Clinicians have two options for MACRA participation—an Advanced Alternate Payment Model (AAPM) or the Merit-Based Incentive Payment System (MIPS).
CMS has structured MACRA to encourage AAPM participation, offering clinicians a 5% lump-sum bonus on top of a share in the savings achieved by the organization. The following questions will help you determine whether you qualify for the AAPM option:
- Do you participate in an APM? (An ACO or other risk-based healthcare delivery program?)
- Is your APM an AAPM? The APMs identified in the image above qualify as AAPMs by virtue of the fact that:
- the hospital and the clinicians use certified EHR technology,
- the organization bears both upside and downside financial risk, and
- the providers report quality measures.
NOTE: The CMS CJR (Comprehensive Care for Joint Replacement) program is now considered an AAPM. (According to the CMS Fact Sheet, this program was recently added to the list of 2017 AAPMs.)
- Do you meet the participation volume thresholds, i.e., do you derive 25% of your Medicare revenue or see 20% of your Medicare patients through one of these channels?
If the answer to all the questions above is “Yes,” you may be a QP (qualified participant) in an AAPM. Talk to the organization’s sponsor (typically a hospital) about your participation in MACRA.
If the answer is “No,” to all, or some, of these questions, your route to MACRA success will be via MIPS, or a MIPS APM, respectively.
For more information about MIPS and MIPS APMs, see the CMS QPP website or contact me at SRS Health. I also invite you to watch (or watch again) my webinar titled, “MACRA/MIPS: The Future Starts Now.”
You’ve come out of your eggnog-induced holiday fog and realize that you did not organize your practice for full-year MIPS reporting. With January 1 now in the rear-view mirror, you regretfully—but erroneously—conclude that you have missed out on the opportunity to earn the maximum positive payment adjustment in 2019. This is a common misconception that has been perpetuated in many MIPS-related webinars, blogs, and other communications. (That confusion exists is not surprising, given the spate of changes to MACRA in the last few months and the inherent complexity of the program itself.)
The fact is: Full-year reporting is NOT required to earn the maximum positive MIPS incentive in 2019. Rather, it is performance that counts, i.e. the number of MIPS points you earn and the level of quality you demonstrate, not the length of your reporting period or the amount of data you submit. If you look at the most recent CMS presentations, you will see images and text that clarify this point.
It could be argued—and representatives of CMS have done so—that it might be easier to achieve a high MIPS score with a longer reporting period, particularly on certain quality measures. Perhaps so… but this does not preclude clinicians from achieving an equally high score in a shorter period.
Of course, there is no such thing as a free lunch; and there are consequences—possibly unintended—of CMS’ largess in offering the Pick Your Pace options for 2017. Regardless of how many MIPS points an eligible clinician earns in 2017, his/her 2019 payment adjustment will, of necessity, fall short of the originally planned 4% due to the legislative mandate for budget neutrality. In the Final Rule, CMS estimated that the upward adjustment potential will now be less than 1% for the base performance and under 2.4% when the additional money for exceptional performance is included. (For an explanation and graphic that explains the required “scaling process”, see pages 77340 – 77342 of the Final Rule.)
That said, however, the good news remains: You have not missed the boat! But it is time to get to work to allow yourself the time and flexibility to maximize your performance, identify the optimal reporting period, and earn the greatest reward.
CMS has given providers an early holiday present with the Final MACRA Rule, affording everyone the opportunity to easily avoid a penalty in 2019. This is surely reassuring news and has been widely received with a huge sigh of relief—but before you let your guard down, it is important to acknowledge that the program will build back up to an only slightly modified version of its originally proposed self, with many of the complexities and challenges intact. CMS is calling 2017—and to a lesser extent 2018—“transition years.” Treating them as such offers an opportunity to prepare for the future, while treating them as a free pass only delays the inevitable.
In 2017, eligible clinicians who participate in MIPS can protect their 2019 Medicare fee schedule by merely reporting any ONE of the following:
- 1 quality measure, or
- 1 Improvement Activity (formerly called Clinical Practice Improvement Activities), or
- The 4 required Advancing Care Information (formerly Meaningful Use) measures.
Anyone who has participated in Meaningful Use and/or PQRS has already far exceeded these requirements, and will find this an extremely low bar. So why not aim for one of the more advanced “pick your pace” participation options and potentially benefit from an upward adjustment to your fee schedule? All it takes is reporting anything more than the above for a period of at least 90 days, and you could earn a “small” adjustment in 2019. Participate more fully—for anywhere from 90 days to a full year—and you could be eligible for the maximum, albeit “modest,” payment adjustment. (Note that it is performance that drives the payment adjustment, not the length of the reporting period.)
