An ounce of prevention: Prepare now for MACRA mandates coming in 2019

Doctors often tell patients that "an ounce of prevention is worth a pound of cure."

In other words, taking proactive steps to live a healthy lifestyle is easier and less expensive than treating disease. In many ways you should heed this advice, as well, when it comes to ensuring that your practice is properly prepared to address the impending requirements mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

MACRA officially kicked off in 2017 with the introduction of some basic requirements and few penalties. This year is designed as a transition year – one that gives you the opportunity to inject that ounce of prevention into your practice through greater flexibility and time to implement the proposed measures.

Through the most recent continuing resolution, Congress authorized the Center for Medicare and Medicaid Services (CMS) to continue the transition period through 2021. However, each year CMS must raise the performance threshold, with the goal of preparing the market for mean or median scoring. In 2022, in addition to mean or median scoring, the Cost category will likely represent 30% of your total MIPS composite score. With these dramatic changes close at hand, now is the time to start preparing to ensure a smooth evolution and to minimize the associated financial risks to your organization.

MACRA at a glance
MACRA replaces the previous Medicare reimbursement schedule with a new payment framework that aims to focus on quality, value and accountability, rewarding healthcare providers for giving better care instead of more service. MACRA's Quality Payment Program is broken into two tracks:

Merit-based Incentives (MIPS) — The default program, MIPS measures eligible clinicians (ECs) on four factors: Quality, Cost, Clinical Practice Improvement Activities and Advancing Care Information (ACI). ECs currently include physicians (MD/DO and DMD/DDS), physicians assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. However, CMS may expand this in 2019 to include physical or occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists and dietitians/nutritional professionals.
Advanced Alternative Payment Models (APMS) — Advanced Alternative Payment Models evaluate ECs on measures similar to MIPS. However, in this model the organization takes on an additional element of financial risk. An Advanced APM must put at least 8% of its Medicare revenue on the line as a bet. To win that bet, you must lower the total cost of patient care for your attributed beneficiaries while maintaining or improving quality. The policy goal of MIPS is to push more ECs in Advanced APMs over time.

2018
It’s important to understand some of the major changes CMS implemented through its final rule for MACRA in 2018:
Exemptions for extreme and uncontrollable circumstances: CMS is automatically exempting from the 2017 performance period those practices that have been impacted by natural disasters, such as flooding in Houston and wildfires throughout California.
Weighting of the Cost category raised to 10%: Originally set for 0 in 2018, CMS felt that 10% would provide a reasonable onramp. A corresponding reduction of the Quality category will offset this weighting for your total MIPS score.
Expansion of low-volume thresholds: Individual MIPS-eligible clinicians or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries are excluded from MIPS. This is an increase over 2017’s thresholds for exclusions, which were set at $30,000 in Part B revenue or 100 patients. This means that some ECs who were subject to MIPS last year may not be this year.

Now, you have to assess your clinical and financial goals. Consider these questions:

• Do you want to comply with the minimum requirements to avoid penalties?
• Are you interested in transitioning your practice, starting with some gradual changes?
• Do you want to fully participate, excel and achieve significant payouts?

How you answer these questions will define your approach during this transition year. In 2018, the performance threshold — or the score you need to earn to avoid a penalty — is set at 15. There are a variety of ways you can hit this minimum threshold. For example, you could report on six quality measures while meeting data submission thresholds, or you could fully participate in Clinical Practice Improvement Activities.

For those interested in leveraging this transition year to get ready for future years, 2018 provides an opportunity to conduct workflow analyses across your organization to ensure that data, such as quality and ACI measures, is being captured and your providers are following workflows compliant with measure specifications. You can raise your composite score by choosing up to four improvement activities depending on your practice’s size.

If your goal is to earn incentives, then you should focus on efforts that achieve a composite score of 70 or higher. While MIPS is designed ultimately to be budget-neutral, there are financial upsides for exceptional performers during the first few years of the program. In addition to choosing and collecting data on six Quality and ACI measures, you will want to do additional analysis to determine your practice's strengths and make changes to ensure a score that is in at least the fifth decile across all quality measures.

You also will want to participate in full-year reporting to prepare for the eventual transition to an Advanced APM and begin evaluating those available to you — whether through Medicare, Medicaid or the All-Payer Option. To determine if it makes sense to participate as an APM, you should evaluate your process readiness, clinician culture, financial performance under MIPS, and alignment with other programs and initiatives in your payer mix.

Getting prepared for full implementation in 2022
By addressing these questions and taking the appropriate actions this year, you'll be much better prepared for what's on the horizon and into the next three years where we’ll see gradual increases to the MIPS performance threshold. It’s important to note that there are two statutory provisions for 2022 — the weighting of Cost at 30%, and the setting of the performance threshold at the mean or median of the prior year's scores, which will put significant pressure on many practices to strengthen performance.

In the meantime, you should take the time to learn about the program — what it means for your practice’s bottom line and changes in the future. You’ll also want to compare your data. Look at historical data and measures to understand what your practice excels at, what is relevant to your patient population, and where you can make the easiest, most obvious improvements. Using this data, you can then design a plan to test during this transition year before the stakes — and penalties — are higher.

About David Heller
David Heller is an attorney and Greenway Health’s Industry & Government Affairs Manager. He collaborates with providers, practices, and other ambulatory healthcare organizations to coordinate Greenway Health’s industry engagement strategy and policy initiatives. David’s combined experience in healthcare includes regulatory analysis, product marketing and business development, with a special emphasis on population health and interoperability. He focuses on how value-based contracts and government programs impact providers’ clinical and business strategies.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

MACRA officially kicked off in 2017 with the introduction of some basic requirements and few penalties. This year is designed as a transition year – one that gives you the opportunity to inject that ounce of prevention into your practice through greater flexibility and time to implement the proposed measures.

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