Proposed MIPS rule requires new vocabulary for physician payments

When CMS published the advance release of a Proposed rule to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10), it changed existing and created new terms and acronyms to describe aspects of the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) incentive under the physician fee schedule (PFS). As providers and health lawyers prepare to adjust to MACRA’s changes, they should also train themselves to be conversant in this new language.

New language

MACRA created a number of new terms, most of which are used in the Proposed rule. A few of the terms MACRA created have been changed in the Proposed rule; see Obsolete terms, below.

APM: For the purposes of the APM incentive, MACRA defines an APM as a model under section 1115A of the Social Security Act (the Act) (excluding a health care innovation award), the Shared Savings Program under section 1899 of the Act, a demonstration under section 1866C of the Act, or a demonstration required by federal law.

Other Payer APMs: The Proposed rule uses this term to refer to arrangements in which eligible clinicians may participate through other payers.

APM Entity: Under the Proposed rule, an APM Entity is an entity that participates in an APM through a contract with a payer.

Qualifying APM Participant (QP) / Partial Qualifying APM Participant (Partial QP): These terms, defined in Act secs. 1833(z)(2) and 1848(q)(1)(C)(iii) do not report on MIPS applicable measures and activities that are required under MIPS. QP and Partial QP status is determined based on participation in Advanced APMs during a corresponding QP Performance Period.

MIPS eligible clinician:  The Proposed rule uses this term to replace MACRA’s wording of MIPS eligible professional (EP), defined at Act sec. 1848(q)(1)(C). MIPS eligible clinicians will include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians. This definition does not include QPs and Partial QPs.


Obsolete terms

Sustainable growth rate (SGR): MACRA ended the SGR, which came from a 1997 law aiming to control Medicare costs. The SGR has been rendered ineffective for more than a decade due to Congressional “doc fixes.”

Physician Quality Reporting System (PQRS); Physician Value-based Payment Modifier (VM); Medicare Electronic Health Record Incentive Program for Eligible Professionals, also known as the Meaningful Use program: These three programs will sunset after 2018, while some elements of each will be incorporated into MIPS, which begins in 2019.

MIPS EPs: The Proposed rule would define MIPS program participants as “MIPS eligible clinicians” rather than “MIPS EPs.” The agency believes that eligible clinicians is a more flexible, inclusive term than EP.

“All-or-nothing” scoring: The PQRS required EPs to meet all program criteria or receive a negative adjustment. The Proposed rule instead would give MIPS eligible clinicians partial credit, rewarding them partially for the measures they do meet.

For Wolters Kluwer’s analysis of the Proposed rule, see Physician reporting streamlined, less burdensome under flexible Quality Payment Program, Health Law Daily, April 28, 2016.