The downside of this new flexibility is that these “small” and “modest” adjustments for successful MIPS participants will now be very small or modest in 2019—far short of the originally planned 4%. Congress mandated that MACRA be budget neutral, so with dramatically fewer losers in 2017 to fund the gains of the winners, bonuses will be scaled down. Near-term financial rewards are unlikely to be a strong motivator of compliance this year.
However, by 2020, the difference between the most and least successful providers will exceed 18% (i.e., 2022 payment adjustments will range from -9% to +9% with potential additional bonuses available for the highest performers). So while it might be tempting to sit back and relax next year, consider using 2017 instead as it was intended—as a transition from MU and PQRS to MACRA. If you have been successful in the past, now is a good time to experiment with new workflows, new technologies, and/or alternate measures or reporting methods that might improve your performance. If you’ve never participated in these programs before, you can start now and get off the penalty track.
You can view the 2017 Final Rule as a free pass or as an opportunity—the choice is yours.
As everyone is in the midst of anxiously trying to prepare for MACRA while awaiting the Final Rule, (due November 1), CMS announced yesterday that it is stepping back the requirements and the timetable to make it easier for providers to avoid the 2019 negative payment adjustments set out in the Proposed Rule. This decision comes in the wake of 4,000 comments and subsequent pressure from professional groups and from Congressmen/women pleading for relief from the rushed implementation of a complex and overly aggressive set of requirements that would negatively impact many practices, particularly small groups.
Andy Slavitt, Acting Administrator of CMS, published a blog that gave an overview of the new options that allow providers to “pick their pace” of complying. It appears that the only way a provider would receive a negative adjustment in 2019 would be if they do almost nothing in 2017. He outlined 4 options for participation:
- Do something! Avoid a negative payment adjustment in 2019 by submitting some data in 2017. This begs the question: what constitutes “some data?” Does this mean some data in each MIPS category, some data in one category, quality data only? (To me, the wording in Slavitt’s blog is reminiscent of CMS’ past MU shift to “capability enabled” or “met for 1 patient”.)
- Report for a short reporting period (“a reduced number of days”) could qualify you for a “small” positive payment adjustment.
- Comply with MIPS as defined in the Proposed Rule—or I assume, as it will be defined in the Final Rule— for the full calendar year and you could qualify for a “modest” positive payment adjustment.
- Participate in MACRA’s Advanced Alternate Payment Model option. CMS is hinting that it may broaden the definition of an APM.
This news will no doubt be greeted with relief and cheers by most providers, but I wouldn’t be surprised if they are left feeling more uncertain now of what will be required in 2017 than they did before the announcement! What constitutes sufficient reporting in options 1 and 2 above? How many days are in a short reporting period—90 perhaps? How do the revised “small” and “modest” payment adjustments compare to the potential 4% proposed for 2017 and to each other? Will performance still be evaluated relative to other providers? And what happened to budget neutrality, i.e., where is this money coming from if hardly anyone will receive a negative adjustment?
Please let us know what you think of this latest MACRA news, and stay tuned as we learn more!
Even though the final MACRA rule is not expected until November 1, 2016, you would be well advised to start putting an action plan in place now. As proposed, the first performance year begins on January 1, 2017, a mere 2 months after the expected release of the Final Rule—you won’t have sufficient time to prepare if you wait until then. Yes, CMS has hinted about a possible delay or a shortened reporting period (in response to numerous concerns expressed in the 4,000 comments to the proposed rule), but you cannot bank on that until it is finalized. There are things you can do to start planning your strategy and improve your chances of success when this first regulatory foray into value-based payment begins:
- Focus on 2016 PQRS reporting: Quality reporting carries a 50% weighting next year, which makes it the most important of the 4 MIPs performance targets, (the others being Advancing Care Information, aka MU; Clinical Practice Improvement Activities; and Resource use, aka cost). Take advantage of the next 4 months to improve your quality measure workflow and reporting.
- Think about whether to report MIPS as individual physicians or as a group: It’s important to look at your practice’s current MU and PQRS performance as a predictor of which option might be more beneficial. You may already be reporting PQRS as a GPRO—success here makes a strong argument for reporting all categories as a group. (Remember, as proposed, you must report consistently across all 4 MIPS categories.)
- Develop workflows to support success: Identify the ACI patient engagement and health information exchange (HIE) measures that are of most interest or relevance to your practice. Analyze and try to enhance the workflows that support these measures. Ask your EHR vendor for a professional services evaluation—they may be able to offer assistance in this regard.
