hysician practices can take steps to improve their chances of succeeding under the upcoming Merit-based Incentive Payment System.

When Congress finally repealed the much-maligned sustainable growth rate (SGR) and its proposed payment cuts, medical groups rejoiced. But the new payment system would present its own challenges.

The Medicare Access and CHIP Reauthorization Act (MACRA), in the form of a proposed rule from the Centers for Medicare & Medicaid Services (CMS), aims to encourage medical groups to pursue advanced payment models and accountable care. MACRA replaces several Medicare reporting systems and creates two potential paths for medical groups: the Merit-based Incentive Payment System (MIPS) and advanced payment models (APMs). The MIPS program replaces and incorporates the former EHR incentive program (Meaningful Use), Physician Quality Reporting System (PQRS), and Value-based Payment Modifier program. The APM path is for groups that are willing to assume two-sided risk under new payment models, including select accountable care organizations (ACOs) and demonstration programs.

The APM track provides for a 5 percent annual incentive payment, while MIPS has upside and downside risk starting at as much as 4 percent in 2019 and increasing to as much as 9 percent by 2022. MIPS is budget-neutral, so there will be winners and losers.

Both tracks begin to measure performance in 2017 and to impact reimbursement to groups in 2019. (However, the acting administrator of CMS recently told Congress the agency is considering a delay in the start of the reporting period in response to physician concerns.)

MACRA is currently a proposed rule, with CMS required to issue a final rule by Nov. 1. Although CMS has recently been willing to revise some rules based on comments submitted by providers, significant deviation from the proposed rule is not expected. Given that most groups will not be ready to start on the APM path by January, it is estimated that more than 90 percent of groups will start under MIPS in the absence of drastic changes to the proposed rule.

As a leader in your medical group, how can you help ensure success under MIPS? How can your group benefit from incentive payments and avoid payment reductions? In this article, the first of a series on MACRA for Physician Business Adviser, we focus on how performance is measured and how medical groups can succeed under MIPS.

Measuring MIPS Performance

Your medical group probably began reporting quality with the inception of the PQRS (formerly PQRI) program in 2007. Under this program you received credit, and financial rewards, simply for reporting, regardless of actual performance.

MIPS takes a different approach to measuring the performance of eligible clinicians, initially including physicians (MD/DO and DMD/DDS), nurse practitioners, physician assistants, and certified registered nurse anesthetists and, in 2019, expanding to include physical and occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dietitians/nutritional professionals. MIPS clinicians can elect to be measured individually or as a group under a common tax identification number. (For the purpose of this article, we will refer to individuals and groups collectively as MIPS clinicians.)

Eligible clinicians’ performance in the four MIPS components will be assessed using a composite score on a 100-point scale. The four components are quality, advancing care information (ACI), clinical practice improvement activities (CPIA), and resource use. The weighting of the score for the first year of reporting is as illustrated below. 

Preparing for MACRA_Part I_Exhibit 1

The weighting of these categories is scheduled to change after 2017, with more emphasis on resource use (cost) and less on quality and meaningful use of technology. 

MIPS maintains budget neutrality by grading on a curve. A MIPS clinician’s score within each of the four categories is determined by benchmarking his or her results against other providers. Therefore, achieving fixed performance targets will not be sufficient to protect against payment reductions or to ensure bonuses. Clinicians must be among the higher-performing providers to maintain or increase their Medicare reimbursement.

The following provides more detailed information on the four components:

Quality. MIPS adopts many of the same measures as the PQRS and the Value-based Payment Modifier program, along with similar reporting methods. MIPS clinicians select six PQRS measures that they feel best represent their practice. CMS uses claims data to calculate an additional two population quality measures for individual clinicians or groups with less than 10 clinicians, or three additional measures for larger groups. Performance is measured on a 90-point scale.

