Life Science Compliance Update

December 05, 2016

Part Two: MACRA More MIPS, and APMs

MIPS_blog

In part two of our MACRA analysis, we continue our look at MIPS and evaluate the APM pathway of MACRA’s new quality payment program.

Small Practice Considerations

Exemption

Key finalized policies include a small practice-friendly low volume threshold. In 2017, the threshold has been set at “less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients.” CMS says this new threshold represents 32.5 percent of Medicare clinicians but only 5 percent Medicare Part B spending.

CMS says that the new flexibilities from the final rule lessen the impact on small and solo practices. CMS says “we believe that small and solo practices will respond to MIPS by participating at a rate close to that of other practice sizes.” CMS estimates each practice size will achieve either an 80 percent or 90 percent participation rate, and that at least 80 percent of clinicians in small practices will receive a positive or neutral adjustment.

Virtual Groups

MACRA allows solo and small practices to join “virtual groups” to combine their MIPS reporting. Many commenters asked CMS to allow groups with more than 10 clinicians to participate as virtual groups, even though the statute limits virtual groups to groups of not more than 10 clinicians. CMS notes that it is not implementing virtual groups in the first year of the program, and that it believes it has addressed some of the concerns expressed by clinicians hesitant to participate in the Quality Payment Program. It left the question open and said it would work with stakeholders on how it would structure and implement virtual groups going forward.

In a letter signed by Robert Horne, Executive Director of Health IT Now addressed stakeholder concern over virtual groups. Dated October 17, 2016, the group wrote to CMS:

“There is growing recognition among lawmakers and the public that implementation of the MACRA statute will be challenging for both physicians and CMS. Establishment of virtual group reporting options appear no different. We recognize that part of the problem may lie with the CMS legacy IT system, which some suggest are incapable of performing many functions that are commonplace among IT systems today. While we believe it imperative that Congress work with the administration to identify ways that the CMS computer systems can be updated to increase Medicare’s efficiency and reduce costs, we do not believe such a barrier need impact the effectiveness of the virtual group concept. Rather, we believe that the solution can be found in closer collaboration with health IT industry leaders.

“Many members of Health IT Now (HITN), and the health IT community more generally, have platforms and expertise in technology solutions that could facilitate provider engagement in virtual groups, performance feedback in real-time, and other solutions that might better prepare providers to meaningfully engage in APMs. We want to collaborate more closely with CMS to put such ideas into practice.

“We encourage CMS to establish a virtual group reporting option, or at the very least begin laying the foundation for such an option, as soon as possible. There is ample public support for such a move, as demonstrated by comments on the proposed rule from various stakeholders. HITN has a number of ideas on how to accomplish this lofty goal, and stands ready to support your efforts.”

Problems for IT vendors

Beginning in 2018, physicians must use EHR technology that is certified for 2015 instead of 2014. That could be a problem, since more than 75% of the providers participating in the Medicare EHR Incentive Program as of July had 2014-certified edition technology, according to the Office of the National Coordinator for Health Information Technology, which establishes the certification criteria. This, as reported by Modern Healthcare, could be burdensome on smaller EHR vendors.

According to Corinne Proctor Boudreau, senior manager of marketing for physician experience at Meditech, a Westwood, Mass.-based developer of hospital and physician EHRs, under the meaningful-use program, “you have seen some of those smaller vendors not be able to make those requirements. But this is the direction the industry has been going in. It's a little bit the cost of doing business,” Boudreau said.

“This situation is unfortunate for providers who have invested in an EHR that does not acclimate to agile change at scale,” but it's not an issue for others, including athenahealth. According to a statement from Allison LaValley, executive director for quality performance and value-based care at athenahealth, “As a cloud-based network, we are very nimble and can adapt not just to MACRA but to anything the government throws forward.”

However, as noted by others in the industry, the rule did make concessions to the health IT community. EHR testing and certification launched in 2006 under the Office of National Coordinator for Health IT (ONC).  Since that time and accelerated by the Meaningful Use programs, there has been an ongoing narrowing of EHR vendors leaving healthcare providers to comtemplate a “rip and replace” IT strategy. Advancing Care Information (ACI) will not take an all-or-nothing approach to EHR requirements, especially since the final rule reduced the total number of required measures to five, ultimatley down from 18 under stage 2 meaningful use. The five ACI requirements include basic measures:

  • Security risk analysis,
  • e-Prescribing,
  • Providing patient access,
  • Sending a summary of care, and
  • Requesting and accepting a summary of care.

The rule also no longer requires reporting on measures for clinical decision support and computerized provider order entry.  The reduction was designed to ease the burden on providers and allow the EHR industry to address issues of usability and interoperability.

Arguably, CMS “reduced the number of measures … but the measures you do have to meet are predicated on interoperability,” which is often outside the control of the physician, said Mari Savickis, vice president of federal affairs at the College of Healthcare Information Management Executives, an association of chief information officers at hospitals and health systems. Yet Boudreau points out that interoperability-related measures such as sending and receiving a summary of care through EHRs “have been out there for a while for physicians that have been (participating in) meaningful use.” She supports the idea that the reduction in required measures under MACRA gives vendors some “breathing room” to develop certain tech capabilities. LaValley said vendors such as athenahealth have “skin in the game” regarding their clients' success under MACRA. More importantly, "the industry is rife with EHRs that are not architected to enable cross-continuum care coordination and connectedness, which is critical to long-term MACRA success.”

