MACRA 101: MIPS and the Quality Reporting Category

Christine Bulgozdi
Associate Editor
Loyola University Chicago School of Law, JD 2018


The Merit-based Incentive Payment System (“MIPS”) is one of the two different payment methods that MACRA will use for eligible clinicians. MIPS replaces the existing fee-for-service model and is expected to be the payment track that most clinicians take. Clinicians will be evaluated based on a single Composite Performance Score from four reporting categories: Quality, Resource Use, Advancing Care Information and Clinical Practice Improvement Activities.  This article will detail the requirements of the Quality reporting category as well as provide tips on how to maximize this score.


In the first year that MACRA takes full effect, Quality reporting is the first and highest ranking reporting category. The Quality score will make up 60% of the overall composite score. Each subsequent year, the weight of the Quality score decreases, where it will remain steady for 2021 and beyond.


The Quality reporting category replaces the Physician Quality Reporting System (“PQRS”) and the quality component of the Value Modifier Program currently in practice. The Quality score contains similar measures as the current PQRS but reduces the amount of measures to be reported from nine to six and contains an emphasis on outcome measurements.


Under this new Quality reporting category, clinicians are able to choose which six measures they will report and be evaluated on. Of these six measures, one must be a cross-cutting, multidisciplinary measure and one must be an outcome measure or a high priority measure if the former is unavailable. Clinicians choose these six measures from either the list of proposed measures or from a set of more specific specialty measures. Additional population measures will also be automatically calculated for each clinician based off of Medicare claims data. If a clinician is unable to identify six measures that apply to his or her organization, the clinician should report on all the measures that are applicable.


Luckily, the final rule has established a lower threshold for the first reporting year. During this first reporting year for 2017, clinicians need only report on six quality measures, or they can choose to report one specific specialty measure or a specific subspecialty measure set. For subsequent years, the reporting will be as proposed above.


Clinicians, or groups, may report these measures in a variety of ways: claims data, qualified clinical data registry, qualified registry, administrative claims, or EHR vendors.  For groups of 25 or more clinicians, these measures may also be reported via a CMS web interface.


Calculating the Quality Performance Score


The Quality performance score is calculated by converting each measure into points and dividing a clinician’s points with the total possible points which can be awarded. Each of the six measures is converted to a score between one and ten. There are no points awarded for unreported measures. Furthermore, there is a possibility of bonus points which can be awarded for additional reporting outcomes, patient experience, appropriate use, patient safety and EHR reporting. A clinician’s total points is calculated by adding all the measure points and the bonus points together.


The points awarded for each of the measures is calculated based on deciles. Deciles are published by the Center for Medicare and Medicaid Services (“CMS”) based on national performance two years prior. Points are given based on where a clinician’s performance data lies within the decile range. Clinician’s with top performances will land in the highest decile and receive ten points. Any reported data will receive no lower than one point and clinicians who report less than required will receive zero points for the unreported measures.


Additionally, there are opportunities for up to 10% in bonus points. Bonus points are awarded for additional high priority measures that are reported and for a CEHRT bonus, each bonus allows up to 5% of possible total. The additional high priority measures give two bonus points for additional outcome and/or patient experience and also one bonus point for other high priority measures. The CEHRT bonus allows one bonus point for each measure using CEHRT in end-to-end electronic reporting.


What’s Next for Compliance Programs?


As MACRA slowly becomes more understandable, clinicians should start to look at whether they will be eligible for the MIPS or APM payment path. Clinicians subject to MIPS will need to start considering how this new payment method will affect their organization. These clinicians can compare the current method and its measures to the new ones that will apply under MACRA and MIPS in 2017. The new Quality Reporting category will be especially important during the first two years MACRA becomes active. With the entire healthcare industry moving towards quality based payments, a focus on quality improvement and the new quality measures will be essential for maximizing payment. Compliance officers can begin looking at the variety of measures to choose from for their reporting and figure out which ones apply to their organization. By determining which measures to report in advance, compliance programs can help ensure that the transition to MACRA will be as smooth as possible.