Merit-Based Incentive Payment System:
Meaningful Changes in the Final Rule Brings
Cautious Optimism
Authors: Manchikanti Laxmaiah 
Published: October 2019

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) eliminated the flawed
Sustainable Growth Rate (SGR) act formula – a longstanding crucial issue of concern for health
care providers and Medicare beneficiaries. MACRA also included a quality improvement program
entitled, “The Merit-Based Incentive Payment System, or MIPS.” The proposed rule of MIPS sought
to streamline existing federal quality efforts and therefore linked 4 distinct programs into one.
Three existing programs, meaningful use (MU), Physician Quality Reporting System (PQRS), valuebased payment (VBP) system were merged with the addition of Clinical Improvement Activity
category. The proposed rule also changed the name of MU to Advancing Care Information, or
ACI. ACI contributes to 25% of composite score of the four programs, PQRS contributes 50%
of the composite score, while VBP system, which deals with resource use or cost, contributes
to 10% of the composite score. The newest category, Improvement Activities or IA, contributes
15% to the composite score. The proposed rule also created what it called a design incentive that
drives movement to delivery system reform principles with the inclusion of Advanced Alternative
Payment Models (APMs).
Following the release of the proposed rule, the medical community, as well as Congress, provided
substantial input to Centers for Medicare and Medicaid Services (CMS),expressing their concern.
American Society of Interventional Pain Physicians (ASIPP) focused on 3 important aspects:
delay the implementation, provide a 3-month performance period, and provide ability to submit
meaningful quality measures in a timely and economic manner. The final rule accepted many of the
comments from various organizations, including several of those specifically emphasized by ASIPP,
with acceptance of 3-month reporting period, as well as the ability to submit non-MIPS measures
to improve real quality and make the system meaningful. CMS also provided a mechanism for
physicians to avoid penalties for non-reporting with reporting of just a single patient.
In summary, CMS has provided substantial flexibility with mechanisms to avoid penalties, reporting
for 90 continuous days, increasing the low volume threshold, changing the reporting burden and
data thresholds and, finally, coordination between performance categories. The final rule has
made MIPS more meaningful with bonuses for exceptional performance, the ability to report for
90 days, and to report on 50% of the patients in 2017 and 60% of the patients in 2018. The
final rule also reduced the quality measures to 6, including only one outcome or high priority
measure with elimination of cross cutting measure requirement. In addition, the final rule reduced
the burden of ACI, improved the coordination of performance, reduced improvement activities
burden from 60 points to 40 points, and finally improved coordination between performance
categories.
Multiple concerns remain regarding the reduction in scoring for quality improvement in future
years, increase in proportion of MIPS scoring for resource use utilizing flawed, claims based
methodology and the continuation of the disproportionate importance of ACI, an expensive
program that can be onerous for providers which in many ways has not lived up to its promise.
Key words: Medicare Access and CHIP Reauthorization Act of 2015, merit-based incentive
payment system, quality performance measures, resource use, improvement activities, advancing
care information performance category