MIPS APMs

MIPS APM provides participants a pathway improve their MIPS scores through APMs that do not meet criteria to be Advanced APMs or do not meet the revenue or patient thresholds to be exempt from MIPS. Potentially included in these MIPS APMs, Medicare Shared Savings Program and Next Generation ACOs would report MIPS quality measures on behalf of their participants; and, the CPIA and ACI performance categories will be reweighted to 20 percent and 80 percent respectively. Non-ACO MIPS APM participants will have their quality score reweighted to zero for the 2017 performance period and the CPIA and ACI performance categories will be reweighted to 25 percent and 75 percent respectively.

Each year, CMS will compare the requirements of recognized APMs with the list of Improvement Activities and score those measures in the same manner they are otherwise scored for MIPS eligible clinicians. Prior to the start of each performance period, CMS will publish a list of the pre-assigned Improvement Activities score for each MIPS APM. In the event that the assigned score does not represent the maximum Improvement Activities score, APM Entities will have the opportunity to report additional Improvement Activities.

General thoughts on changes made by CMS in final MIPS rule

As pointed out in an article at Healthcare Informatics, John Goodson, M.D., staff internist at Massachusetts General Hospital and associate professor at Harvard Medical School, believes CMS’ decision to modify reporting measures and timelines in the final rule serves as a “strategic movie” to get more physicians invested in the program. Many physicians did not participate in PQRS, and Goodson noted that the reporting required in MACRA’s Quality Payment Program will necessitate good, solid data which CMS will never get unless they get doctors to buy into the reporting mechanisms. As such, the pathways laid out by the federal agency are attempts to at the least, get the community of providers engaged at a minor level, Goodson says.

Additionally, much of MACRA is already in law because of what has been spelled out by through bipartisan, bicameral Congressional efforts. Goodson does not think Congress will readdress the program right now and wants to see how it plays out. At some point physicians will have to make the choice between staying in Medicare or getting out. “There is a fear that this whole system will implode because doctors won’t want to play this game anymore. They think it’s too demanding and crazy.” However, Goodson believes that in the end, most providers want to partake in Medicare, and the key will be to be able to obtain the meaningful data that these programs under MACRA will inevitably require.

However, “getting out of Medicare” is a flawed strategy and here’s why.  MACRA has accelerated a growing industry trend towards APM contracting across the payer system at large.  For example, in Aug. 2016 UnitedHealth paid $148 million in performance-base bonuses to almost 1,900 primary care physicians.  37 Blue plans have over 350 value-based programs spanning 49 states, D.C., and Puerto Rico impacting more than 215,000 providers, including 237 ACO contracts with over 93,000 participating physicians.  As states privatize Medicaid through managed care contracting, value-based payment design is an increasing requirement.

Regarding smaller practices, Goodson believes they have more equity in their patient panel, leading to good will and trust, which is the way to save money in healthcare, he says. “Trust allows you to use time as a diagnostic tool and a therapeutic intervention. So if you’re close to your patients, live in the community, and have a relationship with them, you can be a high quality, low cost provider.” Goodson adds that the key thing for these small practices is to have complete control over their data. This means that they know exactly who their patients are, what their problems and medications are, and what all their diagnostic codes are, so every single thing that has been identified as a problem with the patient maps to an ICD code.

Given the growing role of data and measurement in a provider’s economic future, codified data capture within the encounter note, diagnostic results and pharmacologic therapies offer strength in positioning for future requirements.  Many of the larger EHR products map to a growing plethora of coded nomenclatures such as SNOMED, LOINC and NDC.

However, there is a risk the system could be “gamed,” by which a physician practices self-selection and reports only those measures in which they do well while not truly striving for improvements in care. This is particularly pronounced around attribution of patients to the physician and risk adjustment which have not been fully addressed by CMS. Goodson is quoted asking, “How will we as providers know who we are responsible for and held accountable for?” And for risk adjustment, he notes, “People worry so much about cherry picking, so if I deal with a complicated group of patients, will I be judged against someone who selects a much less demanding group of patients? If that happens, if people figure out how to cherry pick the system, things could start to melt down,” Goodson speculates.

Advanced Alternative Payment Models

Clinicians are exempt from MIPS and eligible for up to a five percent bonus payment through calendar year 2024 if they receive a sufficient portion of their payments or see a sufficient portion of their patients through an Advanced APM. These clinicians are referred to as APM Qualified Participants or “QPs.”

In step with MACRA legislative requirements, APMs seeking to qualify as an Advanced APM must meet what CMS describes as “ambitious but achievable goals,” including:

  • The use of certified EHR technology;
  • Payment for covered professional services based on quality measures comparable to those in MIPS’ quality performance category; and
  • Either (a) the bearing of downside financial risk in excess of a nominal amount or (b) being a nationally recognized accredited patient-centered medical home, expanded under section 1115A(c) of the Social Security Act.

