MACRA and the QualityPayment ProgramFrequently Asked Questions2020 Edition

ContentsWhat is New to Consider in 2020?   1Overview   2What is MACRA?   2What is the Quality Payment Program?   2How do payments work under the QPP?   2What is at risk under the QPP?   3Who participates, and who is excluded?   3How do I know if I’m eligible?   3Where do hospitalists fall?   3Merit-based Incentive Payment System (MIPS)   4how is the MIPS Score calculated?   5Merit-based Incentive Payment System (MIPS)   6How can I participate in the MIPS?   6What is the Quality Category?   6Why is the Quality category worth more for hospitalists?   7What is the quality measure validation process?   7Applicable Quality Measures for Hospitalists   8What is the Cost Category?   9What is facility-based measurement?   9What is the Promoting Interoperability (PI) category?   10What is the Improvement Activities Category?   10When will CMS provide information about our performance in the MIPS?   11How is the MIPS final score calculated?   11How are MIPS payment adjustments applied?   11Alternative Payment Models (APMS)   12How can hospitalists participate in the APM Pathway and get the bonus payment?   13What about the Bundled Payments for Care Improvement (BPCI) Advanced model?   13Can a hospitalist group, such as one employed in a hospital, be counted in their hospital's APM?   14What can hospitalists do now?   14More Resources    14Questions?    14

What is New to Consider in 2020?The Quality Payment Program is a complicated, ever-changing program. From year to year, theCenters for Medicare and Medicaid Services (CMS) makes changes to the program. SHM consistentlylistens to your experiences, monitors upcoming policy changes and works to address issues in theprogram on behalf of hospitalists.Major relevant changes to the program in 2020 include: Expanded the hospital-based exemption from Promoting Interoperability (PI) for groups. CMSfinalized changes pushed by SHM to ensure that hospital medicine groups would be categorized ashospital-based and exempt from the PI category of the MIPS. Groups will now be exempt from PI if75% or more of their individual Eligible Professionals (EPs) meet the criteria to be exempt from PI asindividuals. Changed Improvement Activities participation requirements. CMS will now require 50% ofclinicians in a group to report on the same improvement activity during any continuous 90-dayperiod during the performance year. Increasing the MIPS Performance Threshold. In the 2020 performance year, MIPS participants mustachieve at least 45 points in the MIPS to avoid a penalty. This is an increase from 30 points last year.Hospitalists should also keep in mind that the Facility-based Measurement Option will apply to theirpractice and will give them or their group a score in the Quality and Cost categories of the MIPS. CMSautomatically calculates a score in each of these categories based on a provider or group's hospital'sHospital Value-Based Purchasing (HVBP) score. Providers or groups may also elect to report onmeasures in the Quality category, in which case CMS will use the higher of the scores (facility-basedor self-reported measures) for the total MIPS score.CMS has issued administrative relief and reporting flexibilities for providers participating in theQuality Payment Program in light of the COVID-19 Public Health Emergency Declaration. Weexpect CMS will continue to make adjustments to the program for the 2020 reporting year andSHM will update guidance as more detail emerges.Take a look at SHM's Quality Payment Program (QPP): COVID-19 Flexibilities, Exemptions, andDelayed Reporting Timelines overview on and the Quality Payment Program Frequently Asked Questions 1

