024 there are also additional bonuses provided to those who are considered “exceptional performers” in MIPS. For the 2019 payment year, CMS has proposed that a clinician must be in the top 25 percent of all MIPS eligible clinician scores to receive the additional exceptional performer bonus, which could result in up to 10 percent added to the clinician’s bonus amount. This means the maximum positive adjustment clinicians could potentially see to their 2019 payment could be as high as 22 percent. However, as stated above, the exact numbers will vary depending on the scaling factor used by CMS. Therefore, maximum bonus amounts could be much lower than the maximum 22 percent, depending on overall performance in the MIPS program.

Therefore, these amounts could potentially exceed the automatic 5 percent APM bonuses provided to those who meet the Advanced APM and QP thresholds. However, ACOs must consider that their payment adjustment under MIPS will be based on performance compared to a threshold performance for the year, causing some uncertainty. Additionally, ACOs who fall under the MIPS APM Scoring Standard will need to ensure they have reported on the Clinical Practice Improvement Activities (CPIA) category for all eligible clinicians in the ACO Entity. NAACOS has advocated that ACOs should receive full credit in this category. For more detail on our recommendations, see below and read our comment letter to CMS. Further, CMS does not specify in the proposed rule whether any potential bonus payments received under MIPS would count as expenditures for the ACO in the MSSP and/or Next Generation Model benchmark calculations. NAACOS has advocated that these bonuses not be included as costs in any benchmark calculations. 

Lastly, CMS proposes to inform APMs of their QP status after the MIPS performance period has closed. This timing is problematic as it causes uncertainty for all ACOs and makes the details of the MIPS APM Scoring Standard even more important. Below you will find additional information on each performance category as it will be applied in the MIPS APM Scoring Standard. 

MIPS APM Scoring Standard- Overview

Each provider will receive a CPS between 0-100 based on performance in the following categories:

1. Quality (50 percent)
2. Resource Use/Cost (0 percent)
3. Advancing Care Information-formerly Meaningful Use (30 percent)
4. Clinical Practice Improvement Activities (20 percent)

If the clinician scores above the threshold for a given year, a bonus will be provided. A penalty will be applied if the score is below the threshold. CPSs at the performance threshold receive a neutral MIPS adjustment factor. The general MIPS payment adjustment details discussed above also apply to the MIPS APM Scoring Standard.

MIPS APM Scoring Standard: ACO Considerations

CMS will establish an APM participant database of MIPS APMs and Advanced APMs, this will include all the MIPS eligible clinicians who are part of the APM Entity. For MSSP, all MIPS-eligible clinicians who bill through the Tax Identification Number (TIN) of an ACO participant are considered to be participating in the ACO (the ACO = the APM Entity). However, a clinician must be listed as part of the APM Entity as of December 31 of the performance year in order to be counted as participating in the ACO for the purposes of the MIPS APM Scoring Standard. For the 2019 payment year, CMS will look to 2017 performance.

Calculating the Composite Performance Score (CPS)

CMS will calculate one MIPS CPS for each ACO (at the APM Entity level). This score will be applied to all MIPS eligible clinicians in the group. MIPS payment adjustments will be applied at the unique TIN/National Provider Identifier (NPI) level for each MIPS-eligible clinician in the APM Entity group.

NOTE: CMS has not stated whether any bonus payments paid under the MIPS APM Scoring Standard would be counted as expenditures for ACOs in calculating benchmarks. NAACOS has advocated that these payments should not be included as expenditures for ACO benchmark calculations.

Quality

For the MIPS APM Scoring Standard, ACOs will submit CMS Web Interface measures on behalf of their participating MIPS eligible clinicians as they currently do in the MSSP and/or Next Generation Models. No additional quality reporting will be required. CMS will use MIPS quality performance category requirements and benchmarks to determine the MIPS quality performance score. MSSP quality benchmarks will be used not only for ACOs, but also for all eligible clinicians reporting using the Web Interface for MIPS.

NOTE: ACOs will automatically be awarded bonus points in the quality performance category for reporting high priority measures that are already included in the Web Interface measure set.

