The contents of this document are intended to convey general information only and not to provide legal advice or opinions.
MACRA, MIPS, and Clinical Decision Support
On March 26, 2014, Congress passed H.R. 4302, known colloquially as the Protecting Access to Medicare Act (PAMA). In it, Congress instructed the Centers for Medicare & Medicaid Services (CMS) to specify a program that requires physicians ordering certain imaging exams to consult with a qualified Clinical Decision Support Mechanism (CDSM) that relies on established Appropriate Use Criteria (AUC).
On April 16, 2015, Congress passed H.R.2, known colloquially as the Medicare Access and CHIP Reauthorization Act (MACRA). As part of MACRA, the Quality Payment Program established the Merit-Based Incentive Payment System (MIPS) to drive evidence-based and practice-specific quality improvement through a performance-based payment system.
CMS has since published updates and revisions to PAMA and MACRA through the Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) rulemaking cycles. These updates begin a process to align the qCDSM consultation requirements of the PAMA with the quality initiatives of MACRA.
MACRA & MIPS – An Overview
The Medicare Access and CHIP Reauthorization Act creates a new pay-for-performance program with a focus on quality and value to reward health care providers for improved care instead of more service and to:
- Repeal the Sustainable Growth Rate formula
- Change the way that Medicare rewards clinicians for value over volume
- Streamlines multiple quality programs under the Merit Based Incentive Payments System (MIPS)
- Allocates bonus payments for participation in eligible alternative payment models (APMs)
MACRA combines parts of the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and the Medicare Electronic Health Record (EHR) incentive program into one single program called the Merit-based Incentive Payment System, or “MIPS”.
MIPS determines Medicare payment adjustments using a composite performance score. Eligible professionals (EPs) may receive a payment bonus, a payment penalty, or no payment adjustment. Measurement for MIPS started on January 1, 2017 and will annually measure eligible providers in four performance categories to derive a “MIPS score” base on four performance categories. The four categories are weighted as follows:
- 50% for Quality Measures
- 25% for Promoting Interoperability
- 15% for Improvement Activities
- 10% for Cost Measures
The percentages provided for each category will shift over time to place an increasing focus towards Cost Measures.
CDS & MIPS Performance Categories
The Quality Payment Program aligns the AUC requirements of PAMA with the quality improvement initiatives of MACRA and MIPS. Early adopters of the Medicare AUC program are eligible to receive credit in two MIPS Performance Categories:
Consulting AUC Using Clinical Decision Support when Ordering Advanced Imaging is defined by CMS as a High-Weight Improvement Activity. In addition, this activity is eligible for a 10% bonus points award in the Promoting Interoperability (PI) performance category.
Cost Display for Laboratory and Radiographic Orders is defined as a Medium-Weight Improvement Activity. In addition, this activity is eligible for a 10% bonus points award in the Promoting Interoperability (PI) performance category.
This allows early adopters to receive MIPS points in both the Improvement Activities and Promoting Interoperability Performance Categories. These categories total 35% of the MIPS Final Score. AUC consultation can also impact the Quality Measures (50%) and Cost Measures (10%) performance categories through an overall improvement in care quality and a reduction in the total cost of care.
Quality & Cost Improvement Opportunities
CareSelect delivers advanced decision support, incorporating patient assessment tools such as Pediatric Head Trauma (PECARN) or Adult Head Trauma (GCS calculators), and medication information into its decision support algorithms. Aligning the intervention with the measure.
Our implementations can be tuned to enable focused, condition-based interventions and reporting that link to high-priority MIPS measures (or other targets). Qualified mechanisms will be able to provide a report to the ordering clinician that can be used to assess patterns of image-ordering and improve upon those patterns to ensure that patients are receiving the most appropriate imaging for their individual condition.