By Richard A. Royer, chief executive officer, Primaris.
Back in the day – the late 1960s, when social norms and the face of America was rapidly changing – a familiar public service announcement began preceding the nightly news cast. “It’s 10 p.m. Do you know where your children are?”
Today, as the healthcare landscape changes rapidly with a seismic shift from the fee-for-service payment model to value-based care models, there’s a similar but new clarion call for quality healthcare: “It’s 2018. Do you know where your data is?”
Compliance with the increasingly complex alphabet soup of quality reporting and reimbursement rules – indeed, the fuel for the engine driving value-based car – is strongly dependent on data. The promising benefits of the age of digital health, from electronic health records (EHRs) to wearable technology and other bells and whistles, will occur only as the result of accurate, reliable, actionable data. Providers and healthcare systems that master the data and then use it to improve quality of care for better population health and at less cost will benefit from financial incentives. Those who do not connect their data to quality improvement will suffer the consequences.
As for the alphabet soup? For starters, we’re as familiar now with these acronyms as we are with our own birth dates: MACRA (the Medicare Access and CHIP Reauthorization Act of 2015), which created the QPP (Quality Payment Program), which birthed MIPS (Merit-based Incentive Payment System).
The colorful acronyms are deeply rooted in data. As a result, understanding the data life cycle of quality reporting for MACRA and MIPS, along with myriad registries, core measures, and others, is crucial for both compliance and optimal reimbursement. There is a lot at stake. For example, the Hospital Readmissions Reduction Program (HRRP) is an example of a program that has changed how hospitals manage their patients. For the 2017 fiscal year, around half of the hospitals in the United States were dinged with readmission penalties. Those penalties resulted in hospitals losing an estimated $528 million for fiscal year 2017.
The key to achieving new financial incentives (with red-ink consequences increasingly in play) is data that is reliable, accurate and actionable. Now, more than ever, it is crucial to understand the data life cycle and how it affects healthcare organizations. The list below varies slightly in order and emphasis compared with other data life cycle charts.
Find the data
Capture the data
Normalize the data
Aggregate the data
Report the data
Understand the data
Act upon the data
One additional stage, which is a combination of several, is secure, manage and maintain the data.
Find the data. Where is it located? Paper charts? Electronic health records (EHRs)? Claims systems? Revenue cycle systems? And how many different EHRs are used by providers — from radiology to labs to primary care or specialists’ offices to others providing care? This step is even more crucial now as providers locate the sources of data required for quality and other reporting.
Capture the data. Some data will be available electronically, some can be acquired electronically, but some will require manual abstraction. If a provider, health system or accountable care organization (ACO) outsources that important work, it is imperative that the abstraction partner understand how to get into each EHR or paper-recording system.
And there is structured and unstructured data. A structured item in the EHR like a check box or treatment/diagnosis code can be captured electronically, but a qualitative clinician note must be abstracted manually. A patient presenting with frequent headaches will have details noted on a chart that might be digitally extracted, but the clinician’s note, “Patient was tense because of job situation,” requires manual retrieval.
Normalize the data. Normalization ensures the data can be more than a number or a note but meaningful data that can form the basis for action. One simple example of normalizing data is reconciling formats of the data. For example, a reconciling a form that lists patients’ last names first with a chart that lists the patients’ first name first. Are we abstracting data for “Doe, John O.” or “John O. Doe?” Different EHR and other systems will have different ways of recording that information.
Normalization ensures that information is used in the same way. The accuracy and reliability that results from normalization is of paramount importance. Normalization makes the information unambiguous.
Aggregate the data. This step is crucial for value-based care because it consolidates the data from individual patients to groups or pools of patients. For example, if there is a pool of 100,000 lives, we can list ages, diagnosis, tests, clinical protocols and outcomes for each patient. Aggregating the data is necessary before healthcare providers can analyze the overall impact and performance of the whole pool.
If a healthcare organization has quality and cost responsibilities for a pool of patients, they must be able to closely identify the patients that will affect the patient pool’s risks. Aggregation and analyzing provides that opportunity.