Clinical Practice Improvement Activities (CPIA)

This is a new area of measurement for CMS. As proposed, all MIPS eligible clinicians in the APM Entity group would submit CPIAs according to the MIPS requirements. This means ACOs would need to have every clinician in the ACO report on one-to-three approved CPIAs for the 2017 performance year to receive full credit in this category. See Table H of the proposed rule for a list of CMS approved CPIAs. As currently proposed, CMS would provide ACOs with an automatic 30 points (or half the total points) for this category. This is an additional reporting burden for ACOs, and as such, NAACOS has advocated to allow for ACOs to receive full credit in this category for participating in the MSSP and/or Next Generation Models. Since practice improvement is an inherent goal of the MSSP and Next Generation Models, ACOs should not be burdened with an additional reporting requirement.

As proposed, performance will be assessed as an ACO but CPIA reporting will be done by each of the billing TINs associated with the ACO for MSSP ACOs. All of the ACO participant TIN scores will be aggregated, weighted and averaged to yield one ACO-level score. Next Generation ACOs will be required to have their clinicians submit individual-level data for this category, and all of the MIPS eligible clinician scores will be aggregated across the Next Generation ACO and averaged to yield one ACO score.

Advancing Care Information (ACI)

CMS proposes to require ACOs to continue to report on Meaningful Use measures, now included in the new Advancing Care Information (ACI) performance category. CMS does not provide any details on how this change to the Meaningful Use Program will affect MSSP measure 11, Percent of PCPs who Qualified for EHR Incentive Payment. NAACOS has sought clarification on this point. However, since ACOs are currently required to have at least 50 percent of their eligible clinicians successfully report under Meaningful Use, there is no additional reporting or evaluation caused by this performance category in the MIPS APM Scoring Standard. CMS also proposes to make certain changes to the scoring of the ACI category, including the creation of a Base Score and a Performance Score that will contribute to the overall score in this performance category. Please see the proposed rule and CMS website for more details on all of the proposed changes to current Meaningful Use measures caused by the transition to ACI.

MSSP ACOs

All MIPS eligible clinicians participating in the APM Entity group will submit according to MIPS requirements. Performance will be assessed as a group through the billing TINs associated with the ACO for MSSP. All of the ACO participant group billing TIN scores will be aggregated as a weightedaverage to yield one ACO group score.

Next Generation ACOs

All MIPS eligible clinicians participating in the APM Entity group submit as individuals according to MIPS requirements. All of the MIPS eligible clinician scores will be aggregated and averaged to yield one ACO score. An ACO eligible clinician who does not report this category contributes a score of zero.

Resource Use

CMS proposes to not calculate a Resource Use performance score for MIPS APMs under the APM Scoring Standard. This is due to the fact that ACOs are already being measured on cost in their respective MSSP and Next Generation ACO Models. This allows ACOs to continue to focus on one set of cost measures and not be subject to additional cost measures with different specifications and benchmarks.

Performance Category Scoring

Below is an outline of how each performance category will be scored under the MIPS APM Scoring Standard.

  *CMS will provide the exact amount of bonus points available to ACOs reporting Web Interface measures in the final rule

NAACOS Advocacy to Change Certain Elements of the MIPS APM Scoring Standard

NAACOS submitted comments to CMS in response to these proposals in late June 2016. A final regulation is expected in the fall of 2016. NAACOS has urged CMS to make the following changes, among others, to the proposed MIPS APM Scoring Standard:

• Make QP determinations in a timely manner and notify ACOs of their QP status by February 1 following the performance year
• Provide ACOs with full credit in the MIPS CPIA performance category to recognize ACOs’ ongoing work on performance improvement inherent in the MSSP and Next Generation Models
• Redistribute the MIPS Resource Use category points entirely to the CPIA performance category, increasing the weight in that category from 15 to 25 percent
• Clarify that MIPS APM payment adjustments resulting from the MIPS APM Scoring Standard will not be included in MSSP and Next Generation ACO expenditures for benchmark calculations
• Allow ACOs to report MIPS ACI attestations at the ACO Entity level

Read our full comment letter by visiting our advocacy website.