Advancing Care Information. This component is a simpler and less burdensome version of the Meaningful Use program, which it replaces. The number of measures decreases from 18 to 11. MIPS clinicians receive 50 base points for providing numerator/denominators or answering yes/no for six meaningful-use objectives and their measures. An additional 80 points are based on performance in the areas of patient engagement and information exchange. Finally, one bonus point is awarded for reporting to one additional public registry. The total maximum score is 131, but clinicians need only 100 to receive full credit.

Clinical Practice Improvement Activities.Performance is measured on a 60-point scale and is based on six sub-categories including expanding practice access, population management, and care coordination. MIPS clinicians must select three to six activities that total 60 points from among a list of 90 options. Examples of medium-weighted activities (worth 10 points each) include implementing regular care coordination training and establishing standard operations to manage transitions of care. Examples of high-weighted activities (worth 20 points each) include offering integrated behavioral health services and seeing new and follow-up Medicaid patients in a timely manner. Patient-centered medical homes receive the full 60 points, and participation in an APM earns 30 points.

Resource Use (cost). Performance is measured on a 20-point scale. There are no reporting requirements under this category. Instead, CMS will use claims data to assess MIPS clinicians’ performance based on cost measures that account for different clinical specialties. 

How to Succeed Under MIPS

Where should you start your MIPS journey? To begin, it will be critical that you not only understand how your group is currently performing on the MIPS measures, but that you also take actions to improve performance to ensure that you earn incentive payments, or at least avoid payment reductions.

Consider the following three steps for MIPS readiness.

Perform a gap analysis. The first steps toward MIPS success are to understand how your group performs under current Medicare programs and to identify opportunities for improvement. As noted, the goal is to achieve a composite score of as close to 100 as possible.

Preparing for MACRA_Part I_Exhibit 2

Quality. Your group’s performance will be determined based on how you compare to peers on measures of quality, cross cutting (i.e., measures applicable across multiple settings and specialties), outcomes, and population health. To understand how Medicare currently rates your performance in these areas, a good place to start is the Quality and Resource Use Report (QRUR).The QRUR report compares your scores relative to your peers by calculating standard deviations from the national mean for both quality and cost. The report also includes a high-risk bonus adjustment that is based on ICD-10 coding, an area in which many groups do not focus enough energy—if your clinicians are not assigning appropriate or accurate diagnosis codes, their patient risk score may be lower than it should be. Use the QRUR to identify measures in which your group falls below the average, especially in areas where you have a large volume of patients. 

Based on your group’s technology resources, you may also be able to access quality information through your EHR, registry, or Qualified Clinical Data Registry. Some vendors include CMS benchmarks in their systems, allowing you to compare your performance on quality measures. If not, the benchmarks are available on the CMS website.

Resource Use. The resource use measures assess the cost of care provided by your clinicians. The QRUR includes cost data and therefore is a good resource when assessing your group’s performance in this area.

The QRUR provides a cost composite score and performance derived in two ways:

  • Per capita costs for all attributed beneficiaries and for beneficiaries with one of four specific conditions (diabetes, chronic obstructive pulmonary disease, coronary artery disease, heart failure)
  • Cost for the medical spending per beneficiary measure surrounding specific inpatient hospital stays (three days prior through 30 days post-discharge)

The costs reflect payments for all Medicare Part A and B claims submitted by all providers who treated Medicare fee-for-service patients attributed to your tax identification number for each measure (excluding prescription drug costs). As a result, you will need to assess how your costs are impacted by the coordination of care with other providers, including acute and post-acute facilities.

Advancing Care Information. The ACI measures and objectives have been adopted from Stage 3 as finalized in the 2015 EHR incentive final rule, with modifications of thresholds. The goal is to create less burdensome data submission mechanisms, meaning IT vendors will be upgrading to meet the requirements. Working with your IT vendor to understand its planned upgrades and functionality enhancements will be key. Does your certified electronic health record technology (CEHRT) have the ability to meet the requirements? How are you performing on the measures?

