Stay on Track with MACRA

CMS released the final rule with comment period (Final Rule) that, implements provisions of the MACRA law relating to the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) which begins on January 1, 2017 with comments due by December 31, 2016. MIPS and APMs are collectively referred to as the Quality Payment Program (QPP). There were some changes from the proposed rule earlier this year in this Final Rule (probably a good idea to refresh your memory on the framework of the proposed rule and the MACRA law itself). CMS is still requesting comments on the Final Rule from interested stakeholders which means we may yet see some technical corrections or slight changes around the edges, but it best to develop a strategy now in terms of how you are going to maximize benefit and avoid any downward adjustments (penalties) in Medicare payments.

CMS heard howling from across the industry that the proposed rule was not going to work, especially for rural and solo providers as well as small practices. So they raised thresholds for MIPS-eligible clinicians (ECs) to participate in the program leaving a larger number of clinicians not to be subject to MIPS. ECs are now only part of the QPP if they bill Medicare more than $30,000 a year or provide care for more than 100 Medicare patients a year.

What types of clinicians are MIPS ECs?

·        Physicians,

·        Physician assistants,

·        Nurse practitioners,

·        Clinical nurse specialists and

·        Certified registered nurse anesthetists

There are two tracks for clinicians in the QPP: MIPS and advanced Alternative Payment Models (APMs). The Final Rule designates 2017 as a transition year and outlines the following four pathways for participation in the QPP:

1. If MIPS-eligible clinicians feel they are ready out of the gate they may choose to begin full participation in MIPS beginning in 2017, clinicians can choose to report on all MIPS required measures for at least a full 90-day period or, ideally, the full year. MIPS-eligible clinicians who fulfill this requirement and are exceptional performers in MIPS, as shown by the practice information that they submit, could be eligible for an additional positive adjustment each year of the first six years of MIPS (these exceptional performance payments are separate from the other MIPS adjustments and not subject to the budget neutrality requirement).
2. For CY 2017, in order to avoid a negative MIPS payment adjustment and to possibly receive a smaller positive MIPS payment adjustment in 2019, clinicians can choose to report on MIPS for at least a full 90-day period, so long as they report at least the following: more than one Quality measure; more than one Clinical Practice Improvement Activity (CPIA); or more than the required measures in the Advancing Care Information (ACI) performance category.
3. For clinicians that only seek to avoid a negative MIPS payment adjustment in 2019, CMS will allow the reporting of the following for a period of less than 90 days in 2017: one measure in the Quality performance category; one activity in the CPIA performance category; or all of the required measures of the ACI performance category.
4. MIPS-eligible clinicians can still participate in an Advanced APM beginning in 2017, and if they receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM, they will qualify for a 5 percent bonus incentive payment in 2019. Participation in an Advanced APM exempts a MIPS-eligible clinician from the reporting requirements they would otherwise need to fulfill under the MIPS track of the QPP.

MIPS ECs have the option to begin reporting on MIPS performance measures anytime between January 1 and October 2, 2017 to meet the 90-day period minimums imposed by these pathways. There are some additional changes and reduced reporting obligations during the transition year. During the 2017 transition year, a provider’s MIPS score will only be based on the Quality, ACI and CPIA performance categories. The Final Rule assigns a weight of 0% to scores in the Cost performance category for 2017.

The Final Rule also makes the following changes to the required reporting measures under each performance category during 2017:

Ø Quality: For full participation, MIPS-eligible clinicians or groups must report on all applicable measures (up to six measures), including at least one outcome measure if available for a minimum of a continuous 90-day performance period. Alternatively, for a minimum of a continuous 90-day period, the MIPS-eligible clinician or group can report one specialty-specific measure set, or the measure set defined at the subspecialty level, if applicable. If the measure set does not include any available outcome measures, MIPS-eligible clinicians must instead report on another high priority measure (appropriate use, patient safety, efficiency, patient experience, and care coordination measures).

Ø CPIA: The Final Rule reduces the number of improvement activities required to achieve full credit under MIPS from six medium-weighted (or three high-weighted) activities to four medium-weighted (or two high-weighted) activities. There are also additional reductions in reporting requirements for small practices, rural practices, or practices located in geographic health professional shortage areas (HPSAs), and non-patient facing MIPS-eligible clinicians.

Ø ACI: The Final Rule reduces the number of required measures in this performance category from 11 to five, and makes all of the other measures optional for reporting purposes.

Ø Cost: 0% weight for the Cost performance category for the 2017 transition year.

The Final Rule also made some changes with regards to Advanced APMs.

