• Optimizing Provider Reputation Under MACRA and MIPS

    Tom S. Lee Oct 25, 2016

    MACRA has the potential to significantly affect provider reputation, which in turn can be a major driver of customer acquisition and physician recruitment.

    The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is the most significant change to Medicare physician reimbursement in a generation. Beyond substantially tying payment to physician performance, MACRA accelerates and amplifies a potentially even greater factor in the long-term health of a provider organization: its public reputation.

    In particular, most Medicare Part B clinicians will be subject to MACRA’s Merit-based Incentive Payment System (MIPS), which takes effect Jan. 1, 2017, and each year will publicly report clinician performance on a 100-point scale. 

    Senior leaders of provider organizations are increasingly focused on provider reputation because of its impact on:

    • Customer acquisition and revenues
    • Returns from marketing efforts, with low provider ratings negating marketing dollars spent promoting those providers
    • Provider referral patterns and physician recruitment 

    Of particular concern is the fact that once a provider’s reputation is damaged, it is very difficult to repair. Public reputation can be thought of as a glass vase. Once it shatters, it is difficult if not impossible to piece back together in this world of pervasive online marketing and social media. 

    Payer reimbursement is more like a rubber ball in that bouncing back from a down year is more feasible. It is more difficult to reverse consumer perceptions stemming from news that a provider has earned, say, only 40 out of 100 performance points in MIPS than it is to rebound from temporary reimbursement cuts.

    The Growing Importance of Public Reputation

    Consumer awareness and use of provider ratings and reviews is high and growing. As far back as 2014, a survey found that 65 percent of consumers were aware of provider-rating websites and 36 percent had used a rating site at least once.1 Sites such as Healthgrades.com and Vitals.com capture tens of millions of visits per month and publish quality indicators derived from a broad array of data sources, including the Centers for Medicare & Medicaid Services (CMS). This year, Angie’s List (100 million visits per month) granted free access to all consumer reviews, including those of healthcare providers.2

    CMS currently publishes quality metrics from the Physician Quality Reporting System (PQRS) on a named-provider basis on the Physician Compare website, where the data is also available as a free download for third parties such as Healthgrades. Furthermore, CMS is planning to fold those metrics into a single 5-star rating for each provider’s 2016 performance, to be published by early 2018.3 Provider organizations such as Cleveland Clinic self-publish quality metrics or patient reviews of providers. 

    A provider’s public reputation does not yet override other selection factors, such as referrals from physicians or from friends and family members, out-of-pocket costs, and location.4 However, as adoption of high-deductible insurance plans grows, consumers are increasingly paying more out-of-pocket for health care and are seeking to make more-informed choices. Many providers are concerned that the status quo may be disrupted, as it has been in other consumer-oriented industries such as automobiles, by the proliferation of ratings sites and the rising tide of provider quality information being published by the likes of CMS.

    Impact of MIPS on Public Reporting

    The MIPS scoring system and the expected scope and quantity of MIPS measure data are likely to accelerate and broaden public reporting of provider performance. Each provider is rated on a continuous 100-point scale composed of four performance categories: quality (60 percent for 2017, 50 percent for 2018), advancing care information (25 percent), clinical practice improvement activities (15 percent), and resource use (0 percent for 2017, 10 percent for 2018). For many of the MIPS measures, providers earn points based on their performance relative to national peer benchmarks, meaning there are effectively a limited number of points to go around.

    Providers earning a score above an annual performance threshold set by CMS receive an incentive, whereas those scoring below the threshold are assessed a penalty. Each point below or above the threshold translates proportionally into financial impacts. The penalties assessed nationally help fund the incentive pool for the higher performers, meaning the winners are effectively paid by the losers. The performance threshold is expected to increase annually as average MIPS performance improves nationwide.

    The impacts on public reporting and, consequently, provider reputation are significant. First, within approximately 15 months of the end of the performance period, CMS will publish each provider’s MIPS score and component category scores to the Physician Compare website. Consumers will be able to see how providers rate relative to each other on a 100-point scale and within each of the four MIPS performance categories. It is apparent that CMS chose a 100-point scale for MIPS because consumers easily understand how to interpret such a score from their experience with other forms of comparison shopping, such as movies and hotels. CMS projects that about 600,000 clinicians will receive a MIPS score for the 2017 performance year.

    Second, Physician Compare also will release the scores in a freely downloadable and structured format (such as an Excel document or text file), as is currently done for PQRS measure data. Third-party provider rating sites are currently hampered by low sample sizes, such as too few patient reviews for a given provider. Hence, these sites will seek to enhance their provider ratings by incorporating MIPS scores that CMS has deemed to be statistically significant. This dynamic will greatly expand the reach and audience for MIPS scores, which will be much easier for consumers to interpret than are current quality indicators, such as performance measure rates. A consumer is more likely to be influenced by seeing a score that is based on a 100-point scale and verified by Medicare than by reading a few patient reviews about that provider. 

    Third, CMS will publish national aggregate information about the MIPS score, including the national average score and the range of scores for all clinicians overall and in each of the four performance categories. This information enables provider-rating sites to more directly show how a provider’s performance compares with that of other Medicare clinicians nationally, rather than limit the peer comparison group to only those providers for which a site is able to collect data on its own. For many providers, the MIPS score will be the first time their public reputation may be impacted by a 100-point scale placed on a national comparison platform and distributed to an audience of potentially millions. 

    Fourth, one of the most impactful aspects of the MIPS score is that once a clinician earns a score, that score is tied to the clinician through the payment adjustment year (e.g., through 2019 for performance in 2017) regardless of where the clinician may subsequently be employed. Hiring organizations will want to know a clinician’s MIPS score for preceding years to know what incentive or penalty the clinician is bringing along. Similarly, Physician Compare will continue to show that clinician’s most recent MIPS score even if he or she has switched organizations. 

    How Provider Organizations Are Preparing

    Providers will not learn their MIPS score until late in the year after the performance year (e.g., in late 2018 for the 2017 performance year). When providers learn of a bad score, the current year will be nearly over, meaning those providers then can focus only on improving for the following performance year. These factors combine to mean that a provider could effectively need two or more years to reverse a low MIPS score in the public domain. During such a wide gap, a provider could lose market share to providers with higher scores yet not be able to change that score until the damage is already done. Provider organizations are increasingly interested in ways to estimate their MIPS scores while there is still time to improve performance before reporting data to CMS. 

    Many providers are concerned that their MIPS scores will not accurately reflect their actual performance. For instance, data-capture issues in electronic health records may result in low scores even though clinicians are performing the work required to score well. Provider organizations are optimizing their IT systems to improve the consistency between actual and reported performance with an eye towards maximizing MIPS scores. 

    Last, educating clinicians about the financial and reputational impacts of MIPS and what they can do is perhaps the most important preparation. Current knowledge and awareness of MIPS is low among clinicians, so increasing numbers of organizations are explaining to clinicians how the MIPS score is important to their reputational health, not just their immediate financial health. And that’s good advice, indeed.


    Tom S. Lee, PhD, is CEO and founder, SA Ignite, Chicago.

     

    Footnotes:

    1. Hanauer, D.A., et al., “Public awareness, perception, and use of online physician rating sites,” JAMA, February 2014.

    2. Gensler, L., “Angie’s List Is Tearing Down Its Paywall, Will Soon Be Free,” Forbes, March 3, 2016.

    3. Centers for Medicare & Medicaid Services, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016,” Nov. 16, 2015, pp. 718-19.

    4. Saxena, S., et al., “Health Care Consumerism Is Real—And Providers Need to Adapt,” Boston Consulting Group, Aug. 10, 2016.
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