MACRA 2019 Changes Address Physician Concerns

By Kim Hathaway, MSN, CPHRM, Healthcare Quality Patient Safety and Risk Consultant

Centers for Medicare & Medicaid Services (CMS) is taking steps to ease regulatory burdens by removing process measures, developing more outcome measures, changing the fee schedule to support telemedicine technology, and focusing on EHR interoperability. That's because CMS listened to stakeholder input before releasing the final changes to the Quality Payment Program (QPP). The changes were effective on January 1, 2019.

This marks the third year of the QPP, which was established in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repealed the sustainable growth rate (SGR) formula for reimbursing physicians and other clinicians participating in Medicare. The QPP encourages value-based care through two tracks, the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

With these new changes, CMS vows to continue using the Patients over Paperwork framework so that physicians may focus more on taking care of patients and less on redundant documentation. Other changes are that CMS has renamed the EHR Incentive / Meaningful Use / Advancing Care Information category to “Promoting Interoperability,” placing a strong emphasis on sharing healthcare data between providers and providing full access to patients of their healthcare records.

Highlights of the changes made to MIPS for 2019 that will affect clinicians include:

  1. Category weights have changed for two categories. The categories are fundamentally the same. The category changes include:
    1. Quality: 45 percent (down from 50 percent in 2018).
    2. Promoting Interoperability: 25 percent.
    3. Improvement Activities: 15 percent.
    4. Cost: 15 percent (a 5 percent increase from 2018).
    5. Hospital-based or facility-based clinicians have some flexibility in 2019. Eligible clinicians may use facility-based reporting for MIPS Quality and Cost categories based on the hospital value-based program. Eligibility will be published on the QPP website in quarter 1 2019.
  2. Important general MIPS changes for performance year 2019 include:
    1. The performance period for the third year of the QPP/MACRA is the calendar year 2019. Performance for 2019 will affect payment in 2021.
    2. The performance threshold increases in 2019 from 15 MIPS points to 30 MIPS points to ensure a neutral payment adjustment, and greater than 30 points for an increase.
    3. The exceptional performance bonus increased to 75 points (up from 70 points in 2018).
    4. The total amount of Medicare reimbursement at play for 2019/2021 has increased. Practices scoring between zero and 30 total MIPS points will see up to a -7 percent adjustment. Practices scoring over 30 points could see up to a 7 percent increase. (Note: Any positive payment adjustments will be multiplied by a scaling factor to ensure budget neutrality, so the maximum positive adjustment will likely be below 7 percent.)
    5. The five bonus points added to the final score of clinicians in small practices (TINs with fewer than 15 associated NPIs) increases to six points. The points will be added to the numerator of the Quality score rather than the overall MIPS score.
    6. Eligibility has been adjusted to allow more clinician participation in MIPS, even by providers excluded based on the low-volume threshold criteria.
      1. Options include: (a) voluntary participation without a payment adjustment, or (b) choosing to opt in and be subject to the performance requirement and payment adjustment.
    7. Eligible clinician types have expanded. These will include the five categories that were included in the two previous years, plus clinical psychologists, physical therapists, occupational therapists, speech-language pathologists, audiologists, and registered dieticians or nutrition professionals.
  3. The MIPS Quality category has:
    1. Separated collection types from submission types, clarifying some of the confusing language.
    2. Added eight measures, with four being patient-reported outcomes, and removed 26 measures that didn’t add value, were process measures, or were topped out.
    3. Made claims-based measures available only to small groups with fewer than 15 physicians.
  4. MIPS Advancing Care Information category changed in 2018 to Promoting Interoperability. In this category, it is much more difficult than it has been in the past to achieve maximum points. The Promoting Interoperability changes for 2019 include:
    1. Four aims clinicians must meet: e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. Clinicians would be required to report certain measures from each of the four objectives, unless an exclusion is claimed.
    2. Any unreported measure or no answers to a yes/no measure will result in a zero Promoting Interoperability score.
    3. MIPS-eligible clinicians are required to use the 2015 Edition of Certified Electronic Health Record Technology (CEHRT) if they report in this category, and must submit evidence to CMS.
    4. The Promoting Interoperability reporting period will remain a minimum of a continuous 90-day period.
    5. Scoring is now solely based on performance and the base. Bonus and performance scores are eliminated.
    6. Security risk analysis is still required, but no points will be assigned.
    7. Two new measures are added for the e-Prescribing objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement as an option to earn bonus points.
  5. MIPS Improvement Activities category changes include:
    1. Removal of the 10 percent Promoting Interoperability bonus for using a CEHRT to complete the Improvement Activity.
    2. Clarification of the criteria for “high-weighted” classification.
  6. MIPS Cost category changes include:
    1. Eight episode-based Cost measures have been added. The same two core measures for Medicare Spending per Beneficiary and Total Per Capita Cost remain.
    2. All cost measures have the same weight.
  7. Alternative Payment Models: More specialty-related models will be developed.

Practices that are looking to achieve top scores should review past performance, especially the Cost and Promoting Interoperability categories, as the Cost weight increases, and the Promoting Interoperability measures will be more difficult to achieve. For more information:

  1. Calendar Year 2019 Updates to the Quality Payment Program
  2. Quality Payment Program Year 3 (2019) Final Rule Overview webinar
  3. 2019 MIPS Quick Start Guide

Practices that find these changes overwhelming may want to reach out for expert help with industry-leading best practices to maximize Medicare payments. Visit Medical Advantage Group  for more information. 

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.


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