Note: This is Part 3 in a series on how physicians can prepare for MACRA, the new Medicare payment law. Read Part 1 for an overview of how the Merit-based Incentive Payment System works and Part 2 on applying change management to practices ahead of the new law.

January 2017 marks the beginning of the first reporting period that will affect physician reimbursement under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The Centers for Medicare & Medicaid Services (CMS) is scheduled to publish the final rule by Nov. 1, and while the agency has provided flexibility for participation in 2017 (as detailed in this blog post by CMS Administrator Andy Slavitt), the time is now to develop and implement strategies for success in the Merit-based Incentive Payment System (MIPS) track. Failure to prepare could hamper practices financially starting in 2019, when payment adjustments go into effect.

The key to success in MIPS rests on a practice’s ability to gather, quantify, and report on elements of patient care that exhibit improvement in outcomes and cost reduction. IT infrastructure, scalability, and continued development and process improvement are all necessary components of a MIPS strategy. Here we explore how a practice can achieve its goals, regardless of size or specialty, in the four defined areas of MIPS.

Quality (50 Percent of MIPS Composite Score)

Quality reporting under MIPS replaces the Physician Quality Reporting System (PQRS) program and uses basically the same measures and methods, with some modifications. Eligible providers (EPs) will select six measures across any combination of quality domains, as compared with nine measures currently required under PQRS. When choosing the six measures, the provider must include one outcomes measure or another high-quality measure, and one cross-cutting measure if the EP is patient facing. Additionally, the proposed rule requires CMS to calculate two (for physician groups of less than 10) or three (for groups of 10 or greater) population quality measures from claims data. 

Instead of the six measures as described above, providers may choose to report a specialty measure set that is designed around specific specialties and conditions. The proposed rule allows for data submission of performance measures through registries, Qualified Clinical Data Registries, health IT developers, and certified survey vendors.

To succeed under the Quality domain, medical groups must take the following action steps:

  • Evaluate or implement electronic health record (EHR) use and reporting methodology
    • Understand connectivity to area hospitals and networks
    • Explore partnering opportunities to offset capital investment
    • Gain understanding of data-registry and interoperability capability

  • Review measure selection
    • If successful in past PQRS reporting, validate measure selection for 2017
    • Evaluate previous-year performance against benchmark
    • Adopt new measures based on previous experience and consider specialty-specific measure groups 

  • Monitor and track performance of measures
    • Understand performance against benchmarks to ensure the highest composite score
    • Model scoring scenarios to ensure success
    • Enroll in additional measures and monitor performance throughout 2017
    • Create or redesign workflows and implement changes to address performance improvement

CMS has published PQRS results for the 2015 reporting year, along with benchmarks. These can be used to track performance and set high-performance targets. Given that CMS is allowing clinicians to choose the measures on which they will be evaluated, clinicians should be very intentional when selecting measures. 

Resource Use (10 Percent of MIPS Composite Score)

CMS defines the scoring for Resource Use in MIPS as “comparing resources used to treat similar care episodes and clinical condition groups across practices.” The calculations for this category replace the Value Modifier (VM) program and are based solely on claims data. The key change from the VM program is the addition of over 40 episode-specific measures to address specialty concerns. Although this category only accounts for 10 percent of the composite score in 2017, it eventually grows to 30 percent. Therefore it is imperative that physician practices understand how the calculations are occurring and what aspects of the spending formula they can control and influence. 

Actions for medical groups include:

  • Review the Quality and Resource Use Report (QRUR) to determine relative position among peers
    • Use your Enterprise Identity Management System (EIDM) account to access and review the QRUR, which is published at 
    • Use the QRUR to identify opportunities for improvement and to develop improvement plans

  • Review the 41 episodes to determine for which ones to consider a redesign of care management
    • If you are in a specialty practice, understand which episodes are applicable to your specialty and how to improve care design

There are no reporting requirements for this category.

Advancing Care Information (25 Percent of MIPS Composite Score)

Advancing Care Information replaces the Meaningful Use program and is less burdensome, with a smaller number of measures. The maximum score for this category is 131, although clinicians need only 100 points to receive full credit. Clinicians receive 50 base points for achieving the following six meaningful-use objectives:

  • Protecting patient health information
  • Electronic prescribing
  • Patient electronic access
  • Coordination of care through patient engagement
  • Health information exchange
  • Patient health and clinical data registry reporting 

An additional 80 points will be awarded for performance in the areas of patient care and information access (and one bonus point is available for reporting to an additional public registry). Actions for medical groups include:

  • Ask your IT vendor about its rollout plan for MIPS
    • Ensure your vendor has the ability to report measures
    • Track measures by individual provider, and by group if applicable, to improve performance scores 

  • Perform a review of current measure performance based on future targets
    • Identify deficiencies and redesign workflows to capture data, specifically focusing on measures involving portal usage, electronic exchange of transition of care, and direct messaging

  • Align with other providers, hospitals, and clinically integrated networks on health information exchange and interoperability efforts to share and build on relevant information  

This category’s factor in the MIPS composite score may decrease in future years once more users adopt EHR technology.

Clinical Practice Improvement Activities (15 Percent of MIPS Composite Score)

CPIAs comprise a new category. From a list of 90 activities, clinicians choose a combination of three to six activities that are most meaningful and applicable to their specialty and practice. Performance is measured on a 60-point scale with medium- (10 points) and high-weighted (20 points) activities. Patient-centered medical homes receive full credit for CPIA, while participation in an alternative payment model earns half-credit. 

Subcategories include:

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

Many medical groups have implemented some form of practice transformational effort such as chronic care management services, group visits, use of a prescription drug monitoring program, and providing 24/7 access for urgent and emergent care. Going forward, medical groups should:

  • Evaluate current transformational efforts or initiatives to determine whether such efforts warrant points in this category
    • Assess efforts made by clinical staff and care management teams
    • Review participation in population health initiatives or with quality improvement organizations
  • Select activities that are aligned with the overall strategic direction of the practice (e.g., improving the patient experience, enhancing patient access and implementing telehealth services, implementing and optimizing the use of technology and registries)

  • Document improvement activities to substantiate efforts made

CPIA is probably the easiest category in which to score the maximum points, so clinicians should take advantage to increase their overall composite score.

No Time to Waste

Each point counts under MIPS, and performance next year can result in a bonus or penalty of as much as 4 percent in 2019. Hence, clinicians must have a plan to prepare for 2017. CMS’s goal is for 90 percent of Medicare fee-for-service payments to be tied to quality or value by the end of 2018, and commercial payers are being invited to match or exceed this goal. In that context, medical practices need to start now in an effort to promote care coordination and better patient outcomes.

Lucy Zielinski is vice president, GE Healthcare Camden Group.

Cami Hawkins, MHA, is manager, GE Healthcare Camden Group.

Publication Date: Monday, October 03, 2016