OverviewWhat is MACRA?MACRA stands for the Medicare Access and CHIP Reauthorization Act. It is legislation that wassigned into law on April 16, 2015. It permanently repealed Medicare’s Sustainable Growth Rate (SGR)formula, restructured Medicare provider pay-for-performance programs and created an incentive forthe adoption of alternative payment models.What is the Quality Payment Program?The Quality Payment Program (QPP) is the program that the Centers for Medicare & MedicaidServices (CMS) created to implement MACRA. In other words, the QPP is MACRA. It is the newpayment system for providers who care for Medicare beneficiaries. The intent of the QPP is to beginmoving Medicare away from straight fee-for-service payments towards payment that rewards qualityand value.How do payments work under the QPP?The QPP is broken down into two pathways. The Merit-based Incentive Payment System (MIPS),which combines past programs such as the Physician Quality Reporting System (PQRS), value-basedpayment modifier and Meaningful Use into one streamlined pay-for-performance program, andAlternative Payment Models (APMs), which incentivizes the adoption of payment models that moveaway from a fee-for-service system.The MIPS pays providers on a modified fee-for-service system. Providers will receive paymentadjustments based on performance across a range of measures and activities.APMs pay providers based on the rules associated with the model itself. Providers in APMs receive theirAPM payments and are potentially eligible for an additional 5% payment increase to their Medicare PartB billing if they and the APM in which they are participating meet the APM pathway requirements.MACRA and the Quality Payment Program Frequently Asked Questions 2

What is at risk under the QPP?The QPP has both financial risks and rewards for participants, depending on the pathway. The programoperates on a two-year time lag. For the MIPS, performance on measures in 2020 will determine paymentsin 2022. For APMs, performance in 2020 will determine eligibility for an incentive payment in 2022.The MIPS operates in a budget neutral manner. That is, money collected as penalties form the pool ofmoney available for reward payments.Payment Adjustment Year2020*2021*2022*2023 *MIPS Reward 5.0%† 7.0%† 9.0%† 9.0%†MIPS Penalty-5.0%-7.0%-9.0%-9.0%APM Incentive 5.0% 5.0% 5.0% 5.0%APM RiskDownside risk as part of the alternative payment model rules*Payment adjustment years correspond to the performance year two years prior. E.g., 2021 payment adjustments are based on 2019 performance.†MIPS reward payments can be up to 3x these percentages, depending on the funds available.Who participates, and who is excluded?Providers may participate in the Quality Payment Program in either the MIPS or in an AdvancedAPM. MIPS is the default program for all providers who bill Medicare Part B. These include physicians,physician assistants, nurse practitioners, certified nurse specialists, and certified registered nurseanesthetists. Providers may be exempt from the MIPS if: They do not exceed one or more of the low volume thresholds, which are: Billing 90,000 or less in Medicare Part B allowed charges for covered professional services; or Provide covered professional services for 200 or fewer Part B-enrolled individuals; or Provide 200 or fewer covered professional services to Part B-enrolled individuals. They are in their first year of participating in the Medicare program. They are participating in a qualifying Advanced Alternative Payment Model and meet thethresholds for participation.How do I know if I’m eligible?If you are unsure if you are eligible to participate in the Quality Payment Program, go to your National Provider Identifier (NPI), and CMS will automatically check your participation status.Where do hospitalists fall?Most hospitalists will be subject to MIPS reporting in 2020. Although many hospitalists areparticipating in risk-based alternative payment models, such as Bundled Payment for CareImprovement – Advanced (BPCI-A) or Accountable Care Organizations (ACOs), they may not meet theAPM incentive threshold and therefore may still be required to participate in the MIPS.MACRA and the Quality Payment Program Frequently Asked Questions 3

Merit-based IncentivePayment System (MIPS)Merit-based IncentivePayment System (MIPS)The MIPS combines performance across four categories to create a total score perprovider or group. That total score will then determine whether the providers geta positive, neutral or negative payment adjustment to their Medicare Part B billing.Providers will need to report on measures and activities eligible for a positivepayment adjustment:Qualitywhich replaces the Physician Quality Reporting System, requires thereporting of quality measures.Costwhich replaces the cost evaluation of the Physician Value-Based Modifier,has CMS-calculated cost measures.Promoting Interoperability(formerly, Advancing Care Information) which replaces the Medicare eligibleprovider Meaningful Use program, requires use of Certified ElectronicHealth Record Technology.Improvement Activitiesis a category that requires providers to select and complete activitiesfrom an inventory to get credit.

how is the MIPS Scorecalculated?How is the MIPS ScoreCalculated?Each of the four MIPS categories is weighted a proportion of the overall MIPS score. Mosthospitalists have different category weightings due to an exemption from the PromotingInteroperability (formerly, Advancing Care Information) and that category weight beingshifted to Quality.15%45%Improvement ActivitiesQuality15%CostAll25%Promoting Interoperability15%70%Improvement ActivitiesQuality15%CostHospitalistsFor hospitalists who meet thedefinition of hospital-basedprovider, PromotingInteroperability is 0%.

