B R O U G H T T O Y O U B Y:
WHITEPAPER
BY KEN TERRY
ewer than half of physicians are aware of the Medicare Access & CHIP Reauthorization Act (MACRA), and most of those who do know about it probably wish it would go away. Nevertheless, this law will determine how Medicare reimburses doctors, starting in 2019. Although the Centers for Medicare & Medicaid Services (CMS) won’t release its final MACRA rule until later this fall, CMS recently changed the timeline for measuring the performance of physicians on quality, cost and other parameters. This 1
modification will make things considerably easier for doctors, but they should still start getting ready for MACRA immediately, experts say. Under CMS’ original proposal, physicians would have had to report on their performance for a full calendar year, starting January 1, 2017. The fee for service Medicare income of most physicians would be adjusted up or down 4% in 2019, depending on their scores. The at-risk portion of their Medicare reimbursement would rise to plus or minus 9% by 2022. The new CMS policy gives physicians more flexibility to
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adjust to this new reimbursement approach. In the first option, physicians who submit at least some data to CMS’ new Quality Payment Program in 2017 will not be financially penalized in 2019. In option two, doctors can start submitting the full range of data required by CMS anytime in 2017 and qualify for a partial bonus if they do well. In option three, practices can submit data for the full calendar year and qualify for full bonuses, again assuming that they do better than average on the measures. These three options are designed for physicians who elect to go into the Merit-Based
Incentive System (MIPS), one of two tracks in the Quality Payment Program. The fourth option is to apply for recognition as one of MACRA’s Alternative Payment Models (APMs), which include certain accountable care organizations (ACOs) and the 5,000 practices that will participate in CMS’ new Comprehen-
Physicians who don’t participate in the Quality Payment Program will automatically get the full downward adjustments in their reimbursement rate in 2019. Nevertheless, some doctors might be inclined to take the hit on their Medicare income, at least temporarily, rather than invest in new elec-
ALTHOUGH PRACTICES MAY NOT SEE AN IMMEDIATE ROI, THE PERCENTAGE OF INCOME A PRACTICE COULD GAIN IS SIGNIFICANT AND THE AMOUNT THEY COULD LOSE COULD BE EVEN MORE PROBLEMATIC.
sive Primary Care Plus demonstration. No more than 10% of physicians are expected to participate in APMs, which must take on a significant amount of financial risk for care delivery. Doctors in APMs will automatically receive 5% annual bonuses for five years, starting in 2019.
tronic health records (EHRs) or upgrades or hire additional staff to meet the MIPS criteria. They might also not want to invest in MIPS-mandated clinical practice improvement activities, such as engaging in population health management. David Wofford, a San Diego-
MIPS Guarantee from athenahealth’s network-enabled services help practices thrive through change. athenahealth incorporates quality measures directly into a practice’s workflow to help clients meet requirements without additional work. To support clients in preparing for MIPS, athenahealth guarantees that new clients using its services will avoid any MIPS payment penalties in 2019 based on 2017 performance. If a practice receives a downward payment adjustment, the company promises to credit the client the amount of the penalty for the 2017 reporting period. athenahealth partners with practices of all sizes to help ensure MIPS success.
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based consultant with ECG Management Consultants, acknowledges that practices are unlikely to see an immediate return on such investments with only 4% of Medicare revenue at risk in MIPS. But the percentage of income that a practice could gain or lose will quickly grow, he notes, and the program might evolve into something more problematic for those who don’t participate now. “I see MIPS as just training wheels,” he stated. “They’re preparing us for something else— some kind of expanded risk.” Here’s how to navigate these challenges both now and in the future. WHAT YOU NEED TO DO NOW
Practices should immediately consult with their EHR vendors to find out when their products will be ready for MIPS. CMS will allow practices to use their current certified EHRs until 2018, when they must switch over to EHRs that meet different certification standards. The latter EHRs are not yet available. But the current EHRs were not programmed to work with the MIPS quality measures, which won’t be described in detail until the final rule is issued. So EHR vendors will have to tweak their products to calculate those measures. With the greater flexibility that CMS recently introduced to the rules, however, the vendors won’t have to sprint to meet the January 1 deadline. If a practice’s EHR is upgraded by January 1, the practice can report with minimal difficulty if it chooses the full-year reporting option. Otherwise, the practice might want to wait until it receives the upgrade before beginning to report. While awaiting the EHR updates, practices should carefully evaluate their systems to see how they can be used to support
MIPS. For example, they might decide that their current EHR will not provide them with the capabilities they will need for MIPS going forward. If they decided to switch EHRs, under the new MIPS rules they’d have a large part of next year to choose another system and implement it.
There are ways to obtain comparative data that is more usable than what QRURs offer. Some cloud-based EHR vendors offer benchmarking services based on their customers’ data. Groups can also report their quality data to CMS through qualified clinical data registries
SINCE QUALITY MEASURES COMPRISE HALF OF THE SCORE, EXPERTS EMPHASIZE THE IMPORTANCE OF EXCELLING IN THAT AREA, AND THEY REGARD THE SELECTION OF THE RIGHT QUALITY MEASURES AS THE KEY TO SUCCESS.
