Proactively Prepare for MIPS Now—Your Future Self Will Thank You

Have you heard that change is coming? What was once a quiet tap on the exam room door has quickly transformed to a thumping, then a louder rapping, and now a steady bang with cries of, “Ready or not, here I come!” This beast will no longer be ignored. What’s more, the door is unlocked and about to be forced off its hinges.

What change am I talking about? It’s the shift from paying doctors using a traditional fee-for-service reimbursement model to one that pays according to the value that they provide to their patients, where “value” is defined by participation in several health IT and quality reporting programs. For many providers, this shift in thinking and way of practicing medicine will be one of the greatest challenges of their career.

The main shift is to keep patients at the center of care.

One might think that this new conversation about value is related only to money. Yes, a provider’s value score will affect his or her reimbursement. But if you look more closely, the main shift is to keep patients at the center of care, in hopes of keeping them healthier longer, or—better yet—preventing them from getting sick in the first place.

These changes come into effect under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which affect the 2019 payment year, which is based on the 2017 performance year. Under MACRA, most providers will fall into one of two paths: (1) the Merit-based Incentive Payment System (MIPS); or (2) an alternative payment model (APM).

The majority of providers will fall under MIPS, especially in MACRA’s first years. To help providers position their organizations for this new model before the changes in payment go into effect, this article focuses on MIPS.

Know Where You Are

Three main health IT programs are involved in building the MIPS foundation:

• Electronic Health Record (EHR) Incentive Program (Meaningful Use);

• Physician Quality Reporting System (PQRS); and

• Value-based Payment Modifier (VBM).

Have you participated in these in the past? If you don’t know, you can check your status with each of these programs by visiting the following websites:

• The EHR Incentive Registration and Attestation System(1) shows your Meaningful Use participation and payment history.

• The CMS Enterprise Portal(2) provides access to your Quality Resource and Use Reports (QRUR). The QRUR is basically a report card on the quality and cost measures submitted to CMS via PQRS and claims data.

Educate Yourself about MACRA

Get familiar with the CMS Web page describing the Quality Payment Program.(3) On this page, you can review presentations, webinars, and all sorts of other resources that provide details of the new program.

One main point to understand about MACRA is that the program is budget-neutral. In other words, it’s a zero-sum game that rewards doctors who play it well at the expense of doctors who don’t. Beginning in 2019, penalties will be taken from the losers’ reimbursements, collected into a fund, and then reissued to pay out the incentives to the winners. Because CMS anticipates that there will be far more losers of this game than winners, the incentive paid out could potentially exceed the penalty by a factor of three.

CMS predicts that for every 100 providers who get penalized, only about 33 will earn an incentive.

To put that into context, CMS predicts that for every 100 providers who get penalized, only about 33 will earn an incentive. With 100 losers contributing to a penalty fund, the entirety of those funds would get distributed to those lucky 33 winners. Then in 2019 when each of these providers submits a claim for a $100 service, the 100 losers would receive just $96 for their service, while the 33 winners would receive up to $112.

Who wouldn’t want to be on the winner’s side of this equation? It’s a double win—they get a bonus, plus they get paid by their competition. The flip side of that coin is a double loss, for the same reason.

Table 1 provides a timeline for how the penalties and incentives will increase as the years pass. The longer the game is played, the more money is at risk. In just a few short years, the same $100 service could have a reimbursement spread of $91 to $127.

Tackle each MIPS Component Separately

Four main categories, together, will make up your total MIPS score, which will fall somewhere between 0 and 100 points. Each category will have a maximum number of points that can contribute to the total score. Figure 1 shows the breakdown for the 2017 performance year.

Figure 1. Merit-Based Incentive Payment System score breakdown for the 2017 performance year.

Advancing Care Information

Advancing Care Information (ACI) is essentially Meaningful Use, repackaged. In 2017, most providers will likely still be using an EHR that is certified based on the 2014 edition standards. For them, reporting ACI will look and feel very similar to their current Meaningful Use reporting. They will submit on the same 10 objectives that are currently included in their EHR’s Modified Stage 2 report. However, one big difference will be that the all-or-nothing approach, where providers who miss just one measure on any objective for which they cannot claim an exclusion lose credit for all of their other activities, will go away. Going forward, there will no longer be mandatory thresholds for each objective needed to get credit in this category. Instead, there must be a minimum of at least 1 in the numerator for each objective to receive half of the points available for this category. That’s 14.5 points right there!

To make up for the remaining points available in this category, providers would need to increase their performance rate for each objective (think thresholds) and pay extra attention to the objectives that emphasize interoperability, information exchange, and security.

Doctors who have upgraded their EHRs to the 2015 edition standards will no longer be required to report the Clinical Decision Support and Computerized Provider Order Entry objectives, but the idea for scoring remains the same as described earlier. This new approach is both customizable and flexible, allowing providers to choose which measures best fit their practice and offering multiple paths to success. One last point about how ACI differs from Meaningful Use is that reporting Clinical Quality Measures will no longer be a requirement of this category.

Quality

The category “Quality” is essentially PQRS, repackaged. Through 2016, PQRS has been a reporting program for Medicare patients, where providers are required to report on nine quality measures, over three National Quality Strategy (NQS) domains, for 50% of their eligible Medicare patients. The new Quality category makes some welcome and some potentially unwelcome changes.