Merit-based Incentive Payment System (MIPS)How can I participate in the MIPS?You can participate in the MIPS by reporting at either the group or individual level. Individualreporting can be done through claims, registry, qualified clinical data registry (QCDR) or ElectronicHealth Record (EHR) reporting. Group reporting can be submitted through the CMS web interface,EHR, registry or QCDR. SHM cautions that not every reporting option may be available to hospitalists,depending on how their practice is structured.What is the Quality Category?The largest category of the MIPS is the Quality category. In 2020, hospitalists will generally seea Quality category weight of 70% of the total MIPS score (if they are exempt from PromotingInteroperability). CMS requires the reporting of at least 6 measures, including one outcome measure,and that those measures have at least 20 cases and meet a 60% data completeness threshold.Performance on each measure will be scored individually and rolled up into the Quality category score.Hospitalists can report through either the hospitalist specialty measure set or the broader listof measures, which are available at Note that thehospitalist specialty measure set only has 5 measures. So, hospitalists will not have 6 relevantmeasures to report or have enough cases in each measure to meet the case-minimum. In the event ofreporting on fewer than 6 measures, CMS applies a quality measure validation test to ensure therewere no other additional measures to report.Hospitalists will also have scores in the Quality category associated with their facility and maynot need to report on quality measures. The facility-based measurement option would give eligibleproviders an automatically-calculated score in their Quality and Cost categories based on theirhospital’s Hospital Value-Based Purchasing Score. For more information, see the question on facilitybased measurement.N0te: Beginning in 2019, CMS no longer allows groups of 16 or more eligible clinicians to use MedicarePart B claims to report quality measures. Individuals and small groups may continue to utilize claimsbased reporting but note that CMS has indicated an interest in moving away from claims-basedreporting entirely in the future.MACRA and the Quality Payment Program Frequently Asked Questions 6

Why is the Quality category worth more for hospitalists?Hospitalists are generally exempt from the Promoting Interoperability category. In the case thatan individual or group is exempt from Promoting Interoperability, the 25% category weight forPromoting Interoperablity shifts to the Quality category. So for 2020, the Quality category is generallyworth 70% of the total MIPS score for hospitalists.What is the quality measure validation process?If a provider reports on fewer than 6 measures, the Eligible Measure Applicability (EMA) process willbe triggered to see if there were any other measures that could have been reported by that provider.Because hospitalists have fewer than 6 measures to report on, their reporting will likely be subject tothis validation process. The EMA has a two-step process:1. A clinical relation test sees if there are more clinically related quality measures based on the one tofive quality measures you submitted OR if none of the six or more measures included an outcomesmeasure – the clinical relation and outcome/high priority tests to see if there were any that couldhave applied.2. A minimum threshold test looks at the Medicare claims that you submitted to see if there are atleast 20 denominator eligible instances for any extra measures found in step 1.For more information regarding this process, see and the Quality Payment Program Frequently Asked Questions 7

ApplicableQuality Measuresfor HospitalistsApplicable Quality Measures forHospitalistsSHM worked with CMS to ensure that the “Hospitalist Specialty Measure Set” only containedmeasures that are applicable for hospitalists. Although some will remain low volume measuresfor some providers, as long as providers report as many measures as apply to their practice, theyshould avoid a penalty.QUALITY #5QUALITY #8Heart Failure:ACE/ARB for LVSDHeart Failure:Beta-blocker forLVSDReporting Method:Registry, EHRQUALITY #76Prevention ofCRBSI: CVCInsertion ProtocolReporting Method:Claims, RegistryReportin