1. Incorporating Non-Advanced APMs in MIPS Reporting. For the transition year, CMS has designated certain one-sided risk value-based payment models that do not qualify as “Advanced APMs” – such as the Medicare Shared Savings Program Track 1 Model – as “MIPS APMs.” Clinicians participating in such MIPS APMs will be scored using the APM scoring standard instead of the MIPS framework, and will not have additional reporting requirements under MIPS for the Quality and Improvement Activities performance categories other than those already taken care of through the APM entities. This should make it easier for MIPS-eligible clinicians already engaged in APMs to gradually transition to the Advanced APM track of QPP without duplicating their reporting obligations.
2. Payment Incentives for Advanced APMs. For CMS, APMs are an important step forward in moving our healthcare system from volume-based to value-based care. CMS reiterated its intention for payment incentives for APM participants to drive delivery of better health outcomes and smarter spending. The provisions of the proposed rule were mostly kept in place, with changes that provide more possible options for qualifying as an Advanced APM, which are a subset of APMs that let practices earn increased bonus payments for taking on additional shared risk. For example:

• To broaden opportunities for clinicians to participate in Advanced APMs, the Final Rule eases the risk criteria for Advanced APMs and permits flexible uptake and a broader range of future models.
• The Comprehensive ESRD Care Model Non-Large Dialysis Organization arrangement was added to the six Advanced APM models named in the proposed rule (the Comprehensive Primary Care Plus (CPC+); the Medicare Shared Savings Program (Accountable Care Organizations (ACOs)), Tracks 2 and 3; the Next Generation ACO Model; the Oncology Care Model Two-Sided Risk Arrangement; and the Comprehensive ESRD Care Model (Large Dialysis Organization arrangement)).

CMS is considering the inclusion of a new ACO Track 1+ Model as an eligible Advanced APM beginning in 2018, with lower risk-sharing requirements than currently available to Medicare ACOs.

So what is your strategy?

It might be a good idea if you are not already in, or not yet ready to participate in an APM to begin evaluating your best strategy for maximizing MIPS. Of the four pathways the first three apply to clinicians subject to MIPS in 2017 and offer different opportunities to receive an upward adjust in Medicare payments or avoid a downward adjustment. Starting with the third pathway which is to to avoid a negative MIPS payment adjustment (remember that the payment adjustments for the 2017 performance year are applied in 2019).

Recall that the MIPS track is scored on four categories: Quality, Resource Use (or Cost), Advancing Care Information (ACI - formerly known as MU), and Clinical Practice Improvement Activities (CPIA). These four categories will be used to calculate Medicare Part B bonuses or penalties. For the third pathway a clinician may participate by submitting just some data during 2017 to avoid penalties. The reporting period can be less than ninety days and you would only need report on one measure from the Quality category and one CPIA activity, or you could report on all of the reduced number of ACI measures. Pathway three is basically to avoid a downward adjustment. If this pathway is taken it is key to note that in 2018 it is full reporting for the full year so the transition year in2 2016 should not be viewed as time off, but would be better used too prepare for 2018.

The second pathway allows a clinician to participate for part of the calendar year and submit data for less than the full calendar year of the reporting period to qualify to possibly receive a small positive payment adjustment. If a clinician is capable of reaching this middle way it gets them on the ramp to full participation in 2018, and could gain a little bit of a positive payment adjustment. Again, it is important to be prepared to ramp up to the full reporting for 2018.

About these payments - the program is required by law to be budget neutral - for every dollar paid out in the upward adjustments there must be corresponding losses on the downward side.  However, there is an additional exceptional performance bonus that escalates up to 10% for progressively higher performers who exceed an exceptional performance threshold number of MIPS points. The MACRA law explicitly requires bonuses or penalties in MIPS—not including exceptional performance bonuses—to be budget neutral.

Consistently high performers in MIPS can actually financially outperform physicians in APMs in the coming years. Therefore, clinicians in an APM and who are confident that they would score well on relevant quality and value metrics might actually prefer to be judged as a group under MIPS. In assessing your options it is important to recognize that performance under MIPS as an individual clinician or in a small group practice may be less predictable than as a part of an APM. This due to the performance in MIPS being relative to the performance of other clinicians. Looking for short term gain at the expense of long term stability is not a good strategy. I always tell people when dealing with regulatory requirements, don't do something dumb just for the money.

Thanks for reading my post. I will pick up where we left off and expect to have at least two more over the next few weeks covering payments, the details of measures and requirements, and (with a little help my friends) what for me personally is the most difficult to explain: quality measures and reporting.