The number of clinicians who participated in MACRA's Advanced Alternative Payment Model (Advanced APM) track increased from 2017 to 2018, while the number of clinicians who participated in MACRA's Merit-based Incentive Payment System (MIPS) decreased, according to preliminary data CMS released Thursday.

Background

Under MACRA's Quality Payment Program (QPP), which took effect in 2017, eligible clinicians can choose from two payment tracks:

• The Advanced APM track, for clinicians who take on a significant portfolio of Advanced APMs, which include risk-based accountable care organization (ACO) models; or
• MIPS, for providers who are reimbursed largely through fee-for-service.

Clinicians' pay in the MIPS track largely follows a traditional fee-for-service structure, but CMS adjusts eligible clinicians' pay based on how they "score" in four categories of metrics:

• Cost;
• Improvement activities;
• Promoting interoperability, formerly called Advancing care information (ACI); and
• Quality.

CMS deemed 2017 a "transition year" and required eligible clinicians to submit only 90 days' worth of data. Participating clinicians had the option of submitting data on one quality measure or improvement activity, or four or five advancing care information measures, to meet MIPS requirements. As long as providers scored at least 3 points across those categories, they avoided penalties of up to 4% applied to payments in 2019. Those who scored a 3 or higher received what CMS called a modest payment adjustment of up to 1.88% for the 2019 payment year.

But for the 2020 payment year, which is based on 2018 data, CMS raised the threshold for positive payment adjustments. In 2018, eligible clinicians needed to report on a full year's worth of quality data, and CMS increased the performance threshold to 15 points for providers to avoid the 5% penalty, applied to payments in 2020. The potential penalty will rise incrementally until it reaches 9% in payment year 2022.

Clinician participation rises in 2018, Verma says

According to CMS data, the number of clinicians who participated in:

• Advanced APMs increased from 99,076 in 2017 to 183,306 in 2018;
• MIPS via APMs increased from 341,220 participants in 2017 to 356,828 in 2018; and
• MIPS without an APM decreased from 1,057,824 participants in 2017 to 916,058 participants in 2018.

CMS Administrator Seema Verma in a blog post wrote that the percentage of eligible clinicians who participated in MIPS overall increased from 95% in 2017 to 98% in 2018, and the percentage of eligible clinicians from small practices who participated in MIPS rose from 81% in 2017 to about 90% in 2018.

Verma wrote that the "increase in APM participation supports the evolution of [QPP] and incentives toward a system of value that puts patients first." She continued, "These participation improvements may be related to the increasing number of participation opportunities in 2018, particularly through [ACOs] … in the [Medicare] Shared Savings Program."

More clinicians receive positive payment adjustments, Verma says

Verma also noted that more clinicians are expected to receive a positive payment adjustment in 2020 based on their performance in 2018.

According to Verma, 97% of clinicians participating in MIPS exceeded the performance threshold of 15 points in 2018 to receive a positive payment adjustment on their Medicare Part B claims in 2020, up from 93.1% of clinicians participating in MIPS who exceeded the required performance threshold in 2017. In addition, Verma wrote that 85% of clinicians in small practices are expected to receive a positive payment adjustment in 2020 based on their performance in 2018, up from 74% in 2017.

However, Verma did not specify how much of a bonus payment eligible clinicians could expect to see in 2020.

Verma wrote that the increase in the number of clinicians who will receive positive payment adjustments is "a strong sign that our incremental approach and flexible options lead to clinician success in MIPS." She added, "Scores improved across performance categories, with the biggest gain in the quality performance category, which highlights the program's effectiveness in measuring outcomes for beneficiaries."

Though clinicians' scores have increased under QPP, Verma wrote CMS "recognize[s] that [the program needs] additional long-term improvements." Verma wrote that CMS has "heard from clinicians and stakeholders that the program, specifically MIPS, remains overly complex due to the use of broad clinician flexibility," and that "some clinicians in small practices are still receiving negative payment adjustments." As such, Verma wrote that CMS "will continue to leverage initiatives like Patients Over Paperwork and Meaningful Measures to address concerns and look for possible solutions."

Performance data might appear skewed, expert says

Darryl Drevna, senior director of regulatory affairs at American Medical Group Association, said more clinicians receiving a positive payment adjustment in 2020 does not necessarily mean more clinicians performed better in 2018.

Drevna noted that the number of clinicians who participated in MIPS decreased after CMS raised MIPS' exemption threshold from clinicians who reported up to $30,000 in Medicare revenue or saw fewer than 100 Medicare patients to clinicians who reported up to $90,000 in Medicare revenue and saw fewer than 200 Medicare patients. CMS estimated the adjustment would exclude about 134,000 clinicians from participating in the program.

Because of the adjustment, Drevna said CMS has "excluded too many providers and the only ones left are the high-performing groups."

Further, Drevna said it is unlikely clinicians will see a substantial increase in their bonuses for the 2020 payment year because QPP is budget neutral, which means CMS relies on funds from the pool of penalties to award bonuses, and only 1.95% of clinicians received a penalty in 2018. Drevna recommended that CMS adjust QPP's thresholds to make it more difficult for participating clinicians to receive bonus payments (Ellison, Becker's Hospital CFO Report, 7/15; Slabodkin, Health Data Management, 7/15; Castellucci, "Transformation Hub," Modern Healthcare, 7/12; Morse, Healthcare Finance News, 7/15).