Under the finalized nominal risk standard, APMs could qualify as Advanced APMs if the total annual amount that an APM Entity potentially owes CMS or foregoes is equal to at least:

  • For QP Performance Periods in 2017 and 2018, eight percent of the average estimated total Medicare Parts A and B revenues of participating APM Entities (the “revenue-based standard”); or,
  • For all QP Performance Periods, three percent (down from four percent as proposed) of the expected expenditures for which an APM Entity is responsible under the APM (the “benchmark-based standard”).

Physicians should be aware that they must have at least 25% of their Medicare Part B services or at least 20% of their Medicare Part B patients attributed to the APM to individually qualify for the 5% bonus payment. Nearly every primary care physician in an ACO model will easily push past these thresholds, but specialists and physicians in other models should be wary of this provision especially as it ramps up to 50% and 35% respectively in 2021 (reporting year 2019) and all the way to 75 and 50% in 2023 (reporting year 2021).

CMS understands that widespread clinician participation in Advanced APMs is unlikely, estimating a participation rate in the transition year of only 70,000 and 120,000 clinicians. CMS is clearly interested in encouraging clinician participation in APMs, as evidenced by the planned introduction of MIPS APMs and the ACO Track 1+ model.

Physician-Focused Payment Models

As for Physician-Focused Payment Models (PFPMs), the final rule expanded the definition of PFPM to include practitioners other than physicians. Payment models can target the quality and costs of services that other practitioners provide, order, or significantly influence, rather than just physician services. CMS proposed that in carrying out its review of PFPMs, the Physician-Focused Payment Model Technical Advisory Committee (PTAC, pronounced “P-tack”) shall assess whether the PFPM meets the following criteria:

  1. Incentives: Pay for Higher-Value Care
  • Value Over Volume: Provide incentives to practitioners to deliver high-quality healthcare.
  • Flexibility: Provide the flexibility needed for practitioners to deliver high-quality healthcare.
  • Payment Methodology: Pay APM Entities with a payment methodology designed to achieve the goals of the PFPM criteria. Addresses in detail through this methodology how Medicare and other payers, if applicable, pay APM Entities, how the payment methodology differs from current payment methodologies and why the Physician-Focused Payment Model cannot be tested under current payment methodologies.
  • Scope: Aim to either directly address an issue in payment policy that broadens and expands the CMS APM portfolio or include APM Entities whose opportunities to participate in APMs have been limited.
  • Ability to Be Evaluated: Have evaluable goals for quality of care, cost and any other goals of the PFPM.
  1. Care Delivery Improvements: Promote Better Care Coordination, Protect Patient Safety and Encourage Patient Engagement
  • Integration and Care Coordination: Encourage greater integration and care coordination among practitioners and across settings where multiple practitioners or settings are relevant to delivering care to the population treated under the PFPM.
  • Patient Choice: Encourage greater attention to the health of the population served while also supporting the unique needs and preferences of individual patients.
  • Patient Safety: Aim to maintain or improve standards of patient safety.
  1. Information Enhancements: Improving the Availability of Information to Guide Decision-Making
  • Health Information Technology: Encourage use of health information technology to inform care.

CMS is finalizing its proposed criteria for PFPMs with one modification: broadening the proposed scope criterion. The final scope criterion now requires that PFPMs aim to broaden or expand the CMS APM portfolio by addressing an issue in payment policy in a new way or including APM Entities whose opportunities to participate in APMs have been limited. What does all this mean? PTAC is an official 11-member federal advisory committee on APM payment innovation. While PTAC does not have the authority to approve a provider or community’s alternative payment model as qualifying for the advanced APM payment track, it does have the ability to make recommendations along those lines including whether the APM needs refinement, piloting, additional study and/or implementation. 

CMS initiative: “Reducing medical record review for clinicians participating in certain Advanced Alternative Payment Models”

Responding to concerns of excess paperwork burdens on physician practices, CMS recently launched an initiative that intends to allow physicians to spend more time on patient care and less time on paperwork. A recent study that was sponsored by the AMA found that for every hour physicians spend providing clinical care to patients, they spend two hours on administrative tasks. Another study found physician frustrations run so high that more than half of the doctors in a national survey have considered leaving the profession, with many saying they want to spend more time with patients and less with electronic health records.

As a first step, CMS announced a medical review reduction program to ease the reporting burden for physicians. This 18-month pilot program will relieve doctors who participate in specified advanced alternative payment models (APMs) from additional scrutiny under certain Medicare medical review programs, CMS said. Seeking aligned incentives, the agency identified APMs for the pilot with participating clinicians who shared financial risk with the Medicare program, specifically:

  • Next Generation ACOs,
  • Medicare Shared Savings Program ACOs – Tracks 2 and 3,
  • Pioneer ACOs, and
  • Oncology Care Model 2-side Track participants

The pilot program is part of a broader initiative seeking to boost engagement among clinicians and combat provider alienation driven by economic reform. “The new initiative will launch a nationwide effort to work with the clinician community to improve Medicare regulations, policies, and interaction points to address issues and to help get physicians back to the most important thing they do--taking care of patients,” said CMS Acting Administrator Andrew Slavitt, in announcing the program. CMS said it will analyze results of the pilot program and consider expansion of the program to additional APMs, specialties and provider types. For more details about the pilot program, physicians can find a fact sheet on the initiative.

