Thriving Under Medicare’s Newest Pay-for-Performance Program: Strategies for Success with the Merit-Based Incentive Payment System: Part III

This article is the third of three parts.

In this, the final installment in a three-part series aimed at assisting medical practice managers in reporting under the Merit-Based Incentive Payment System (MIPS) program, the goal is to discuss various strategies that must be considered in tailoring the process for your particular group. The flexibility built into the MIPS requirements allows an informed manager to recommend a course of action for the practice that will achieve the following financial objectives:

• Avoid a Medicare payment reduction for calendar year 2019 based on actions taken under MIPS in 2017;

• Enhance the chances of receiving a payment increase in 2019 and preparing the practice for more robust reporting requirements beginning in 2018; and

• Control the additional costs associated with MIPS participation in order to convert the payment increase into a net profit for the practice.

The Starting Line—Where You Are Today

When this article goes to press, there will still be adequate time to make some strategic decisions about your MIPS participation and get underway by the latest starting date of October 2, 2017. Some reporting methods, such as the CMS Web Interface, require full-year reporting, so that option is already out for late starters. Keep in mind that although there are three MIPS performance categories reportable for 2017, the reporting group does not have to use the same 90-day span for all three categories.

Based on your Physician Quality Reporting System (PQRS), your Value-Based Payment Modifier (VBPM), and your Meaningful Use results for this year, estimate your payment change for 2018. Keep in mind that the .5% annual increase promised in Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) does not always pan out in the final Medicare physician fee schedule released in November. For example, the increase from 2016 to 2017 in the Medicare conversion factor turned out to be about half of that expected amount due to other tweaks in the formula.

Establish Your Goal

Based on your current Medicare conversion rate for this year and the estimated rate for next year, set a payment target rate for 2019. Although your plan may call for very aggressive MIPS reporting in the first year in order to have a chance at receiving some of the bonus money allocated by the law, it is unrealistic at this early stage to anticipate receiving a positive payment adjustment for 2019 greater than +4%. Calculations to determine the eligible clinicians who may receive extra bonus adjustments in 2019 will be based on aggregate benchmarks that will not be known until all 2017 reporting is collected and compiled by CMS.

For those who have briefly reviewed the MIPS requirements and are considering opting out, it would be prudent to reconsider this strategy for 2017. It is only necessary to report one quality measure, one improvement activity, or the required measures in the advancing care information performance category to achieve the three-point minimum for a neutral payment change score. The challenges and associated costs will be greater in 2018 and beyond, thereby justifying additional consideration of continued participation, but the potential for modifications in the regulations or even the MACRA law still exists.

Commercial payers may choose to take a quality shortcut by downgrading providers who do not participate in MIPS.

Managers should also keep in mind that a decision not to participate in MIPS in 2017 may have ramifications for future payments from commercial insurers. Access to a list of Quality Payment Program participants will be available through the CMS Physician Compare website, and commercial payers may choose to take a quality shortcut by downgrading providers who do not participate in MIPS.

Decide on Reporting Option

Every practice with two or more providers has the choice to do MIPS reporting by individual eligible clinician or to consolidate their effort and report all MIPS performance as a group. Group reporting allows economies of scale. As stated in the CMS MIPS Final Rule, “Individual MIPS eligible clinicians who choose to report as a group will have their performance assessed as part of a single TIN.”(1) Later, the Final Rule states “all MIPS eligible clinicians, reporting as a group, will receive the same score.”(2) Group reporting may be a godsend to a small group that contains an intransigent provider who refuses to participate in any further quality reporting. It may also be a good choice for a group with decentralized management and disparate staffing expertise that may place certain individual clinicians at a disadvantage in an individual MIPS reporting scenario.

As part of this strategic decision-making, managers should perform some cost analysis on the MIPS reporting options. Cost factors should include:

• Physician and staff training costs, including overtime pay, consultant’s fees, and webinar access;

• Time and productivity losses due to new, possibly expanded, data gathering and reporting;

• Potential upgrades necessary to the practice’s electronic health record system to improve the efficiency of data gathering or to avoid higher costs of manual reporting; and

• Fees to employ a Qualified Clinical Data Registry to compile and report data.

Smaller groups of 15 or fewer eligible clinicians should consider reaching out to regional Quality Payment Program support organizations that can provide free advice on getting started on MIPS. A list of these organizations and a map of the coverage areas can be found on the CMS website.(3)

Select Quality Measures to Optimize Your MIPS Scores

Managers who wish to enhance their chances of getting a higher MIPS Composite Performance Score in order to achieve the highest possible 2019 Medicare payment rate should attempt to select quality measures that allow higher scores for successful reporting. For 2017 reporting, the Quality performance component makes up 60% of the total composite score. The Clinical Improvement Activities and the Advancing Care Information (EHR) components are weighted at 15% and 25%, respectively.

