Between MIPS and APMs, PQRS, and QCDRs, to name a few, MACRA / Quality Payment Program can feel a bit like alphabet soup. Explore our glossary of terms and definitions to learn what it all means.
Accountable Care Organizations (ACOs)
Groups of doctors, hospitals, and other healthcare providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending healthcare dollars more wisely, it will share in the savings it achieves for the Medicare program.
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Advancing Care Information (ACI)
It's not good enough to just buy an EHR. It must be used in a meaningful way (as defined by Advancing Care Information regulations) to improve quality, safety, and efficiency and reduce health disparities; engage patients and family; improve care coordination and population and public health; and maintain privacy and security of patient health information. MACRA will continue to require that physicians be measured on Advancing Care Information for purposes of determining their Medicare payments, but the approach will begin to look different under MACRA.
Learn More About ACI Regulations
Alternative Payment Models (APMs)
Examples include Accountable Care Organizations (ACOs), patient-centered medical homes (PCMHs), and bundled payment models. Under MACRA, between 2019 – 2024, qualifying APM participants will receive an annual lump sum incentive payment of 5%. Qualifying APM participants will not be subject to Merit-Based Incentive Payment System (MIPS) adjustments; however, many components of MIPS, including electronic health records (EHRs), are also requirements of APMs. APMs involve increased transparency of physician-focused payment models, and starting in 2026, will offer some participating healthcare providers higher annual payments. In addition, qualifying APMs will require that the provider organization take on some financial risk.
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Attribution
Process by which patients are assigned to a particular doctor for measurement of cost and quality. Attribution within the Merit-Based Incentive Payment System (MIPS) pathway uses Tax Identification Numbers (TINs) and not National Practitioner Identifiers (NPIs).
Center for Medicare and Medicaid Innovation (CMMI)
The Innovation Center develops new payment and service delivery models in accordance with section 1115A of the Social Security Act. Innovation models are organized into seven categories: Accountable Care Organizations (ACOs), episode-based payment initiatives, primary care transformation, initiatives focused on the Medicaid and Children’s Health Insurance Program (CHIP) population, initiatives focused on Medicare/Medicaid enrollees, initiatives to accelerate the development and testing of new payment and service delivery models, and Initiatives to speed the adoption of best practices.
Learn More About CMMI
Children’s Health Insurance Program (CHIP)
Provides free or low-cost health coverage to children of families that earn too much money to qualify for Medicaid. In some states, CHIP covers parents, pregnant women, the elderly, and people with disabilities. Each state offers CHIP coverage, and works closely with its state Medicaid program.
Learn More About CHIP
Clinical Practice Improvement (CPI)
One of four performance categories under the Merit-Based Incentive Payment System (MIPS); other three are quality, resource use and meaningful use of certified EHR technology. Six CPI subcategories are expanded practice access, population management, care coordination, beneficiary engagement, patient safety and practice assessment, and participation in an alternative payment model (APM).
Electronic Health Record (EHR)
Previously known as EMR. Meaningful use of certified EHR technology is one of four performance categories under the Merit-Based Incentive Payment System (MIPS)
Learn More About EHR
Fee for Service
A service delivery system where healthcare providers are paid for each service separately (e.g., office visit, test, or procedure). Medicaid develops fee-for-service payment rates state by state, based on the costs of providing the service, a review of what commercial payers pay in the private market, or a percentage of what Medicare pays for equivalent services.
Learn More About Fee for Service
Improvement Activities (IA)
The Improvement Activities performance category within MIPS assesses how much you participate in activities that improve clinical practice. Examples include ongoing care coordination, clinician and patient shared decision making, regular implementation of patient safety practices, and expanding practice access. Under this performance category, you’ll be able to choose from many activities to demonstrate your performance. This performance category also includes incentives that help drive participation in certified patient-centered medical homes and APMs.
Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)
Huge piece of legislation that replaced the sustainable growth rate (SGR) with an alternative set of predictable, annual baseline payment increases and two potential payment tracks, from which all providers must choose. The goal is for CMS to pay for value, rather than fee for service. Through 2019, there will be an annual baseline payment increase of 0.5%. From that point on, annual automatic increases come to an end and physicians will have to choose between the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs). Their choice and performance in each system will determine reimbursement rates after 2019.
Learn More About MACRA, MIPS, and APMs
Medicare Physician Fee Schedule (PFS)
A comprehensive list of fee maximums used by Medicare to reimburse a physician and/or other providers in a fee-for-service system.
Learn More About PFS
Merit-Based Incentive Payment System (MIPS)
New program, invented by MACRA, that combines elements of the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VBM), and meaningful use. Eligible professionals will be assessed for reimbursement based on four weighted performance categories: 1) quality, 2) resource use, 3) clinical practice improvement activities, and 4) advancing care information (MU). Physicians will be assessed as a group based on every doctor who is part of their tax identification number (TIN). The ACR’s Rheumatology Informatics System for Effectiveness (RISE) registry can be used for quality data reporting under MIPS.
Learn More About MIPS
National Practitioner Identifiers (MPIs)
Unique identification number for covered healthcare providers. For those choosing the Alternative Payment Model (APM) option under MACRA, the method of attribution will be by the physician’s MPI.
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Patient-Centered Medical Home (PCMH)
This care delivery model aims to transform how comprehensive primary care is provided by coordinating patient treatment through the primary care physician to ensure patients receive the necessary care when and where they need it, in a manner they can understand. The objective is to have a centralized setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Ideally, care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the appropriate care.
Learn More About PCMH
Pay for Performance
An approach wherein a health insurer or other payer compensates physicians according to an evaluation of physician performance, typically manifest as a potential bonus on top of the physician’s fee-for-service compensation. The payer bases its evaluation on the data it has on that physician or physician group, most commonly administrative or claims data measuring quality and/or cost of care.
Learn More About Pay for Performance
Physician Quality Reporting System (PQRS)
A quality reporting program that encourages individual Eligible Professionals (EPs) and group practices to report information on the quality of their care to Medicare.
Learn More About PQRI
Rheumatology Informatics System for Effectiveness (RISE) Registry
The ACRR's registry, which provides participants with an infrastructure for robust quality measurement and improvement activities for patient outcomes, patient population management, and quality reporting. RISE automatically syncs with Electronic Health Records (EHRs) to gather data that flow automatically into the registry for reporting and reimbursement requirements. RISE is a Quality Clinical Data Registry (QCDR) and can be used for quality data reporting under MIPS.
Learn More About RISE
Quality Clinical Data Registry (QCDR)
A CMS-approved registry that collects data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. Physician Quality Reporting System (PQRS) reporting requirements according to CMS specifications can be satisfied with participation in a QCDR such as the ACR’s Rheumatology Informatics System for Effectiveness (RISE) registry.
Learn More About QCDR
Sustainable Growth Rate (SGR)
A means for CMS to regulate spending on medicare physician services. For several years, the formula used as part of the SGR system recommended that payments for Medicare physicians be cut drastically, which caused congress to step in with temporary fixes to avoid these cuts. In April 2015, the SGR was repealed and replaced with MACRA.
Tax Identification Numbers (TINs)
Number assigned by the Internal Revenue Service (IRS) for tax purposes. Under Merit-Based Incentive Payment System (MIPS), rheumatologists will be judged as a group based on every doctor who is part of a single TIN. If a patient with a complex condition sees many different doctors, cost and quality measurements will be aggregated for all doctors in the TIN.
Learn More About TINs
Value-Based Modifier (VBM) (also called the value modifier and the physician value-based modifier)
An adjustment made on a per claim basis to medicare payments for items and services under the Medicare Physician Fee Schedule (PFS). The Value Modifier program determines the amount of Medicare payments to physicians based on their performance on specified quality and cost measures. The program rewards quality performance and lower costs.
Learn More About VM and PVBM