Do you need to know where your APM lands in the MACRA payment effort?  CMS published the following chart to outline current Advanced APMs and MIPS APMs, based on the criteria outlined in the final rule:

2017 APM List Based on Final Criteria

APM

MIPS APM under  the APM Scoring Standard

Medical Home  Model

Use of CEHRT Criterion

Quality Measures Criterion

Financial Risk Criterion

Advanced

APM

Accountable Health

Communities (AHC)

no

no

no

no

no

no

ACO Investment Model

(AIM)

no

no

no

no

no

no

Bundled Payment for

Care Improvement

Model  2 (BPCI)

no

no

no

no

YES

no

Bundled Payment for

Care Improvement

Model  3 (BPCI)

no

no

no

no

YES

no

Bundled Payment for

Care Improvement

Model  4 (BPCI)

no

no

no

no

YES

no

Comprehensive Care for

Joint Replacement

(non-CEHRT)

no

no

no

YES

YES

no

Comprehensive ESRD Care (CEC) Model  (LDO

arrangement)

YES

no

YES

YES

YES

YES

Comprehensive ESRD Care (CEC) Model  (non- LDO two-sided risk

arrangement)

YES

no

YES

YES

YES

YES

Comprehensive ESRD Care (CEC) Model  (non- LDO arrangement one-

sided risk arrangement)

YES

no

YES

YES

no

no

Comprehensive Primary

Care Plus (CPC +) Model

YES

YES

YES

YES

YES

YES

Financial Alignment

Initiative1

N/A

N/A

N/A

N/A

N/A

N/A

Frontier Community Health Integration Program (FCHIP)

no

no

no

no

no

no

1This table reflects the design of the Financial Alignment Initiative agreements between CMS and state and health plan participants.  CMS will assess agreements between states or health plans and health care providers under the All-Payer Combination Option.

APM

MIPS APM under  the APM Scoring Standard

Medical Home  Model

Use of CEHRT Criterion

Quality Measures Criterion

Financial Risk Criterion

Advanced

APM

Oncology  Care Model

(OCM) (two-sided risk arrangement)

YES

no

YES

YES

YES

YES

Prior Authorization: Repetitive Scheduled  Non-Emergent

Ambulance Transport

no

no

no

no

no

no

Prior Authorization: Non- Emergent Hyperbaric Oxygen Therapy Model

no

no

no

no

no

no

Initiative to Reduce Preventable Hospitalization Among Nursing Home Residents:

Phase 2

no

no

no

no

no

no

State Innovation

Models—Round 2 (SIM

2)2

N/A

N/A

N/A

N/A

N/A

N/A

Strong Start For Mothers

And Newborns

no

no

no

YES

no

no

Transforming Clinical

Practice Initiative (TCPI)

no

no

no

no

no

no

November 28, 2016

Part One: MACRA Overview and MIPS

Macra_acronym_definition_webinar

In its final MACRA rule, CMS significantly revamped the physician pay rule to make it easy for physicians to avoid penalties and to earn bonuses, and the agency is leaving the final rule open for comment to make it easier to revise. Among the changes, physicians need only report on one quality measure in each of two categories next year to avoid penalties, a third of practices are exempted from the program entirely, and there is a new alternative pay model option aimed at making it easier for small practices to qualify for the 5 percent bonus that comes with being counted as an alternative pay model.

MACRA: An Overview

The Medicare Access and CHIP Reauthorization Act (MACRA) creates two paths for physicians in the Quality Payment Program (QPP). Either physician performance is measured by the Merit-based Incentive Payment System (MIPS) or they earn enough revenue from alternative pay models to receive the 5 percent bonus on Part B revenues. Although the law refers to them as APMs, CMS calls them advanced APMs to distinguish them from what the agency generically calls alternative pay models, many of which do not include penalties and therefore do not qualify for the bonus. Although physicians in APMs are not subject to MIPS, they must participate in quality programs comparable to those in MIPS.

“In 2017, we estimate that we will pay approximately $1 billion in bonuses for high quality care to clinicians in both advanced APMs and MIPS,” Acting CMS Administrator Andy Slavitt said.

That $1 billion estimate is for the first payment year of the program (2019), but it’s based on performance in 2017. CMS estimates about $200 million to $320 million in pay hikes will be awarded to clinicians who participate in MIPS, plus $500 million in MIPS exceptional performance payments. The law authorizes the additional $500 million, and that money is separate from the MIPS pool created by penalties. CMS also estimates that clinicians who qualify for APM bonuses will receive between about $330 million to $570 million in 2019.

One of the key takeaways from that CMS guidance is that QPP will shift providers' risk in the program from reporting to performance. Once the low risk 2017 performance year ends, QPP will quickly increase the risk that providers face. As more providers move into the APM track—and the MIPS track becomes more competitive—providers will need a solid strategy for driving toward high performance.