For scoring purposes, there are two classes of quality measures differentiated by whether the measure has a historical benchmark and how many cases the eligible clinician successfully reported. “Class 1 includes those measures for which performance can be reliably scored against a benchmark, whereas Class 2 includes measures for which performance cannot be reliably scored against a benchmark.”(4)

In general, to maximize scoring, the group or each individual reporting clinician should report on at least six different Class 1 quality measures. The data completeness standard finalized for 2017 states that to be scored as a Class 1 measure, the provider must report on at least 50% of his or her patients that fall within the denominator of the measure. This computed number of patients must be a minimum of 20 cases. If reporting via claims, the 50% measure is of Medicare patients. If reporting via registry or EHR, the requirement is half of all patients in the denominator. One of the six measures should be an outcome measure. If no outcome measure is available, another high-priority measure may be substituted. Providers can select a specialty measure set or select a la carte. CMS has constructed a measure selection webpage that provides filtering to aid selection.(5) Each Class 1 measure can score up to 10 points based on performance compared with historical benchmarks from previous PQRS data based on the method of data submission (e.g., claims, registry, EHR). If a selected measure is reported that does not satisfy the data completeness standard, it becomes a Class 2 measure and will score only a maximum of 3 points. The following quality measure scoring example was provided in the CMS MIPS Final Rule:

If the MIPS eligible clinician, as a solo practitioner, scored 10 out of 10 on each of five measures submitted, one of which was an outcome measure, and had one measure that was below the required case minimum, the MIPS eligible clinician would receive the following weighted score for the quality performance category: (5 measures x 10 points) + (1 measure x 3 points) or 53 out of 60 possible points _ 60 (weight of quality performance category) = 53 points toward the final score.(6)

Although managers may have selected measures in the previous PQRS program based on the ease of data gathering, this approach under MIPS may result in lower scores per measure because the associated benchmarks may be very high. Check your previous PQRS performance reports to review the conglomerate reporting benchmarks. According to Elias and Ross of Pershing, Yoakley and Associates, “before deciding to continue with the same measures, a physician or group should compare their historical scores to the aforementioned benchmarks. Keep in mind that all scores are relative: a score of 95% isn’t worth much if 90% of physicians scored at 96% or above.”(7)

Plan to Upgrade Your EHR System to Meet CEHRT Standards

The MIPS Advancing Care Information performance category replaces the Medicare EHR Incentive Program for eligible professionals, also known as Meaningful Use (MU).(8) In 2017, it counts for 25% of the composite score, so it merits some strategic thought. The Advancing Care Information measure set applied depends on the version of Certified Electronic Health Record Technology (CEHRT) for which your system is certified. The measures are broken into a base score set and a performance score set, which may be met by attestation or calculation of individual measure numerator and denominator input. They are very similar to the Meaningful Use measures in place through 2016. As explained in the CMS Advancing Care Information fact sheet, “The base score Advancing Care Information measures are(8):

• Security risk analysis;

• e-Prescribing;

• Provide patient access;

• Send a summary of care; and

• Request/accept summary of care.”

The performance score measures are also similar to MU measures for either certification level. The important strategic fact is that beginning with the 2018 reporting year, which will affect the 2020 Medicare payment rates, MIPS participants “must only use technology certified to the 2015 Edition to meet the objectives and measures specified for the advancing care information performance category.”(8) Groups that have not initiated upgrades to CEHRT 2015 certification standards may see a significant portion of their MIPS composite score disappear next year, resulting in a Medicare payment reduction in 2020.

Select Improvement Activities Already in Place

CMS has listed 92 MIPS clinical improvement activities on the CMS website. In this new performance category for 2017, clinicians are rewarded for care focused on care coordination, beneficiary engagement, and patient safety.(9)

Maximum results can be achieved by carrying out four of these activities. The best approach is to review the list and attest to conducting four of them over a 90-day reporting period. Examples of activities that you may already be doing now include patient satisfaction surveys; engagement of patients, family and caregivers in your plan of care; or conducting group visits. Small groups (fewer than 15 eligible clinicians) or those located in rural healthcare settings need only report two activities in this performance category. Finally, those practices that are certified as Patient-Centered Medical Homes or Patient-Centered Specialty Practices automatically receive full credit in the improvement performance category.

Conclusion

For medical practice managers in groups serving any significant Medicare population, participation in the Medicare MIPS program is a sound strategy for 2017. Depending on how established your reporting processes are this year, even a very modest level of quality program reporting is a good income-protecting investment for 2019 by anchoring your Medicare payment rate. For those who take a robust approach to reporting this year, the Medicare revenue two years from now could be significantly improved over the status quo. The flexibility of the reporting processes provides an easy entrée for the novice and a manageable transition from PQRS to MIPS for the experienced quality reporter. The growth in the portion of Medicare payments attributable to the new quality payment formula, coupled with the expected expansion in reporting requirements in future years, supports a strategic decision to engage in MIPS reporting as early and extensively as possible based on the practice’s current capabilities.

References

1. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models: Final rule with comment period. Fed Regist. 2016;81:77072.

2. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models: Final rule with comment period. Fed Regist. 2016; 81:77181.

3. Quality Payment Program: Support for small practices. CMS.gov . https://qpp.cms.gov/docs/QPP_Support_for_Small_Practices.pdf . Accessed May 1, 2017.

4. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models—Final rule with comment period. Fed Regist. 2016;81:77324.

5. Quality Payment Program: Quality Measures, Centers for Medicare and Medicaid Services. https://qpp.cms.gov/mips/quality-measures . Accessed May 8, 2017.

6. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models—Final rule with comment period. Fed Regist. 2016; 81:77289.

7. Elias A, Ross M. Optimizing your MIPS score: Quality Measure Benchmarks and Reporting Mechanisms. PYA Healthcare Blog. http://healthcareblog.pyapc.com/2017/01/articles/pay-for-performance/optimizing-your-mips-score-quality-measure-benchmarks-and-reporting-mechanisms/. Accessed May 8, 2017

8. Quality Payment Program: Advancing Care Information Fact Sheet. CMS.gov . https://qpp.cms.gov/docs/QPP_ACI_Fact_Sheet.pdf . Accessed May 8, 2017

9. Quality Payment Program: Clinical Improvement Activities fact sheet. CMS.gov . https://qpp.cms.gov/measures/ia. Accessed June 6, 2017.