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Learn the Lingo: Key Terms for Navigating the Value Based Care World

With the shift toward value-based payment models, pharmacists are seizing new opportunities to improve patient care in medical homes, accountable care organizations, and other innovative care models. This resource includes acronyms and terminology commonly used when practicing in or discussing innovative practice models. Each term includes a short description and references so you can further your practice in a value based care world. This is the first of multiple volumes that will be published by the Medical Home/ACO SIG.

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-based Incentive Payment System (MIPS)

Published on Thursday, September 2, 2021

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-based Incentive Payment System (MIPS)

Definition: MACRA is legislation signed in April 2015 that is designed to transform the basis of health care clinician payment from volume to value.1 MACRA created the Quality Payment Program (QPP), which repealed the sustainable growth rate formula used to determine physician and other clinician FFS payment rates in Medicare as well as creating the MIPS.2,3 It also created bonus payments for entities participating in APMs.4

QPP gives clinicians 2 choices for participation:

  • Merit-based Incentive Payment System
    • MIPS-eligible clinicians receive payment adjustment for the services they provide for Medicare patients based on performance in 4 categories: quality, cost, improvement activities, and promotion of interoperability. Performance in these categories results in a MIPS payment adjustment to the FFS rate 2 years after the performance measurement (for example, performance in 2019 impacts MIPS payment adjustment in 2021). Payment adjustments can be positive or negative depending on the clinician’s performance score.
  • Advanced Alternative Payment Models
    • Participation in APMs allow clinicians to earn incentive payments for providing high-quality, cost-effective care to Medicare patients. There are multiple advanced APMs available to clinicians.

How it relates to ACO/PCMH: Performance-based payment is increasingly common. Team-based care is imperative to improving the quality of care provided for patients. Pharmacists working in ACO/PCMH models have the expertise to positively impact quality measures and other performance metrics that are increasingly determining payment to practices and organizations.

Involved organizations/oversight: CMS

Resources:

  1. MACRA. Available at: www.cms.gov/Medicare/Quality CMS. -Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs/
  2. CMS. Quality Payment Program. Available at: www.cms.gov/Medicare/Quality-Payment-Program/Quality-Payment-Program
  3. CMS. Merit-based Incentive Payment System. Available at: https://qpp.cms.gov/mips/overview
  4. CMS. Advanced Alternative Payment Models. Available at: https://qpp.cms.gov/apms/advanced-apms

Contributing author:

Kelli Barnes, PharmD, BCACP

The Ohio State University Division of General Internal Medicine Clinics

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