CMS Final Rule concerning MIPS program

Meaningful use is changing into a 4 step process called MIPS where nearly every aspect of a practice will be measured.


  • Physicians who participate could receive payment incentives  ( Medicare only ) from 12% in 2019 up to 27% by the year 2022.
  • Most likely any upside percentages will range from 4% to 9%.
  • Physicians not participating in these measurements could receive pay reductions from -4% in 2019 up to -9% by the year 2022.


Will our new administration change any of the above ?

This is unknown at this time, however it is widely anticipated that some changes will be forthcoming. Remember that CMS requires a large lead time of up to 24 months to implement a significant change.


Meanwhile the following changes are being put in effect.



MIPS stands for Merit-Based Incentive Payment System.

MIPS  rewards clinicians for providing high-quality care at a reasonable cost.

  • The performance of other physician groups in a determined area will be used to set the threshold in which your quality performance is measured against.
  • If a physician falls short of this threshold, they will be paid less. If a physician meets or surpasses the set threshold, they will be paid more.

How Physicians will be graded.

The four components of MIPS are:

  1. Quality ( Reporting PQRS Measures )
  2. Resource Use ( e.g. Chronic Care Management )
  3. Advancing Care Information ( Using a Certified EHR )
  4. Clinical Practice Improvement Activities ( Expanding Access, Care Coordination, etc )

Each of the four components are weighted – See Chart Below

Composite Performance Score

2017 Weight 2018 Weight 2019 Weight 2020 Weight 2021 Weight
Quality 60% 50% 50% 45% 30%
Resource Use 0% 10% 10% 15% 30%
Advancing Care Information 25% 25% 25% 25% 25%
Clinical Practice Improvement Activities 15% 15% 15% 15% 15%

The reporting that a care provider submits to CMS in 2017 will affect their pay in 2019,  The reporting that a care provider submits to CMS in 2018 will affect their pay in 2020, etc.


MIPS penalty and incentive calculations:

Year Maximum -% Medicare Part B Payment Adjustment Maximum +% Medicare Part B Payment Adjustment
2019 -4% 4 (*X +10%= 12%)
2020 -5% 5 ( *X +10%= 15%)
2021 -7% 7 ( *X +10%= 21%)
2022 -9% 9 (*X +10%= 27%

To score the highest bonus offered by CMS, a doctor has to score in the top percentile, multiplied by X (the budget neutral factor which is capped at 3) and get the 10% exceptional performance bonus.


A second method to generate a possible payment increase is called the Alternative Payment Model (APM)

APMs are payment models that require doctors to take on risk for the cost and quality of the care they provide.” Like MIPS, Alternative Payment Models include a set of governing rules and regulations that providers must follow in order to receive top financial reward. Like MIPS, in APMs (which include Bundled Payments) clinician compensation and quality of care are directly linked and the providers adopts financial risk.

The majority of physicians will not use this model.

However, doctors that meet the requirements for APM (including minimum volume thresholds) can be exempt from MIPS participation.

According to AAFP, in order to be exempt from MIPS, the APM must also meet the following eligibility requirements:

  • Use quality measures comparable to measures under MIPS
  • Use certified electronic health record (EHR) technology
  • Assume more than a “nominal financial risk” OR is a medical home expanded under the CMMI.

APMs come with their own set of challenges for physicians, but also come with some pluses. The reporting required by physician groups operating under APMs are lighter than that of MIPS. In addition, the payment structure is set up so that less emphasis is placed on “Keeping up with the Joneses”, or competing with the quality set by physician peers.MACRA offers a 5% annual lump sum payment to providers who participate in APMs (like CJR).

To receive the 5% incentive payment (starting in 2019) for Advanced APM participation, you must:

  • You receive 25% of your Medicare Part B payments through an Advanced APM


  • See 20% of your Medicare patients through an Advanced APM

The Pros and Cons


Both MACRA tracks require physicians to report more, be held accountable for beneficiary outcomes and episode of care costs, and really step up the efficiency and quality of the health care they deliver.

Eligibility Providers who meet volume minimums for patient numbers and profit (called eligible participants In 2017: MDs, PAs, NPs CNSs, CRNAs By 2020 most Medicare fee-for-service payments will be part of the MIPS track. Approx. 600,000 Part B clinicians will participate in 2017. Meet billable patient volumes for conditions, care episodes, or populations that can be defined as “Alternative Payment Models” A list of Medicare models considered to be APMs are found here
Payment Structure Providers must report on 4 different categories of measures to determine the composite performance score (0-100). Performance year threshold is determined by CMS and +/-% payment adjustments are made based on CPR score A competitive, budget neutral system with incentive bonuses delivered for highest scorers 0.5% annual baseline bonus for all participants 5% annual lump sum bonus for qualified Advanced Alternative Payment Model participants Payment structure dependent on Medicare model but must have sufficient and measurable risk
Differences In MIPS, doctors are in a competitive model in which their composite score is measures against the benchmark set by their peers Clinicians and clinician groups bare all risk, not the institution they work for In APMs, participants are incentivized to join this model with a 5% bonus regardless of performance quality In Bundles (specifically CJR), the hospital bears the risk for poor performance, not the clinicians themselves