To improve performance on quality measures, Wofford says, physicians need both historical data on their patient populations and near-real-time data on the services they’re providing—or not providing—to their patients. Much of that data will come from EHRs, but there are other information sources that can be valuable. For instance, doctors need benchmarking data to see how they stack up with their peers in MIPS. Practices that have submitted data to the Physician Quality Reporting System (PQRS) can access Quality and Resource Use Reports (QRURs) on CMS’ web portal. These reports are annual, so the data in them is not timely. Nevertheless, QRURs can help physicians see where they stand on quality measures compared to their colleagues, says Krista Teske, a consultant with The Advisory Board Company, a Washington, D.C., consulting firm. 3
(QCDRs) that are provided by specialty societies, certification boards, and regional healthcare collaboratives. If practices do that, says Erin Mastagni, also of ECG Management Consultants, physicians should be able to see how their performance compares whenever they want. CHOOSING MEASURES
A physician’s MIPS score represents his or her comparative performance in four categories: quality (50%), meaningful use of EHRs (25%), clinical quality
improvement activities (15%), and cost (10%). Since quality measures comprise half of the score, experts emphasize the importance of excelling in that area, and they regard the selection of the right quality measures as the key to success. They suggest choosing metrics that the practice has done well on in the PQRS program, especially those on which their performance exceeds that of their peers. Groups should also choose some measures that cut across specialties, which will increase the completeness of their data, Teske notes. Some EHR suppliers help practices select the measures that they’re best suited for. To improve quality scores, practices should use the patient registries built into their EHRs. Besides sending alerts and reminders to providers at the point of care, these registries can also be used to run reports on which subsets of patients have not received certain types of preventive and chronic care. Practices can then alert doctors that they need to provide those services when these patients visit. They can also send out automated phone or email reminders to let patients know that they are overdue for recommended care. CMS will allow practices to report quality data using any of the methods they have employed to report to PQRS. These include the use of special procedure codes, direct EHR reporting,
A PHYSICIAN’S MIPS SCORE REPRESENTS HIS OR HER COMPARATIVE PERFORMANCE IN FOUR CATEGORIES:
50% 25% 15% 10% QUALITY
MEANINGFUL USE OF EHRs
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CLINICAL QUALITY COST IMPROVEMENT ACTIVITIES
qualified registries, and QCDRs. Groups of 25 or more eligible clinicians may also use a CMS web interface for reporting. While claims-based reporting is still the most common method, Teske points out that it may become more difficult to do it this way in MIPS. That is because the percentage of Medicare patients on which practices must report for a particular measure will rise from 50% to 80%. “Groups should be evaluating other EHRbased and QCDR mechanisms
have already met the stage 2 requirements. In 2018, they will have more stringent requirements based on stage 3 metrics. The clinical practice improvement activities (CPIA) section requires changes in practice operations. Practices can choose among 90 activities as diverse as expanding access to the practice, improving communications with patients, and delivering test results in a timely manner. For example, expanded practice access might include increased evening
AS THEY CHOOSE A PARTNER, THE PRACTICE SHOULD MAKE SURE THIS COMPANY IS FOCUSED ON HELPING IT GENERATE HIGH MIPS SCORES WITHOUT TOO MUCH EXERTION. and migrating toward those because of the data completeness component,” she says. MEANINGFUL USE SUCCESSOR
The successor to Meaningful Use, called Advancing Care Information (ACI), will include 11 measures of EHR use that have been modified from the Meaningful Use Stage 2 criteria. ACI’s objectives encompass data security, patient electronic access, coordination of care, and health information exchange. Graduated scoring will replace the pass/ fail Meaningful Use approach, and doctors will get 50% of the points just for reporting. To do well on ACI, practices will have to exceed the average ranking. But it shouldn’t be a big challenge in 2017 if they
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and weekend hours, urgent care access, use of telehealth services, collection of patient experience data and a plan for improvement, or the hiring of an onsite diabetes educator. Some of these CPIAs will require a substantial investment, while others may be things a practice is already doing. In some cases, a practice can use its quality measurement efforts to meet CPIA requirements, Wofford notes. The American Academy of Family Physicians (AAFP) suggests that physicians consider using Medicare’s Chronic Care Management Program, which pays $40 per patient per month for enhanced care management, to cover the costs of practice transformations
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that will help them with CPIAs and other MIPS criteria. The resource use section doesn’t require reporting, because CMS will use Medicare claims data to measure utilization. Right now, resource use comprises only 10% of the MIPS score, but that percentage is expected to rise. Teske recommends that independent practices focus on reducing hospitalizations to improve their utilization scores. They could also be careful not to over-order diagnostic tests. CONCLUSION
Even small practices can tackle MIPS successfully if they prepare and have the right technology partners. As they choose a partner, the practice should make sure this company is focused on helping it generate high MIPS scores without too much exertion. For example, an EHR supplier should be able to ease the burden of data collection, reporting and feedback. In the near term, practices should stay in touch with their EHR vendor, observe what comes out of the final rule, and select the right quality measures. In the long run, they should keep trying to improve and should work at it all year round, not just when it’s time to report, says Teske. Practices that want to succeed in a value-based environment should not just look at the short-term ROI from MIPS, notes David Zetter, a healthcare consultant in Mechanicsburg, Pennsylvania. They should be trying to transform themselves so they can raise their performance scores, he says. Ultimately, there will be winners and losers under MACRA, and the proactive practices are more likely to be winners.