Now that at least 96 percent of hospitals have implemented an electronic health record (EHR) most organizations are facing the reality that the technology has not truly helped them achieve their clinical quality and financial goals.
Electronic, enterprise-wide data is essential to manage highly complex, high-cost patients that providers care for every day. However, EHRs typically do not deliver the insight or tools providers need to manage these high-risk or the near high-risk patients when they are not in the hospital.
If the EHR does offer such population health management (PHM) capabilities, it typically requires an excessive amount of manual data access and manipulation, leading to even greater costs. That means patients who require more intensive care support at home, or who could highly benefit from timely and targeted intervention, face care delays simply due to lack of provider resources.
The Medicare Access and CHIP Re-authorization Act (MACRA) of 2015’s Merit-based Payment System (MIPS) brings this challenge into clear focus, highlighting how individual providers and healthcare organizations need automated patient interventions to efficiently deliver care throughout the continuum. Automation and more precise outreach not only helps care managers work more efficiently, but it also forges stronger engagement between providers and patients for long-term clinical quality and financial gains.
Gaps In Technology Capabilities
According to a recent survey conducted by our company of more than 800 healthcare professionals, most organizations seem to understand how crucial PHM technology is to MIPS success. Few professionals, however, are apparently taking full advantage of available opportunities to better their organization. For example, 80 percent of healthcare professionals reported they have the necessary technology for PHM or to manage MIPS performance, but only 30 percent reported they are able to automate interventions across populations.
Automating interventions is becoming a critical piece of PHM to reduce the significant resources required to analyze data and conduct outreach. Currently, a care manager can spend approximately 40 percent of their time just searching for patient data, while PCMHs require 59 percent more staff per provider to fulfill care management requirements.
Streamlining the data aggregation combined with technology that continuously analyzes data and initiates communication with the patient will eliminate the manual efforts that burden the care managers and providers assigned to PHM today. More importantly, such technology delivers consistency and predictability for patient interventions, an essential component to modify patient behavior and yield successful outcomes.
Yielding More Precise Guidance
Guidance to deliver precise and effective interventions and outreach is possible, yet very limited if confined to single-practice EHR data alone. By only utilizing a provider’s own patient data, organizations will be limited to a partial view of a designated population and the accuracy of patient care-gaps will be substantially degraded. Numerous other data sets, including EHR data captured from unaffiliated providers as well as non-clinical sources, must be included for more accurate outcome predictions and targeted interventions.
For example, by including data from community providers that co-manage patients, data from regional and national HIEs (Carequality/Commonwell), as well as other key data points concerning social determinants of health will yield much more accurate risk scoring and prioritize patients for interventions. Information such as patients’ nearby relatives, home address, and car ownership can change frequently and be incorporated into sophisticated algorithms that help predict behaviors and outcomes.
A care manager can then use those analytic capabilities to stratify these patients into risk categories for more frequent interventions that can be initiated automatically based on pre-defined rules. Patients at varying risk levels for acquiring Type-2 diabetes, for instance, may need different levels of support from the provider to help them make the healthcare and lifestyle choices to better manage their health and improve their outcomes.
Guest post by Justin Rockman, vice president of sales and business development, Surgimate.
Since the late ’80s, the inflexible and cumbersome Health Level 7 (HL7) protocol has been the standard form of sending messages between healthcare applications. However, HL7 integration is timely to implement, technically limited and costly. It is not uncommon for a medical practice to face upwards of $10,000 in expenditure for one simple message.
Application programming interfaces (APIs) have recently become a fashionable alternative. The term API sounds complicated, but it’s really just a way in which software applications (like your EHR) can talk to other systems, and exchange large amounts of data rapidly and securely. In short – they support better, faster, cheaper interoperability.
In addition to transmitting data between systems, APIs offer the ability to plug in chunks of functionality to another system, in a clean and predictable manner. Instantaneous and seamless interaction between systems is the leanest and trendiest way to design software in 2018. New applications should not “reinvent the functionality wheel” but provide unique integratable services.
As the EHR market estimated to reach $28 billion in 2016, it is no surprise that tech titans like Amazon, and Apple are looking for ways to get a slice of the pie. With top of the line products sure to come from those companies and others, here are 4 reasons why healthcare IT vendors must offer their clients a way to integrate using APIs.
