MACRA Basics: MIPS vs APM - What You Need to Know About the New Rules

Header - MACRA MIPS vs APM (1)

What is MACRA?

The MACRA (Medicare Access and CHIP Reauthorization Act) is the new healthcare reform poised to replace all of the different “patchwork programs” for physicians who receive Medicare payments. As part of the shift towards value-based programs proposed by CMS (Centers for Medicare & Medicaid Services), it’s purpose is to set up a new framework that rewards physicians, not on the amount, but the quality of care they provide. As a provider, you have two different options for how you want to get reimbursed: MIPS (Merit-based Incentive Payment System) and APMs (Advanced Payment Model).


What is MIPS?

MIPS determines your reimbursement rates by the quality of care. Payment adjustments under MIPS are based on the MIPS Composite Score, which comprises of 4 key areas:

  • Quality (Formerly Physician Quality Reporting System or PQRS)
  • Advancing Care Information (Meaningful Use)
  • Clinical Practice Improvement Activities
  • Resource Use

If your score is above the threshold, you’ll receive a positive payment adjustment. But if you’re below, you’ll have a negative payment adjustment for the following year. Scores will be compared to both year-over-year improvements and other providers.


Benefits of Merit-Based Payments

High performers under MIPS receive a positive payment adjustment for up to 3x the adjustment factor, but physicians still have to report on quality measures to make sure standards are being upheld. Providers can maintain a higher score by simply improving patients’ outcomes through care coordination and ensuring patients have easy electronic access to their health information. Many are already using technology to increase patient engagement. By communicating with their patients in real-time, providers can better serve patients who have a higher risks of complication and readmission to the hospital. Through patient engagement and communications, providers receive credit for helping patients through personalized reminders to take their medicines, monitor their performance, and keeping them healthy throughout the continuum of care. Tying clinical practice improvement activities such as improving patient safety, population health, and long-term outcomes together, ultimately makes your practice much more efficient.


What is APM?

Aside from MIPS, the other payment track is an Advanced Payment Model or APM. Currently, patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) use this model. CMS, however, anticipates that more individual providers will qualify for this option. APMs will provide a 5% lump sum bonus based on the prior year’s payment beginning in 2019 over a 6 year time period.

To be eligible for APM, participants must:

  • Have serious quality measures comparable to MIPS
  • Use EHR (Electronic Health Record) technology
  • Bear “more than a nominal financial risk” similar to an ACO or PCMH

Physicians who choose an APM have an opportunity to earn more, but run the risk of paying Medicare back if they don’t meet savings goals. Understanding these risks and determining if they outweigh the potential benefits is a decision that providers will have to make individually or with their practice management team.


How to Choose the Best Payment Model

Which path do you take? You and your partners can weighout both payment models under the MACRA, but first, you’ll want to get the facts to make an informed decision.

Know yourself - Dig through the quality data. Are you a high performer? Find out why or why not. Know your current quality metrics and create a plan to improve.

Know your patient population - Do you know you take on patients that have multiple health problems or things you can’t control? That could be a factor in your reimbursement rates.

Under MIPS, there are over 90 activities you can choose from to demonstrate how you’re improving your clinical practice. These tactics can give you credit for helping patients overcome challenges like making sure they’re taking their medicine or adhering to a rehab program.


How Meaningful is Meaningful Use Technology

Another thing to consider is your meaningful use technology. Now, you’ll be measured on how well patients are making use of their electronic health information. Is it actually providing value? The intent is that providers and patients are actually sharing information and making prevention and high-quality care more accessible to patients.


Start Planning Now

The good news is that the current payment programs requiring reporting on quality metrics will be absorbed into the MACRA. Physician practices have until 2019 to choose their payment track, however, it’s never too early to understand your options and have a general idea of what makes the most sense for your practice. In the meantime, you should honestly evaluate your quality metrics and how you’re meeting meaningful use. Take the time to look for ways to improve and implement tactics that can help your patients now.



NPRM - Quality Payment Program Fact Sheet

CMS Quality Reporting Programs

Medicare Access and CHIP Reauthorization Act (MACRA) Preview Module

Quality Payment Program - CMS

Quality Payment Program - MIPS and APM

MIPS or APM: Which is better for your practice?