To that end, providers should not view 2017 as a year off. The flexibility CMS offers for 2017 should be viewed as an opportunity to reexamine strategy for Medicare risk-based payment models, reassess and synchronize performance improvement efforts, and ensure that any MACRA related investments are positioning the organization well for long term success.

 

Some Key Highlights

 

  • The Final Rule removes the negative payment adjustment under MIPS in 2017 by allowing clinicians to submit one quality measure, or one improvement activity, or the required measures in the advancing care information category to avoid a penalty.
  • The Final Rule allows for a flexible, pick-your-own-pace approach in the first year.
  • Small clinicians are afforded relief under the raised low-volume threshold. CMS also finalized a plan to set aside $20 million per year for five years to help support and train physicians in practices with 15 or fewer doctors.
  • The MIPS Composite Performance Score will be derived from 4 categories; 3 of which will replace and consolidate the CMS Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM), and the Medicare EHR Incentive Program a/k/a Meaningful Use.
  • One of the four components of MIPS, resource use, will have a zero percent weighting toward the composite MIPS score in the first year.
  • CMS included an option to explore testing of a MIPS APMs in 2018: Accountable Care Organization (ACO) Track 1+ and the Diabetes Prevention Program, among others. MIPS APMs act as an interim step between MIPS and advanced APMs. Although MIPS APMs do meet the more than nominal risk required to eliminate MIPS payment, it does add the financial opportunity for upside APM gainsharing to MIPS bonus opportunities. Earlier this year, a provision that would allow participants to participate in new cardiac and orthopedic bundled payment models was also introduced. These models were included in the final rule with public comment with the possibility to qualify as Advanced APMs beginning in 2018.

The following chart comparing and contrasting the proposed and final rule from the American Medical Association is particularly helpful to view the important changes finalized by CMS. The AMA, one of the most influential medical associations, also notes where its comments on the proposed MACRA rule may have had an impact on the ultimate decisionmaking of CMS:

Capture1

Capture2

Capture3

Capture8

Capture5

Capture6

Capture7

MIPS

The calculation of the amount of the payment adjustment is based on a composite performance score (CPS) in the following performance categories (scoring weights for 2017 are noted parenthetically):

  1. Clinical quality (60%). This category replaces the CMS Physician Quality Reporting System (PQRS). Performance is calculated from the submission of quality measures chosen by the clinician. The measures available to clinicians will be updated annually through a call for quality measures process. Clinicians have the option of submitting general quality measures or specialty-specific quality measures.

Physicians are required to report on 6 measures or a specialty measure set, one of which must be an outcome measure or, if no outcome measures are available, a high priority measure. This requirement is a decrease from the 9 quality measures physicians were previously required to report under the PQRS. CMS also eliminated the proposal to report on a cross-cutting measure as one of the six quality reporting measures.

Additionally, in 2017, any physician who reports on one quality measure for at least one patient will receive at least 3 points on the measure, thereby avoiding a payment adjustment in 2019.  In 2017, successful physician measure reporting will include 50 percent of patients; and, in 2018, successful reporting will include 60 percent of patients. CMS intends to increase the measure thresholds over time. Although poor positioning, if a physician is only seeking penalty avoidance in 2017, they are only required to report on one patient. CMS also provides preferential scoring for physicians who report quality measures using EHR direct, qualified registry, QCDR, or web-interface.

  1. Advanced care information (ACI) (25%). This category replaces the CMS EHR Incentive program also known as “Meaningful Use.” Performance is based on the submission of five required EHR use-related measures (six fewer required measures than in the proposed rule). These measures include:
  • Security risk analysis;
  • e-Prescribing;
  • Providing patient access;
  • Sending summaries of care; and
  • Requesting/accepting summaries of care.

Importantly, the final rule does contain a pass-fail element in the base performance score, as physicians must report on all measures in the base/required score in order to earn a score in the ACI performance category. CMS also provides optional measures to be submitted for a higher score.

Reporting on all five required measures will earn a clinician 50 percent of the weighted category score. All of the other advancing care information performance category elements such as using patient-generated health data or enabling “view, download and transmit” by patients are optional and would give up to 10 percent in the overall performance score or a bonus in the case of public health reporting. CMS is also offering bonuses for reporting to public health or a clinical data registry.

Notation on Information blocking

In the final rule, CMS also reiterated its position on information blocking. Providers and hospitals participating under the existing meaningful use program are required to demonstrate cooperation with provisions concerning blocking the sharing of information.  Separately, they are required to demonstrate engagement with activities that support the performance of their certified EHR technology such as cooperation with ONC direct review of certified health information technologies.

Commenters in the proposed rule were concerned that they’d be to blame if their EHRs didn’t meet the standards in the attestation. CMS responded, saying, among other things:

“We reiterate that a healthcare provider will not be held accountable for factors that it cannot reasonably influence or control, including the actions of EHR vendors. ... We do expect, however, that a healthcare provider will take reasonable steps to verify that the certified EHR technology is connected [that is, implemented and configured] in accordance with applicable standards and law and in a manner that will allow the healthcare provider to attest to having satisfied the conditions described in the information blocking attestation. In this respect, a healthcare provider’s obligations include communicating these requirements to health IT developers, implementers and other persons who are responsible for implementing and configuring the healthcare provider’s certified EHR technology. In addition, the healthcare provider should obtain adequate assurances from these persons to satisfy itself that its certified EHR technology was connected in accordance with applicable standards and law and in a manner that will enable the healthcare provider to demonstrate that it has not knowingly and willfully take action to limit or restrict the compatibility or interoperability of certified EHR technology.”