Physicians need easy access to data supported by EHRs, but hate the time it takes to manually enter patient information. It’s no wonder – doctors typically spend 50 percent of their day working with an EHR. If a physician isn’t happy with the usability or efficiency of their system, they’ll drop it and choose another. While the annual EHR adoption rate among providers is 67 percent, the EHR vendor switch rate is about 15 percent.
APIs offer cheaper and deeper integration options. For EHR vendors to provide better value for their customers they must embrace the API and ditch the expensive, outdated and rigid HL7 protocol.
Using an EHR that is integrated with other programs will make switching systems even more inconvenient. EHR vendors who give customers the additional functionality offered by their partners will be rewarded with brand loyalty, and lower churn.
An Additional Revenue Stream
Innovative EHR vendors are partnering with upstart technology companies to generate additional revenue. Greenway and athenahealth advertise an array of solutions in their marketplace, and provide partners with utilization of their APIs. In exchange, they receive monthly or recurring payment for each license sold. Since most practices already have purchased an EHR, finding new revenue streams is crucial for a company’s growth.
The healthcare API market is predicted to exceed $200 million in the next few years. Former engineers from Epic Systems saw the industry’s need for interoperability and raised $15 million in venture capital to found Redox – a company solely focussed on building bridges between healthcare applications. Creating platforms that deliver easy integrations at reasonable costs will greatly benefit the healthcare industry.
As a provider, you probably have been living with meaningful use in the last many years, and now, MACRA (Medicare Access and CHIP Reauthorization Act), which combines parts of the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and the Medicare electronic health record incentive program into the Merit-based Incentive Payment System, or MIPS.
What really is the part of MIPS that matters, for this year and next, anyway? 2017 is the transition year of MACRA, but you need to report something (for various measures) or lose 4 percent Medicare payment adjustment in 2019. If you make a partial-year (90 consecutive days) report by October 1, depending on how you fare against the CMS’ annual performance benchmark, there may even be a chance to get a positive Medicare payment adjustment. In general, a provider will report in the four MIPS performance categories: quality (weighted 60 percent of total in 2017), cost (not weighted in 2017), improvement activities (loosely “care coordination,” 15 percent ), and Advancing Care Information (“EHR use”, 25 percent). Then in 2018 and 2019, with improvement activities and advancing care information remain the same, the quality category will be weighted 50 percent and 30 percent respectively, giving way to cost (10 percent and 30 percent in each of 2018 and 2019).
This sounds like high school all over again – the authority sets the goals that arguably lead you to learn the materials that matter, and grade you on them. If you score well in the four MIPS performance categories, chances are your operations are running quite well. But deep down, perhaps your priorities are simply to provide great patient care, and get compensated for your expertise and services. Then this high-school approach of grading your services, and you – yes, your performance score will be available publicly on the Physician Compare website – becomes a distraction that few providers like to deal with.
So how will you live with this reality? One approach is to actually embrace and integrate MIPS into your operations! Then all MIPS requirements don’t just become some checkbox items you try to complete, but actually a tool to improve your operations. Here are three ways to “take advantage” of MIPS as a guideline to help you thrive:
Embrace a Data-driven Approach
Run your operations based on data. Many EHRs provide at least some basic level of reports that allow you to keep a finger on the pulse of your operations. Make the relevant reports accessible to your team. For the metrics that are relevant to your operations, dedicate a periodic review session to keep everyone abreast of the numbers, and your targets. To leverage MIPS to improve your bottom line, you will want at least some level of visibility through these reports how working those numbers will bring more revenues and/or patient satisfaction, or lower cost. Then it will become clear MIPS can benefit your operations.