- Review the list of Clinical Practice Improvement Activities: Review the list provided in Table H of the Proposed Rule. Are there activities that fit your practice or possibly some that you were considering, even before MACRA?
- Evaluate your current technology resources: Is your EHR up to the job—or is it killing your productivity, particularly when you use it to meet the government requirements? If you are not satisfied, now is a good time implement new technology.
The most important step to take now and in the coming months is to keep yourself educated and up to date as the regulations evolve and the start date approaches, (But you clearly know that, since you’re reading this post!) On cms.gov, you will find Quality Payment Program Resources pages. You can also consult your professional societies/academies for specialty-specific guidance or reach out to your EHR vendor for training. I invite you to watch (or watch again) my webinar titled, “MACRA/MIPS: 962 Pages in 30 Minutes”, which is available on demand.
Last week, in keeping with what seems to have become a mid-year tradition, CMS issued a proposed rule that—amidst its 700-plus pages related to hospital payments—reduces the 2016 MU reporting period from the full calendar year to any 90 consecutive days. (Note that this applies only to providers participating in the Medicare, not Medicaid, EHR Incentive Program, and has no effect on PQRS reporting.) Would it have been better if the announcement had come in a more timely fashion—i.e., at the beginning of the year instead of the middle? Absolutely! But don’t let that keep you from taking advantage of this opportunity.
This is good news for providers who had given up on MU for 2016—or who got off to a slow start on the program this year. Here’s an opportunity to get back in the game and avoid the 2018 payment adjustment (3% or 4%, to be set at the discretion of the Secretary of HHS). It also provides a bit of a breather for those who are successfully demonstrating meaningful use and may be able to identify an already-completed 90-day period during which they met all the requirements. These providers can now turn their attention to preparing for MACRA, which is proposed to be effective on January 1 and in which MU (renamed “Advancing Care Information”) is only one of the four components.
So, what accounted for this change? Is it an indication of a kinder and gentler CMS to come? The CMS Fact Sheet states that CMS is trying to “assist health care providers by increasing flexibility in the program.” Was it in response to the deluge of comments to the MACRA rule that screamed “Help!,” or to the repeated requests for relief submitted by providers, organizations, and members of Congress? Let us know below what you think brought about this change of heart.
The proposed MACRA rule is here. With the goal of changing the way physicians are paid, this rule proposes how CMS intends to move toward increasingly rewarding value—meaning high quality care at a cost-effective price—over volume.
CMS claims that MACRA will simplify life for providers, (although I’m a little suspicious since it took 962 pages to explain the “simplification”). However, there is no question that the world is about to change. These proposed regs are scheduled to be finalized in November and then be effective on January 1, 2017—a rather ambitious schedule which leaves little time for planning your approach to compliance.
While I haven’t read the entire rule yet, MACRA—Medicare Access and Chip Reauthorization Act—provides two paths for physicians and other clinicians. In the long-term, APMs (Alternate Payment Models, like ACOs) will be a popular route—higher risk/higher reward—but for now, most physicians will participate in the MIPS (Merit-Based Incentive Program) option. So let me provide a few teasers about MIPS, as currently proposed:
- If you expected an end to Meaningful Use, PQRS, and the Value-Based Payment Program, you will be disappointed for certain. MIPS just changes the names, rolls them up into one program, and adds (yet another) set of required activities.
- Providers will be scored on a 100-point scale and compared to other providers—this year’s weighting would be 25% MU-type measures, 50% quality measures, a la PQRS, 10% cost, and 15% Clinical Practice Improvement Activities. (The rule spells out how a provider’s score is calculated and the payment adjustment is determined, but you might need an advanced math degree to follow that discussion!)
- MU is now “Advancing Care Information”. It will have fewer required measures (proposing to eliminate CPOE, CDS, and multiple Public Health reporting requirements), no longer be all or nothing, and will provide some choices to clinicians for how they demonstrate success. CQM reporting will not be part of this component.
- Quality measure reporting (like PQRS) will be the bulk of the score, but only 6 measures will be required. Like under the Value-Based Payment Program, performance will count, i.e., impact the provider’s score.
- Assessment of cost will be done by CMS—providers won’t have to report anything. This is similar to how CMS currently attributes a cost factor to providers in calculating the V-BPM.
- The new category, Clinical Practice Improvement Activities, offers providers a choice of approximately 90 activities from which to choose to earn points in that category.
- MIPS would be reportable as an individual provider or as a group.
Stay tuned to EMR StraightTalk for more in-depth analysis of MACRA in upcoming posts. We welcome your initial comments.