  1. Clinical Practice Improvement Activities (CPIA) (15%). The clinical improvement activities group represents a new category under MIPS and does not replace an existing CMS program. Performance is calculated based on the clinician’s attestation to having completed four clinical practice improvement activities. Bonus scores are available for clinical improvement activities that use certified electronic health record technology (CEHRT) and for reporting to public health and clinical data registries.

To achieve full credit in the CPIA category, clinicians must attest to: two 20-point high weighted activities; four 10-point medium-weighted activities; or another combination of high and medium weighted activities equaling 40 points or more. This is a reduction from CMS’ proposed rule.

The final rule does provide accommodations for small, rural, health professional shortage areas (HPSAs) and non-patient facing physicians, including a lower reporting threshold of two medium-weighted or one high-weighted improvement activities are required for small, rural, HPSA and non-patient facing physicians to receive full credit. Again, the final rule represents a reduction in requirements from CMS’ proposed rule.

Additionally, CMS finalized its proposal to only require a 90-day performance period for clinical practice improvement activities. The agency also expanded the definition of medical homes eligible for full Improvement Activity credit. Participants that have received recognition, certification or accreditation as a patient-centered medical home (PCMH), or comparable specialty practices, including those certified by a national, regional or state program, private payer or other body that administers PCMH accreditation and certifies 500 or more practices for PCMH accreditation or comparable specialty practice certification will automatically receive full credit in the CPIA performance category. This includes but is not limited to such programs as operated by NCQA, URAC, AAAHC and The Joint Commission.

Demonstrating CMS’ long-term goal to move provider communities into risk-sharing APMs, CMS is also providing full credit for MIPS APMs. APM Entities participating in the 2017 MIPS APMs, such as the forthcoming Medicare Shared-Savings Program Track 1+ ACO, receive a full score for the improvement activities category in 2017. The eligible MIPS APMs are subject to change in future years. Other APMs are eligible for at least half-credit. This is an increased opportunity from CMS’ proposal that APMs, regardless of the model, would only receive half credit in the CPIA category.

  1. Cost (0%). This category replaces the CMS value-based payment modifier program (VM) required under the Affordable Care Act. Cost measures are derived from claims data, and providers should make the mental shift that their claims process is a reporting vehicle. It always has been.  Performance under this category (referred to in the proposed rule as “resource utilization”) will be calculated based on claims-based cost measures specified by CMS. Clinicians are report data for this category through claims automatically and claims data allows it to be calculated independently by CMS. To address public comments, this category will be calculated for feedback only and will not be factored into the performance scores for the first payment year 2019.

While in performance year 2017 the cost performance category is reduced to zero percent of the composite performance score, in 2018, the cost performance category is weighted at 10 percent of the CPS. In performance years 2019 and beyond, the cost performance category will make up 30 percent of the composite performance score as required by MACRA. Although this category will not count in the composite performance score year one, CMS will calculate scores on the cost measures and provide them informationally to clinicians. It is important that practitioners use the 2017 feedback on cost to assess their position in resource utilization as compared to their peers.

A range of services provided to treat a patient condition or perform a procedure can be grouped into episodes of care.  Under the Affordable Care Act, CMS developed episode groupers that started to be applied in 2015 as algorithms across the Medicare population to measure episode-based outcomes.  Under the MACRA final rule, CMS finalized 10 episode based measures for 2017, and plans to finalize additional episode-based measures in future years.

Additionally, the agency included issues in the cost measures category that are considered problematic for the current VM. CMS also finalized the total per capita cost and Medicare Spending Per Beneficiary (MSPB) administrative claims cost measures. The minimum number of cases required to count the total cost measure is 20. The minimum case threshold for the MSPB measure is 35. CMS noted it is developing patient condition groups and patient relationship codes to assist with attribution beginning in 2018, as well as working for future years to refine its risk-adjustment methodologies.

Transition Period for MIPS Reporting

In the final rule, CMS moved forward with its previously announced “transitional policies” allowing physicians to “pick their pace” of participation for the first performance period under the MIPS program that begins January 1, 2017. The transition period allows Medicare physicians to choose one of four reporting paths outlined below. CMS establishes a “performance threshold” of three points, allowing clinicians participating in each option to avoid a negative payment adjustment. The first two paths allow for a potential positive adjustment. The four paths are as follows:

  • Report MIPS measures for either a 90 day or one-year period;
  • Report MIPS measures for less than a year but more than 90 days and report more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information performance category;
  • Report one measure in each MIPS category (besides resource use which is automatically reported through claims); or
  • Participate under an Advanced APM.

CMS notes that “if MIPS eligible clinicians choose to not report even one measure or activity [option 3], they will receive the full negative 4 percent adjustment.”