Integrate MIPS Efforts Into Your Workflow
Then the team is to identify and make sure they engage the patients that fall in the categories of the reporting metrics to complete the required actions. While in a smaller clinic, some way of patient tracking; e.g. shared call list, may work fine. If your targets involve hundreds or even thousands of patients over a period of time, an automated, smart workflow approach will serve the situation much better. The smart workflow approach is part of the turnkey service my team at LucidAct built after experiencing such patient-care collaboration problems at San Francisco General Hospital in a consulting engagement. Smart workflows keep track of what have been done by whom for a patient, and conditionally activates the next task(s). It can also automate tasks such as calling a patient. Such care-action details in conjunction with the reports above will reveal how the team’s efforts chisel (or not) off the workloads, and improve the bottom line. Having them available in the review sessions ties the effectiveness of the team’s efforts back to the MIPS targets, allowing you to make adjustments to your operations as needed.
People perform better if they have a vested interest in the outcome of a given situation. Employees who are given an ownership stake in their company historically perform better and enjoy a higher degree of satisfaction from their respective jobs than do their non-stake-holding counterparts.
Recent research has shown that a similar premise holds true in healthcare. Patients who are engaged in their own care generally have better outcomes and enjoy higher satisfaction in the care they received. According to the American Journal of Managed Care, “A growing body of research has established the benefits of patient activation, which is defined as the knowledge, skills, confidence and motivation to make effective decisions and take action to maintain or improve one’s health.”
According to a 2016 New England Journal of Medicine survey of 340 U.S. healthcare executives, clinician leaders and clinicians at organizations directly involved in healthcare delivery, 42 percent of respondents indicated that less than a quarter of their patients were highly engaged, and more than 70 percent reported having less than half of their patients highly engaged. And to underscore the importance of this result, 47 percent of those surveyed revealed that low patient engagement was the biggest challenge they faced in improving patient health outcomes.
This is not only true for hospitals, but also for specialty care practices. In these environments, it is imperative that practices understand the very specific needs and behavior of their patients, so they can determine how best to conduct effective outreach that will increase patient engagement and patient portal utilization.
Importance of User Interface
A results-driven (or high performance) patient engagement platform helps turn patients into partners in their own healthcare. In addition, a proper next-generation solution supports compliance with MIPS (Merit-based Incentive Payment System), a component of MACRA (Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act), and with meaningful use (MU), by providing patients the ability to view, download or share their medical record. Payback is many fold: In addition to helping providers meet regulations through a user-friendly interface, patients are freeing up time for caregivers to spend with them by self-populating data fields that would previously have been handled by caregivers. This streamlining of the patient intake process delivers significant time and cost savings to the practice.
Equally important is a patient portal that helps patients remain engaged while enabling practices to comply with government requirements under meaningful use and the MACRA regulations, thereby increasing Medicare payments and minimizing takebacks. It is imperative that the patient portal seamlessly integrates with the organization’s electronic health record (EHR), health information exchange (HIE) and accountable care organization (ACO), if the practice is participating in one. Ideally, the solution should be able to adapt to any healthcare facility’s IT system—not the other way around. Patient engagement initiatives should permeate the practice’s entire healthcare ecosystem.
Engaging for ACOs, Triple Aim
Originally a concept born of healthcare reform, accountable care organizations (ACOs) were initially little more than a way of redefining the shared responsibility of doctors and hospital staff to coordinate care, improve quality and lower costs. It did not, however, specifically examine the role of the patient. That all changed when the Affordable Care Act (ACA) came along and the ACOs were officially codified into law. Furthermore, the law also recognized that ACOs could not succeed without patient engagement. According to the IHI, “quality,” in this case, is defined from the perspective of an individual member of a given population, hence the logical focus on patient-centric care and patient engagement.
Healthcare providers continue to face new and growing challenges across the marketplace. From the release of the MACRA final rule to the consumerization of healthcare, there is a lot to balance and manage. It can be hard to keep up while also trying to provide quality care and get paid. As a result, providers continue to look at alternate payment models according to a new survey from Kareo and the American Academy of Private Physicians (AAPP).
The survey shows that 25 percent of practices are now using some kind of direct pay, concierge, or other membership model in their practice. This number stayed steady from the 2015 study to the 2016 study. Most do not have all their patients on one of these models, but 30 percent have completely transitioned their practice. The results show that many practices are testing these models while still offering patient other options like traditional fee-for-service. This may suggest that physicians want to see how successful the models before shifting their entire practice.