Meeting the requirements and thresholds will be challenging for practices compared with Stage 2 of meaningful use. Specifically, practices have had difficulty with the electronic exchange of transition of care and with direct messaging. Compared with specialists, primary care physicians may have an easier time with the measures because they have more frequent communication touchpoints with their patients, meaning patients would be more likely to comply with the portal requirements. Understanding your group’s ongoing challenges will be important as you develop your roadmap.

Clinical Practice Improvement Activities. To understand how your group will perform under CPIA, you need to review the proposed list of 90 activities to determine the ones in which you are currently engaged. You may be performing certain activities as part of other initiatives, so focusing on those is recommended. Subcategories include:

  • Expanded practice access
  • Beneficiary engagement
  • Patient safety and practice assessment
  • Care coordination
  • Population management 
  • Achieving health equity
  • Emergency response and preparedness
  • Integrated behavioral and mental health

The gap analysis will help you understand where your group is performing well and is likely to succeed under MIPS, but more importantly where performance is lacking and where opportunities for improvement exist. Armed with this information, you can begin to take action.

Form a steering committee. Success under MIPS will require strategic alignment, appropriate measure selection, accurate measure capture and reporting, workflow analysis and/or development, staff and clinician training, and active performance monitoring. Given the breadth and scope of work needed, it is recommended that groups establish a multidisciplinary MIPS steering committee consisting of clinicians, staff, administrators, IT, and finance. 

The steering committee should be charged with creating the strategy and high-level work plan. Members will oversee the plan’s progress and timeline adherence, and provide direction for the resolution of any obstacles. The gap analysis result should be used to identify the specific areas of opportunity and aid in the development of a roadmap that takes the organization through 2017.

Success under MIPS will require physician engagement and participation. The steering committee should evaluate your group’s physician compensation plan to ensure that it includes incentives for quality, patient satisfaction, and efficiency.

Invest in technology and change management programs. Collecting, monitoring, and reporting MIPS measures may require IT capabilities beyond the typical EHR. According to Beth Houck at SA Ignite, “Most EHRs can at least report a clinical quality measure, but current EHR technology does not have the predictive analytics to translate this data into a MIPS composite score. The submission method, the measures chosen, and the corresponding benchmarks all play a role in maximizing the score.” Evaluate current system functionality and work with your vendors to fill any gaps. Engage your clinicians and staff in efforts to optimize your EHR utilization. Super-users who have demonstrated proficiency with the system can be powerful resources. 

Success under MIPS will require strategic and operational changes, and change can be difficult to implement and even more difficult to maintain. Consider using a formal change management program that combines a well-executed plan for change with the leadership needed to sustain that change over time. Change leadership is an essential, but often overlooked, aspect of change strategy; it addresses the human or cultural component that provides the spark needed to activate change. Change leadership aligns employees with a shared vision for the future of the organization, then mobilizes and motivates them to make that vision a reality. MIPS requires this level of commitment and focus.

Just the Beginning

MACRA relieved medical groups from the threat of SGR cuts but created a new set of challenges. While MIPS carries a risk of payment reductions, it also offers higher-performing groups a chance to attain significant financial incentives. The skills and capabilities developed under MIPS can also help prepare groups for future success under the APM track. The time to get started is now.


Marc Mertz, MHA, FACMPE, is vice president and Physician Services practice leader with GE Healthcare Camden Group. Lucy Zielinski is a vice president with GE Healthcare Camden Group. Nidhi Chaudhary is a consultant with GE Healthcare Camden Group.  

Footnote:

a. Per CMS.gov, “This Annual Quality and Resource Use Report shows how your group or solo practice, as identified by its Medicare-enrolled Taxpayer Identification Number (TIN), performed in 2014 on the quality and cost measures used to calculate the Value Modifier in 2016. Any applicable Value Modifier payment adjustment is separate from payment adjustments made under the Physician Quality Reporting System (PQRS) or other Medicare programs.”


Publication Date: Monday, August 01, 2016