To get the 3 points you need only successfully report one measure for one category. This prevents any 2019 negative payment adjustments. A low bar to be sure, but you must interact with CMS in 2017 at least this much or you will receive a negative 4% adjustment in 2019.

Because CMS expects most physicians to at least report one measure, there will not be a lot of positive payment adjustments available under budget neutrality rule. This means most of the positive potential in MIPS is tied to the exceptional performance bonus pool. To access this pool, you must report at least 90 days preferably the whole year and earn at least 70 points.

While it appears possible to get there while ignoring one of the categories other than quality this is not advisable. Each category has some built in low hanging fruit (for example you get 50% of the points in Advancing Care Information (ACI) just for having 5 basic, required EHR capabilities) that should not be missed. Every organization should look into the three scored categories and plot their best way to get to at least seventy points; and, evaluate efficiency under the cost category for future positioning.

To start you on that path, improvement activities is the easiest category and as mentioned you get 50% of the points in ACI just for basic implementation of your EHR. That is 22.5 points right there in MIPS only and 35 points in MIPS with ACO, certainly a solid base to start from. If you have done PQRS before, if you have done meaningful use before and certainly if you are in an ACO or other “non-advanced” APM then consider how you can be in that exceptional performance pool right away. If those things are new to you then take full advantage of 2017 as a transition year.

Note: This is the first article in a series of three articles, to be featured each Monday for three weeks. 

October 17, 2016

Long-Awaited MACRA Rule Released

Macra

On Friday, October 14, 2016, the Department of Health and Human Services (HHS) finalized its rule on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program. MACRA replaces the Sustainable Growth Rate (SGR), and is set to equip clinicians with the tools and flexibility to provide high-quality, patient-centered care. The Obama Administration is building a system that delivers better care, where clinicians work together and have a full understanding of patient needs, Medicare pays for what works and “spends taxpayer money more wisely,” and patients are the center of care.

This final rule creates two pathways for payment, allowing physicians to pick the right pace for them to participate in the transition from a fee-for-service health care system to one that uses alternative payment models that reward quality of care over quantity of services.

According to the CMS Press Release,

The first path gives clinicians the opportunity to be paid more for better care and investments that support patients. It reduces existing requirements, while still emphasizing and rewarding quality care. In the first year, it also provides a flexible performance period, so that those who are ready can dive in immediately, but those who need more time can prepare for participation later in the year.

The second path helps clinicians go further by participating in organizations that get paid primarily for keeping people healthy. For example, they could be part of an Accountable Care Organization where clinicians come together to coordinate high-quality care for the patients they serve. When they get better health results and reduce costs for the care of their patients, the clinicians receive a portion of the savings.

Compared with the draft rule issued in April, the final rule eases the reporting burden for clinicians and triples the “low-volume” threshold dollar amount for mandating participation. Any provider who bills Medicare more than $30,000 in a year or provide care to at least 100 Medicare patients qualify for MACRA. Providers who are new to Medicare in 2017 are not required to participate next year. Providers who are ready to start collecting performance data can do so as early as January 1, 2017. However, CMS is offering providers the option to start anytime between January 1, 2017, and October 2, 2016. Data will be due to CMS by March 31, 2018, and will be used to determine payment adjustments beginning January 1, 2019.

Additionally, as noted at the American Academy of Ophthalmology (AAO) meeting in Chicago,  for the transition year of 2017, the reporting period has been shortened from a full year to ninety days, including for "Advancing Care Information" (Meaningful Use), for providers who want to be eligible to earn a bonus. The Quality Reporting burden has also been lowered from the proposed rule, from 80-90% to 50%.

The AAO meeting also discussed the importance of Clinical Practice Improvement as part of MIPS, including a wide variety of activities, such as: offering expanded evening and weekend hours; offers same- or next-day care when urgent care needed; using telehealth services; participating in Maintenance of Certification Part IV; and timely seeing new and follow-up Medicaid patients.  

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Slide recreated from AAO Meeting Slideshow

Transition Period for MIPS Reporting 

The final rule confirms that there will be “transitional policies,” allowing physicians to “pick their pace” of participation for the first performance period under the MIPS program, beginning January 1, 2017. The transition period allows Medicare physicians to choose one of four reporting paths outlined below. CMS has also established a “performance threshold” of three points, allowing clinicians participating in each option to avoid a negative payment adjustment. The first two paths allow for a potential positive adjustment.

The four paths are as follows: 1) report to MIPS for either a ninety day or one year period; 2) report to MIPS for less than a year but more than ninety days and report more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information performance category; 3) report one measure in each MIPS category (besides resource use which is automatically reported); or 4) participate in an Advanced APM.

Small Practice Considerations

Some of the key finalized policies for small practices include: a low volume threshold (as noted above to be "less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients."); and virtual groups, a MIPS reporting option where up to ten clinicians can combine reporting as one group (this will not be implemented in the transition year).

Resource Costs, Quality, and EHR

Please see the below-recreated slide from the AAO meeting for a brief synopsis of resource costs, quality, and EHR use, and how they would work in MIPS.

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CME Component

Unfortunately, Continuing Medical Education (CME) was not included as a Clinical Practice Improvement Activity, as many had hoped. For transition year 2017, CMS did not feel as though they had enough data to determine which CME’s should be included, and will consider comments and other submissions for activities in future years.