The welcome changes include the need for each provider to report on only six quality measures, down from nine measures in 2016, and the removal of the requirement to cover at least three NQS domains. The unwelcome change is that quality measures are expected to be reported on for at least 50% of patients for all payers.

Because the reporting threshold is so high, it will be imperative that the six measures that a provider chooses to report are relevant to his or her medical specialty and truly represent the quality of care provided to each patient. In most cases, five of the six measures should be specialty specific, whereas the other measure should be a cross-cutting measure. Cross-cutting measures are defined as relevant regardless of specialty, so this would be something like tobacco screening and cessation or screening for unhealthy alcohol use.

Additionally, outcome measures are scored with more weight than other types of measures (i.e., a process or structural measure) and are thought of as the “golden child” of measure options because they show a patient’s health outcome after a clinical action was taken. For reference, a process measure might quantify the rates of immunizations, screenings, or counseling, whereas a structural measure might track the amount of time spent with a patient or note that a recall system is in place.

When deciding on the five specialty-specific measures, keep an eye out for outcome measures—they will earn you more points.

Cost

Cost is the category where your QRUR comes in. This category will be new for many providers, especially those working in small practices. To help explain, let me back for up a second to talk about how CMS tracks Medicare beneficiaries. Every single Medicare beneficiary in the United States who sees a doctor in any capacity gets attributed to a practice based on the claims that have been submitted for him or her. Medicare beneficiaries are attributed to a practice for one of two reasons. The patient either: (1) does not have a primary care physician and has seen a doctor in the practice; or (2) has a primary care physician but has received more primary care services from a doctor in the practice than from his or her primary care physician.

The QRUR identifies all the Medicare beneficiaries that have been tied to a practice and details the costs of care associated with those patients for the full continuum of care over the reporting period. That means that if the patient was in a car accident and had to take an ambulance to the emergency department and had a hospital stay, those costs would be tied to the practice.

The QRUR will reveal if the costs associated with these patients are at, above, or below national benchmarks and use this information to determine your cost score. Finding out which patients are attributed to the practice, understanding why they are attributed, and managing that list through several focused initiatives will be a top priority for scoring well in this category.

Clinical Practice Improvement Activities

The category Clinical Practice Improvement Activities (CPIA) is new for every provider, and will consist of participating in activities in one of the following subcategories:

• Expanding practice access;

• Population management;

• Care coordination;

• Beneficiary engagement;

• Patient safety and practice assessment;

• Achieving health equity; and

• Integrated behavioral and mental health.

CMS has listed more than 90 activities that count toward CPIA. It would be wise to review the list to see if there are any activities that your practice may already be performing. CPIAs can be anything from communicating test results, using decision support and protocols to manage workflows, providing self-management materials to patients, or participating in patient satisfaction surveys. Some activities carry more weight than others, and providers must demonstrate that the activity has happened for at least 90 days to get credit.

Connect With Others

A massive shift will be taking place, and you will want to connect with organizations that might be able to provide support, education, or resources to help guide you.

Your specialty society may have recommendations for your particular modality of medicine. They may be able to lead you to specialty-specific registries that could act as double or even triple duty for some of the MIPS requirements. For example, participating in the American Urological Association Quality Registry could count for a urologist toward actively engaging in a specialized registry to get credit for the ACI, while also submitting relevant quality measures for the Quality category, and could potentially also earn credit as a Clinical Practice Improvement Activity.

You will definitely want to know which hospitals your patients use most often. Ideally, you will start building your relationships with these hospitals (or subscribe to a service that helps you) so that you are notified if and when any of your patients is admitted or discharged from them. You will want to track the Medicare patients who have been attributed to your practice, because hospital visits tend to be the most expensive type of care. You will want to make sure they are receiving the necessary follow-up care that will keep them from getting readmitted, especially within the first 30 days after discharge.

Because this new paradigm has a laser focus on patients with high-risk—and high-cost—conditions, you will want to make sure you have a solid referral network in place to recommend to your patients with these ailments. The conditions include:

• Diabetes;

• Heart failure;

• Chronic obstructive pulmonary disease; and

• Coronary artery disease.

As an example, for all of your patients with diabetes, you should have an ophthalmologist, a podiatrist, an endocrinologist, and a urologist in your referral network. These are the types of referral networks you’ll need to start getting in place, and fast.

You must make sure that secure lines of communication are open between you and your most important stakeholders—your patients. In coming years, they will be tasked with being more accountable for their care, and you will want to enroll them and help empower them to do that. At a minimum, you will want your patient portal to be enabled, and if possible, get that thing on steroids! Can your patient portal deliver patient education? Do your patients know how to send a message to the doctor from it? Have they taken the time to view, download, or share their health record with their other healthcare providers?

Act Now, Don’t Wait

The message is clear—MACRA represents a complete paradigm shift in our healthcare system. Its implementation will span several years. While this is a long-term project, the need to think about the future implications for your organization is immediate.

Starting is the hardest part. It requires much more energy to get something started than to keep something going. As I’ve heard fitness coaches say, the hardest part of working out is driving to the gym.

References

1. Medicare & Medicaid EHR Incentive Program Registration and Attestation System. https://ehrincentives.cms.gov/hitech/login.action . Accessed October 11, 2016.

2. CMS Enterprise Portal. CMS.gov ; https://portal.cms.gov/wps/portal/unauthportal/home/ .

3. MACRA: Delivery System Reform, Medicare Payment Reform. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html .