How clinicians can come out on top in a MIPS world

Aimed at improving the quality and cost-effectiveness of healthcare delivery in the U.S., the Medicare Access and CHIP Reauthorization Act (MACRA) presents both opportunities and threats to future provider revenue. With the first reporting year of MACRA's Quality Payment Program well underway, it is vital for health systems and multispecialty groups to lay the groundwork for MACRA success.

This content is sponsored by Zotec Partners

MACRA's first performance year began Jan. 1 for eligible clinicians — physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists — who bill Medicare Part B for more than $30,000 a year or provide care to at least 100 Medicare beneficiaries annually.

There are two pathways for eligible clinician participation in MACRA's Quality Payment Program: the Merit-Based Incentive Payment System, or MIPS, and the Advanced Alternative Payment Model, or Advanced APM.

MIPS is the less predictable model, and already has many healthcare organizations nervous. Because scores under the MIPS payment track will be made public, crafting the right strategy for participation is vital not only to the financial health of provider organizations, but also their reputation.

A breakdown of the MIPS payment track
MIPS replaces the disjointed requirements of three legacy CMS programs. Under MIPS, physicians will be scored on performance in four categories: quality, which replaces the Physician Quality Reporting System; cost, which replaces the Value-Based Payment Modifier; advancing care information, which replaces Meaningful Use; and clinical practice improvement activities, which is a new category.

A clinician’s score in each of those categories is consolidated into a final composite score that CMS will use to make payment adjustments in 2019 and subsequent years. Payment adjustments in the first year will be positive or negative up to 4 percent. This will incrementally climb to 9 percent by 2022.

"The program is budget neutral, so CMS doesn't really know how much it can pay out in bonuses until it understands what the penalties will be," said Lonnie Johnson, vice president of corporate services at Zotec Partners, a specialized medical billing and practice management services provider.

Clinicians and provider organizations participating in the MIPS payment track will be scored against benchmarks on a 100-point scale, with 100 being the best score possible. There's an exceptional bonus pool of $500 million to be distributed to those who receive a score of 70 or above.

For 2017, which is the first performance year, the MIPS categories are weighted as follows:

• Quality — 60%
• Advancing care information — 25%
• Improvement activities — 15%
• Cost — 0%

CMS will provide informational feedback to clinicians on how they performed on certain aspects of cost category in 2017, but performance will not affect 2019 payments. In the 2018 MACRA proposed rule, CMS proposes to, again, change the weight of the cost performance category from 10% to 0% for the 2020 MIPS payment year; as they continue to have concerns about the level of familiarity and understanding of cost measures among clinicians. The cost category is scheduled to be weighted at 30 percent of the MIPS final score in the third performance year.

However, CMS is seeking comments from the proposed rule on keeping the weight of the cost performance category at 10% for the 2020 MIPS payment year, so as not to have a dramatic transition to the weighting from zero to 30%.

In 2017, full MIPS participation requires clinicians to report six measures in the quality category or one specialty-specific measure set, report five measures in the advancing care information category and participate in two to four improvement activities (depending on the selection of medium of high weighted activities). Providers can choose from a number of options available for submitting data, including using a qualified clinical data registry, qualified registry, EHR, administrative claims or attestation. Some of the options vary based on performance category.

Not all clinicians are required to participate in the MIPS payment track. Clinicians are exempt from MIPS participation if they are in the first year of Medicare Part B participation, are qualified participants in the Advanced APM pathway or do not meet the threshold for MIPS participation — meaning they treat less than 100 Medicare Part B beneficiaries and bill less than $30,000 in Medicare Part B allowed charges per year.

MIPS participation in the transition year
The final MACRA rule offers flexibility by allowing providers to pick their pace for participation.

Under the final rule, clinicians and provider organizations participating in the MIPS payment track can opt out of sending data to CMS in 2017. However, those who do not report 2017 data will experience a negative payment adjustment of up to 4 percent in 2019.