Moving toward improved care through information

MACRA Payment: APM vs MIPS


I Will Keep Them From Harm and Injustice (Part 2)

Part 2: Preventing No-Shows


Being stood up is never fun and it’s disrespectful in professional appointments. Unfortunately, it’s not a matter of if, but when patients will miss appointments. People will get stuck in traffic and priorities shifting throughout the day. No-shows will continue to occur, but there are ways to dramatically reduce patients from disappearing.

The problem with no-shows is that healthcare providers don’t get notice of a patient’s status. It could be because of time constraints, monetary constraints (e.g. insurance deductibles), or even physical constraints. The reasons behind patient no-shows may vary by individual needs.

Healthcare providers have attempted to reduce no-shows with a fee policy. One office placed “problem patients” on probation. Others simply absorb the lost time and income. While the onus ultimately rests upon the patient, doctors cannot provide proper care if the patients do not show up. It hurts a patient more than the physician.

In part two of our Population Health Management series, we explore the problem of no-shows, and how to prevent it from occurring.


Challenge #2: Preventing no-shows

No-shows are defined as intended appointments that are not canceled or rescheduled less than two hours before the designated time.

The worst part of patient no-shows is not knowing a patient’s condition. For doctors, this uncertainty is cause for concern because it elevates the risk of pain and suffering. Prolonging a diagnosis and treatment for a medical condition can be both physiologically and financially taxing.

Patient no-shows have been reported to be as low as 5.5% and as high as 30%. Higher rates were particularly apparent for academic practices.

No-show patients may seem harmless since it guises itself as a much-needed break for overworked physicians. But it severely hurts a hospital’s bottom line. Not only does the practice lose revenue, cost per patient increases as well as readmission rates, which may lead to hefty penalties.


Opportunity: Reducing Patient No-Shows

Understanding your patients is critical for reducing no-shows. It begins with observing your practice’s no-show rates. Only 63% of healthcare providers tracked missed appointments. The remaining practices are unaware of the severity of their no-show rates, and would be difficult to measure and improve on performance.

In one study, a 47% of patients are habitual no-show patients. The problem is that the 35% of the habitual no-show patients had close ties with the physicians. This makes no-show policies difficult to implement. In fact, 7% of the habitual no-shows are also 15% of the arrived visits. This makes patient management a complex and sensitive challenge.

Understanding the individual patient is as important as knowing the patient population. Each patient is unique and has different reasons for not attending an appointment. The likelihood of patient no-shows can be attributed to their clinical data, claims history, demographics, and socioeconomic status.


Recommendations: Nurture your Patients

There are many reasons why patients fail to appear without notice. There are ways healthcare providers can reduce no-show rates by focusing on actively engaging at-risk patients.

Traditional methods such as no-show fees, double bookings, or first come first serve practices, can marginally improve no-shows. However, these techniques can cause friction and are as unprofessional as a discount domestic airline.

To focus on the cause, rather than the symptom, healthcare providers should place more attention on long lead times. Doctor’s appointments are often made weeks in advance, which patients have to be diligent to reserve. As the appointment approaches, reminders are often necessary.

Suum cuique is the latin verb for “To each their own.” Everyone has a personal preference. Using a personalized approach encourages, rather than punishes, patients for showing up. And it’s showing results.

Patients are five times more likely to keep an appointment when they receive a call reminder. By receiving reminders, 17.3% of patients missed appointments, compared with 23.1% of patients who received no reminder call missed their appointments.

However, calling to remind each patient is laborious. Patient Relation Management technologies such as CareSkore, actively engages patients using Short Messaging Service (SMS). Texting a patient not only provides clear communication, it is automated, bidirectional, and asynchronous.



When an appointment is approaching messaging technologies can automatically send reminders to patients without using admin time.



SMS technologies that leverage Artificial Intelligence (A.I.) like CareSkore engages patients in a natural conversation. Unlike push notifications, A.I. is bidirectional, which means the computer understands the language and responds accordingly.



Unlike a phone call, text messages can be received and responded without needing the recipient to be actively engaged in real time.


The Patient Lifecycle

No-shows hurt both patients and caregivers. But there are ways to reduce the lost time. Nurturing patients throughout their lifecycle helps avoid no-shows. This does not require a large call center, but the careful implementation of intelligent software. Doctors are here to treat, but they are only as effective as the presence of a patient.