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How CMS Would Reimburse ACOs for Value-Based Care under MIPS

For ACOs that do not qualify as Advanced APMs under MACRA, CMS would use a modified MIPS scoring program to calculate value-based payment adjustments.

- With a final rule on implementing MACRA coming in the next couple of months, some accountable care organizations (ACOs) have started to analyze new value-based reimbursement structures under the proposed rule.

ACOs may face a modified MIPS scoring program designed for APMs under MACRA

While only a couple of Medicare ACO programs will qualify as an Advanced Alternative Payment Model (APM), many other ACO participants will have to attest to the Merit-Based Incentive Payment Program (MIPS).

To help these ACOs navigate the proposed Medicare reimbursement system, the National Association of ACOs (NACCOS) has released a guide on how ACOs will be scored under a modified version of MIPS specifically designed for alternative payment models that do not qualify as Advanced APMs.

Under MACRA, only the Medicare Shared Savings Program (MSSP) Tracks Two and Three as well as the Next Generation ACO Model will be considered Advanced APMs. These ACO programs would be exempt from MIPS and earn a 5 percent financial incentive payment.

However, eligible clinicians in the selected ACOs must also demonstrate participation thresholds to earn the financial incentive payments. To qualify, CMS explained that participants must treat at least 20 percent of their patients or make 25 percent of their payments through the Advanced APM in 2017, the first performance year of MACRA.

READ MORE: MIPS Requirements for Clinicians in Small, Rural Hospitals

The patient count and payment thresholds would also increase over time.

For ACOs that fall outside of these Advanced APM designations, CMS has proposed a MIPS APM scoring standard that acknowledges their value-based care progress through the ACO model.

Similar to the general MIPS, these eligible clinicians will be given a Composite Performance Score that determines payment adjustments at the end of each performance year, but CMS will calculate one score at the ACO level for all eligible clinicians in the program.

“This score will be applied to all MIPS eligible clinicians in the group,” the guide stated. “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.”

The MIPS APM scoring standard would also weigh the four categories for the Composite Performance Score differently than the general MIPS.

READ MORE: Oncologists Need Data Reporting, Time for MACRA Implementation

Each eligible clinician would be evaluated based on the following categories:

• Quality (50 percent)

• Advancing Care Information (30 percent)

• Clinical Practice Improvement Activities (20 percent)

Notably, the MIPS APM scoring standard does not have a Resource Use category, which counts for 10 percent of the performance score under the general MIPS.

READ MORE: Is MACRA a True Doc Fix for Value-Based Reimbursement?

“This is due to the fact that ACOs are already being measured on cost in their respective MSSP and Next Generation ACO Models,” explained NAACOS. “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.”

While the Quality component of the score is weighed the same under the modified MIPS, ACOs would only have to submit CMS Web Interface measures on behalf of their eligible clinicians, which MSSP and Next Generation participants already do.

ACOs would also automatically be granted bonus points in the Quality category for reporting high priority quality measures, which are already included in the CMS Web Interface measure set.

Participants in the MIPS APM scoring standard would also report Advancing Care Information data as stipulated under the general MIPS, but their score will be weighed 5 percent more than in the original system.

CMS would aggregate the scores from each eligible clinician in an ACO and produce a weighted average for an ACO group score.

The Clinical Practice Improvement Activities category requires eligible clinicians to demonstrate participation in CMS-approved initiatives that advance value-based care goals.

Under the MIPS APM scoring standard, this component counts for 5 percent more and CMS will automatically award ACOs half of the total points in this category.

However, all eligible clinicians would have to submit clinical improvement activities data to CMS. The agency would collect, weigh, and average the individual scores to produce an ACO-level score.

While CMS has proposed to accommodate ACOs under MACRA’s reimbursement programs, NAACOS has called for some changes to the MIPS APM scoring standard.

The industry group urged CMS to award ACOs with full credit in the Clinical Performance Improvement Activities category to “recognize ACOs’ ongoing work on performance improvement inherent in the MSSP and Next Generation Models.”

NAACOS also suggested that CMS redistribute the Resource Use portion to the Clinical Performance Improvement Activities category, increasing the weight of the category to 25 percent. It also suggested that ACOs report attestations for the improvement category at the ACO level to reduce reporting burdens.

CMS should also notify ACOs of qualifying participant threshold determinations by February 1 before the start of a performance year, stated the guide. This would help ACOs understand their reimbursement position under MACRA for the upcoming performance year.

Additionally, NAACOS asked for clarification on whether MIPS APM payment adjustments would be included in MSSP and Next Generation ACO expenditures used for determining benchmarks. The industry group advocated for the bonus payments to be excluded from benchmark calculations.

Understanding the complexities of the new reimbursement systems under MACRA may take some effort, but ACO participants could have more time to mull over the value-based care programs.

Earlier this month, CMS Acting Administrator Andy Slavitt told Congress that CMS could push back the launch date of MACRA, giving eligible clinicians more time to prepare.

Dig Deeper:

Top 5 Facts to Know about MACRA Alternative Payment Models

Detailing ACO Challenges with Risk, MACRA Implementation

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