To avoid the automatic negative payment adjustment, providers only have to submit a minimal amount of data — one quality measure, one Improvement Activity, or report the required measures of the advancing care information category. However, to master the complexities of the program and work to optimize performance scoring, it is in health systems and multispecialty groups' best interest to participate as much as possible during the 2017 transition year.

Providers that submit a full year of data have the potential to earn a moderate positive payment adjustment. A practice can also achieve a positive incentive by successfully submitting for 90 consecutive days on each applicable category. However by participating a full year the chances of optimizing the Composite Score should improve. On top of the financial incentives, full MIPS participation could also benefit the U.S. healthcare delivery system as a whole.

"Participating as much as possible in the first year is a prudent decision," said Mr. Johnson. "By moving to this model early on a group will become more aware of quality reporting requirements , achieve better utilization of healthcare information technology; more data will be available with a better understanding of the process — it is certainly a move in the right direction."

Reporting data under the MIPS payment track
Because MIPS is designed to be a budget-neutral program, success under the payment track will be determined by three factors: which measures providers choose to report, how they perform on those measures and how their peers perform in comparison.

When deciding which metrics to report on under the MIPS payment track, health systems and multispecialty groups should examine past quality and resource data to determine what areas they excelled in under PQRS and the Value-Based Modifier Program.

"The key is not to choose metrics that you perform well at, but to choose metrics where you perform better than others," said Leslie Flake, a medical group CFO. "There may be a metric that is very difficult that very few providers perform well at, but if you perform better than the rest that would give you a bump in your score. That is how providers will be successful financially in the MIPS payment track."

Once a provider organization chooses which measures to report on, health systems and multispecialty groups must decide on a reporting methodology.

MIPS allows clinicians to report individually or as a group. Although group reporting is less onerous, there are a number of factors to consider in deciding on a reporting method.

"Group reporting is probably much better for a multispecialty situation," said Mr. Johnson. However, he noted it may be a good idea to assess individual reporting at multispecialty groups based on factors such as past PQRS performance, number of clinicians exempt from MIPS, etc.

Individual reporting may also be a good idea when a group or system includes several specialists. "Unless the MACRA reporting structure is adjusted, each specialty may need to report separately … to be able to report on the quality metrics applicable to their specific specialty," said Ms. Flake.

Best practices for MIPS participation
It is critical for health systems and multispecialty groups to map out a MIPS strategy that fits into the organization's current trajectory and helps it move toward value-based care.

This requires provider organizations to take a coordinated approach across all units when rolling out their MIPS plan.

"It's essential for healthcare organizations to align MIPS strategies among divisions such as the health plan, medical group, acute care and ambulatory divisions," said Ms. Flake. "Once all divisions are aligned, MIPS objectives can progress rapidly and quality performance will be realized."

It is also vital for health systems and multispecialty groups to have a mechanism in place to continually track the measures on which they choose to report. This will empower them to provide timely and meaningful feedback to clinicians and various departments and revenue centers within the organization, according to Mr. Johnson. He noted the feedback mechanism should also be used to educate clinicians on how to strengthen clinical reporting and contain costs to achieve optimal scores under the program.

To provide this valuable feedback, health systems and multispecialty groups must be able to access live clinical performance data within the EMR, according to Ms. Flake. She said it's imperative for provider organizations to build the technology infrastructure necessary to access performance data in real-time.

"The biggest challenge with MACRA and any value-based program is accessing live performance quality metrics in the EMR at the provider and patient level," she said. "Historically, health plans have provided data, but it's often at the group level and there's a lag in time. To really be efficient, a provider needs to be able to see specific gaps at the time of service to effectively and efficiently close those gaps."

Although performance in CMS legacy programs can serve as an indicator of performance under MIPS, there is no sure-fire path to success under this new payment track. With careful planning and strategy, health systems and multispecialty groups can position themselves for success under MIPS. It will be difficult for some organizations to make the changes necessary to come out on top in a MIPS world, but taking steps to achieve the pathway's objectives is a step in the right direction in addressing many of the challenges facing the U.S. healthcare system. "It's not easy. It's one of the more complex changes in healthcare in many years, but we have to start somewhere," said Mr. Johnson.

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