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Hitting the Halfway Mark for MACRA: What Clinicians Can Do to Avoid a Penalty

06/16/17

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By:

Robert Dean, DO, MBA, Senior Vice President, Performance Improvement

We are now at the halfway point of 2017, which is the first performance measurement year for MACRA. Have you selected what performance metrics you will report and what method of reporting you will use? If you haven’t done anything up to this point related to MACRA compliance, do you know what to do in the second half of 2017 to avoid a payment penalty in 2019? 

As a refresher, the Medicare Authorization and CHIP Reauthorization Act (MACRA) – or the Quality Payment Program (QPP) as it is referred to by CMS – was passed into law in 2015. This legislation changed professional reimbursement for all clinicians in Medicare Part B with the introduction of two new payment modalities.

The first is the Merit-based Incentive Program (MIPS), which has taken three legacy CMS programs – the Physician Quality Reporting System, Meaningful Use and the Value-based Modifier – and combined them along with the new category, Clinical Practice Improvement (CPI), into an integrated scorecard. MIPS applies a weighted, four-component scorecard to determine if clinicians will receive a potential bonus or penalty on their Medicare fee-for-service payment schedule.

The four components with their associated weights for the 2017 measurement period are:

  • Quality – 60 percent
  • Advancing Care Information – 25 percent
  • Clinical Practice Improvement – 15 percent
  • Resource Use – 0 percent

The clinician’s total score from the four QPP components will be compared to other clinicians to determine if a bonus or penalty will be applied to fee-for-service payments.

The second modality is alternative payment models (APMs). There are multiple APMs available this year, such as Next Gen and Pioneer ACOs, the Comprehensive Primary Care Plus program, end-stage renal disease and oncology. The list will grow in 2018 and beyond.

For 2017, CMS anticipates that 70,000-90,000 clinicians will be qualified providers in APMs, while the remaining 700,000 eligible clinicians will be in MIPS and subject to its reporting requirements. The results of the 2017 measurement period will affect fee-for-service payments beginning in 2019.

Unpacking the pick your pace option

CMS has acknowledged that QPP is a major shift in Medicare Part B reimbursement and has made 2017 a transition year by offering the “pick your pace” option. This provides four ways in which clinicians can report data. Three of the options are for MIPS and allow clinicians to qualify for a partial or full bonus. The fourth option is participation in an APM. All four options will exempt clinicians from any penalty in 2019, which is the first payment year for the program.

For MIPS data reporting, pick your pace offers three options starting this year. The last reporting period for 2017 starts Oct. 2 and ends Dec. 31, 2017. Data must be received by CMS no later than March 31, 2018. Thoughtful planning now about data collection, what to report and analysis will allow clinicians to avoid a 2019 penalty and possibly qualify for a bonus. The three MIPS reporting options are as follows:

  • Full reporting: Requires clinicians to submit data for a minimum of 90 days in 2017, meeting all requirements. This option makes them eligible for positive adjustment and exceptional performance bonuses.
  • Partial participation: Requires clinicians to submit data for a minimum of 90 days for more than one quality measure or improvement activity, or more than the required advancing care information measures. This option makes them eligible to qualify for a positive adjustment.
  • Minimum participation: Requires clinicians to submit data on at least one quality measure or improvement activity or the required advancing care information measures. This option helps them avoid negative payment adjustment.

In 2017, no reporting is required for the Resource Use component. However, it’s important to note that in the coming years, Resource Use and Quality will be the two highest-weighted components in MIPS and clinicians should take steps now to learn how to optimize performance in each.

Take action sooner rather than later

Clinicians should start by selecting metrics within each of the four weighted components that best reflect performance in their specialty and/or practice. 

For the Quality and CPI components of MIPS reporting, there are literally dozens of metrics to choose from, depending on how you are submitting your data, e.g. GPRO, EMR or Web-based submission. 

For Quality, clinicians need to pick six measures including one outcome measure, or they can select a specialty-specific measure set. If no outcome measures are available for their specialty, they should choose an additional highly weighted metric, such as patient experience, safety or appropriate use.

In the CPI component, there are 10 different areas each with multiple choices for metrics. Examples include expanded access, patient and family engagement and care coordination. Those practices that can attest to being patient-centered medical homes will receive full credit (15 points) for this component.

Advancing Care Information is the last required component for reporting in 2017. Clinicians will receive 50 percent credit of the total score (12.5 points) by reporting on the five required metrics. The other 50 percent is determined by how they do in those metrics. They can earn bonus points by reporting on more than the five required metrics or reporting their data on more than one public registry.

In the past, many clinicians have decided that the size of the penalty in CMS programs, such as Physician Quality Reward System, were not worth the EMR and opportunity cost of reporting. The initial MIPS bonus/penalty of 4 percent in 2019 may seem like the same decision is still a good one. This time, however, the stakes for such a decision will grow with each passing year and the bonus/penalty percentage increases to 9 percent in four years.

Perhaps the biggest long-term incentive is the fact that CMS considers MIPS a milestone on the way to participation by all clinicians in one form of APMs in the future. The practice processes, EMR capabilities and reporting in MIPS will all be foundational components for success in APMs.

It’s best to start preparing your practice now for a future with rapidly evolving professional reimbursement models. Consider speaking to other clinicians who are currently reporting or who are engaging an outside expert, for advice on how to proceed in the most efficient manner. 

For more information on getting support during your transition to value-based care, click here.  

About the author. As senior vice president, performance management, Dr. Dean leads the Vizient Transformation of Clinical Practice Initiative team and the Vizient Practice Transformation Network. He is also responsible for providing medical leadership and expertise across a range of clinical, advisory and nursing projects as well as development of interprofessional practice resources.

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