In the Final Rule, CME was acknowledged on page 735,

Comment: Many commenters suggested that CMS recognize continuing medical education (CME) activities provided by national recognized accreditors, completion of other state/local licensing requirements and providing free care to those in need as improvement activities, particularly those CME activities that involve assessment and improvement of patient outcomes or care quality, best practice dissemination and aid in the application of the “three aims” (better care; healthier people and communities; smarter spending), the National Quality Standards and the CMS Quality Strategy. The commenters also recommended that inclusion of surveys or interviewing clinicians to determine if they have applied lessons learned to their practice for at least 90 days following an activity should meet compliance requirements.

Response: We appreciate the suggestions that we grant improvement activities credit for activities already certified as CME activities, however, for the transition year of the MIPS program we do not have sufficient data to identify which CMEs could be included as activities. We will consider these recommendations for additional activities in future years as part of the nomination process.

The Making of the Rule

The rule has been in the making for months, and was formed in part by “a months-long listening tour with nearly 100,000 attendees and nearly 4,000 public comments.” According the HHS, a common theme was “the need for flexibility, simplicity, and support for small practices.”

Through its outreach, HHS crafted six strategic objectives to drive continued progress and improvement: (1) to improve beneficiary outcomes and engage patients through patient-centered Advanced APM and MIPS policies; (2) to enhance clinician experience through flexible and transparent program design and interactions with easy-to-use program tools; (3) to increase the availability and adoption of robust Advanced APMs; (4) to promote program understanding and maximize participation through customized communication, education, outreach and support that meet the needs of diversity of physician practices and patients, especially the unique needs of small practices; (5) to improve data and information sharing to provide accurate, timely, and actionable feedback to clinicians and other stakeholders; and (6) to ensure operational excellence in program implementation and ongoing development.

Industry Response

Industry reactions were varied, and as more organizations have time to review the rule, it is almost certain we will hear more feedback.

The American Medical Association issued a statement,

“By announcing the ‘Pick Your Pace’ approach to give physicians greater flexibility and increased options for participating in MACRA in 2017, HHS Secretary Burwell and Acting Administrator Slavitt took a significant step last month to address AMA concerns about the original proposal. The final rule includes additional steps to help small and rural practices by raising the low volume threshold exemption, and practices of all sizes will benefit from reduced MIPS reporting requirements.

Our initial review indicates that CMS has been responsive to many of the concerns raised by the AMA, and in the days ahead, the AMA will conduct a comprehensive review of the final rule to ensure that it promotes flexibility and innovation in the delivery of care to help meet the unique needs of all patients. With the flawed Sustainable Growth Rate (SGR) formula – and its annual threat of steep payment cuts – permanently eliminated, the new law gives many physicians the opportunity to be rewarded for the improvements they make to their practices and for delivering high-quality, high-value care to Medicare patients.

The American College of Rheumatology also issued a statement on the final rule, noting,

While we have not had time to review the final rule in its entirety, we are encouraged to see that the Centers for Medicare and Medicaid Services (CMS) is listening to the concerns raised by the American College of Rheumatology (ACR) regarding the need for reporting requirements that are simple, transparent, and tenable – especially for small and rural rheumatology practices.  Giving providers the flexibility of multiple options for participation in the first and second years will help ensure a smooth transition to the new payment system, and the continued delivery of quality care to Medicare patients living with rheumatic diseases. We also appreciated the broadening of exemptions from the program, which will help to protect small practices that already struggle to keep up with administrative burdens, along with the reduction in the number of required measures to be reported.

Conclusion

Sylvia M. Burwell, HHS Secretary, noted, “Today, we’re proud to put into action Congress’ bipartisan vision of a Medicare program that rewards clinicians for delivering quality care to their patients. Designed with input from thousands of clinicians and patients across the country, the new Quality Payment Program will strengthen our health care system for patients, clinicians and the American taxpayer.”

According to Andy Slavitt, the Acting Administrator of the Centers for Medicare & Medicaid Services (CMS), “It’s time to modernize the Medicare physician payment system to be more streamlined and effective at supporting high-quality patient care. To be successful, we must put patients and clinicians at the center of the Quality Payment Program. A critical feature of the program will be implementing these changes at a pace and with options that clinicians choose. Today’s policies are designed to get all eligible clinicians to participate in the program, so they are set up for successful care delivery as to program matures.”

This final rule incorporates some of the input HHS has received, but they are launching a new interactive website to help clinicians understand the program and aid in their successful participation. HHS will continue to host listening and learning sessions throughout the country, and will welcome feedback from patients, caregivers, clinicians, health care professionals, Congress, and others, on how to better achieve these goals.

HHS will continue to receive feedback on the final rule with comment period and will accept comments until sixty days after the rule’s release date. Comments may be submitted electronically here.  

In the coming weeks, once we have had time to fully review the rule, we will provide an in-depth analysis.In the interim, AAO recommends that you designate a physician to oversee planning; attend Medicare physician payment reform sessions at industry events; consider EHR adoption; and plan to attend post-rule finalization webinars on implementation. 

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