Clinical Practice Improvement Activity (15%)
• Clinicians must attest to several of a wide range of practice-level activities, such as delivery of telehealth services, participation in registries, and provision of 24/7 access.

But the authors advised that these do not adequately measure "important aspects of quality," as well as not accounting for the severity of the health episodes.
"There is little evidence that pay-for-performance reduces overall costs," they stated, adding, "The resource use measures are scheduled to become more important, but measures to date have a poor track record in identifying efficient physicians and practices."

As an example they note that to date, similar measures in the 2016 Value-Based Payment Modifier program found that "96 percent of physician practices were scored as “average cost.” They suggested that "clinicians can generally expect average scores, which offer little motivation to change."

The proposal also describes "Alternative Payment Models (APMs) , which could allow health care providers to be exempted from MIPS – in return for assuming a greater degree of accountability for quality and costs.

“We estimate that about 10 percent of physicians could qualify for extra payments associated with advanced Alternative Payment Models based on the Medicare payment options and pilots available now. These would mainly include certain primary care doctors and clinicians practicing within large integrated systems that take on significant financial risk,” McClellan told Duke Today, stressing that "physicians have a real opportunity to shape the future of clinical practice, by developing models that enable a broader range of physicians to qualify for advanced APMs."

For Miranda Franco of the Holland & Knight law firm, these changes are "the strongest attempt by the CMS to get to risk-based APMs. The MACRA incentivizes physicians to move into Advanced or Other Payer Advanced APMs through several different mechanisms, including a guaranteed 5 percent bonus for six years and a permanent annual 0.75 percent fee schedule bump."

She stressed that "those in the health care industry should pay close attention to these incentives and to Medicare's evolving payment structures so they can position their organizations for success in the new value-based world."

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