MIPS (Merit-based Incentive Payment System) and APMs (Alternative Payment Models) are two new reimbursement criteria that were established by MACRA (Medicare et al. Act). These standards are intended to support value-based healthcare and raise the standard of care for Medicare beneficiaries while enhancing their effectiveness (Rosenkrantz et al., 2020). While MIPS and APMs are intended to motivate healthcare professionals, they differ in layout, prerequisites, and the kinds of providers eligible for incentive payments.
The Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VBPM), and the Medicare Electronic Health Record (EHR) Incentive Program have been combined and replaced by MIPS, a performance-based compensation program. The program does not affect the budget and modifies payments following a composite performance score derived from four performance categories: Quality, Promoting Interoperability, Improvement Activities, and Cost. Among the eligible clinicians subject to MIPS are doctors, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. These qualified physicians must submit information on various quality indicators and activities to demonstrate their performance and qualify for a favorable payment modification.
APMs, on the other hand, are alternative payment models that give healthcare providers a chance to receive rewards for assuming the financial risk associated with patient outcomes and costs. APMs are made to promote the shift from fee-for-service reimbursement to value-based care. ACOs, bundled payment models, and advanced primary care models are examples of different APMs. Providers mustmust reach certain quality and cost targets due to APMs, which strongly emphasize care coordination, patient participation, and shared savings. The MIPS reporting requirements are waived for qualified practitioners who take part in approved APMs and can receive a lower percentage bonus on their Medicare Part B payments.
MIPS and APMs have different requirements for eligibility for incentive reimbursement. Clinicians who qualify for incentive compensation under MIPS must reach the low-volume requirement. Clinical professionals should evaluate the most recent recommendations because these thresholds could change annually (Hess et al., 2019). In order to prevent a reduction in payment, eligible doctors who exceed the low-volume threshold for MIPS participation must do so.
APMs, on the other hand, have unique restrictions for eligibility. Clinicians must participate in a particular APM classified as an Advanced APM by the Centers for Medicare and Medicaid Services (CMS) to be eligible for incentive compensation under an APM (Kannarkat et al.,2023). The utilization of verified electronic health records, taking on more than minimal financial risk, and satisfying quality performance standards are just a few requirements that these APMs must fulfill. These criteria must be met for eligible physicians to be exempt from MIPS and qualify for the lower percentage bonus payment on their Medicare Part B payments.
In conclusion, MIPS and APMs are two different reimbursement criteria introduced under MACRA to drive the shift toward value-based care. MIPS is a performance-based program applicable to eligible clinicians who report on quality measures and activities. At the same time, APMs are alternative payment models that offer incentives for taking on financial risks related to patient outcomes and cost. Eligible clinicians must meet the low-volume threshold to participate in MIPS. In contrast, participation in specific APMs that meet CMS criteria exempts clinicians from MIPS and offers the opportunity for incentive reimbursement. Healthcare professionals must understand these criteria and requirements to make informed decisions regarding participating in these programs.
References
Rosenkrantz, A. B., Duszak Jr, R., Golding, L. P., & Nicola, G. N. (2020). The alternative payment model pathway to radiologists’ success in the Merit-based Incentive Payment System. Journal of the American College of Radiology, 17(4), 525-533. https://doi.org/10.1016/j.jacr.2019.09.016
Kannarkat, J. T., Shah, S., Parekh, N., & Crosson, F. J. (2023). Strengthening the Center for Medicare and Medicaid Innovation’s Approach to Constructing Alternative Payment Models. The Milbank Quarterly, 101(1), 11-25.
https://doi.org/10.1111/1468-0009.12597
Hess, C. T. (2019). Merit-based Incentive Payment System: 2019 Changes. Advances in Skin & Wound Care, 32(2), 94–96. DOI: 10.1097/01.ASW.0000552866.40487.07
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