Another 35 percent of providers say they are considering a change in part or in whole to an alternate model like direct pay or concierge. The reasons are consistent with the results from the 2015 survey. The top reason cited was to separate from the insurance payer system, closely followed by spending more time with patients and improving work/life balance.
The survey indicates that those physicians who do switch see improvements in those areas. Physicians using direct pay, concierge or another membership model spend more time with patients, see fewer patients each day at longer visits, and work fewer hours than their fee-for-service counterparts.
This infographic shows the details of both the differences and the similarities when physicians use private pay models versus fee-for-service models.
Guest post by Richard Loomis, chief medical officer and VP of informatics, Practice Fusion.
In 2016 the healthcare industry made a number of meaningful strides on the move to value-based care, culminating in October with CMS issuing the final rule for the Quality Payment Program (QPP). As the largest program of its kind, the QPP will replace existing programs such as meaningful use and PQRS and fundamentally change the way providers receive payment for patients with Medicare Part B coverage.
In 2017, this focus on value will begin to shift to the vast value found in restoring the provider-patient relationship that drives individualized care and best outcomes. Healthcare isn’t ultimately about quality programs, big data or population health management — it’s about improving our shared human experience and to live happier, longer, more fulfilling lives. The healthcare industry will start restoring this humanity by unwinding the complexity of care delivery and supporting individualized care through a number of new and exciting ways in the new year. Below are five themes we’re predicting to see in 2017:
The year of EHR usability: EHR usability will become a critical success factor for providers as the burden of quality reporting continues to grow in an increasingly fee-for-value world. Practices already spend $40,000 per doctor per year — $15.4 billion nationwide — on collecting and reporting information about their care to Medicare, payers and others. These costs will increase in 2017 and disproportionately affect small practices. It will be financially impossible to practice medicine without a user-friendly EHR. Given this emphasis in usability, more EHRs will turn to offering cloud-based solutions to stay relevant and cost-effective.
Real world evidence comes of age: Real world evidence (RWE) will increasingly be used to support FDA approval for marketing new drugs, leading to further investigation through one or more RWE studies. Although randomized clinical trials continue to be the gold standard for establishing efficacy and safety, they may not reflect typical patient care or day-to-day experiences. RWE studies can include larger sample sizes and a greater breadth of patient demographics and clinical circumstances, which can help supplement the data derived from clinical trials. The FDA has already signaled their interest in RWE, and in 2017 we will begin to see it come to fruition.
Small practices recognized for their oversized role: Small independent practices are a cornerstone of the healthcare ecosystem: Independent solo and small practices are shown to have a lower average cost per patient, with fewer preventable hospital admissions, and a lower readmission rate among their patient populations. For CMS to drive additional value through the QPP, they will start to recognize and support small practices in 2017.
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
P.J. Carter in a blog explained how the lack of interoperability resulted in extreme physical pain to his father who had to go into an eye surgery for the repair of a detached retina. His father was told by his eye specialist that and an urgent operation had to carried out. The operation began, but doctors could not access the past medical record of his father. Since doctors were unaware of the medical history, they had to carry out a painful operation of the eye without anesthesia! His father was awake the whole time and had to endure the pain.
Healthcare industry is lagging the most when it comes to advancements. There have been innovations, but equal implementation has been lacking. The cost of care has risen to over $10,000 per person in the US because there is huge expenditure on various digital infrastructures, but not for the meaningful use of them.
Interoperability and Its Types
Interoperability is a term that has no single definition. In broad terms, interoperability is the ability of systems and devices to exchange vital information and interpret it. For healthcare, interoperability is the ability of computer systems in hospitals to communicate, share critical information and put it to use to achieve quality health services delivery.
There are three levels of health information technology interoperability:
1) Foundational: This is the most basic level of interoperability. In this tier, the health information systems are equipped to transmit and receive data, but the HIT system on the receiving end may not be decked up to interpret that information.
2) Structural: The middle level, structural interoperability defines how the data exchange will take place. Structural interoperability is all about how data should be presented in pre-described message standards. This tier is critical to interoperability as it allows a uniform movement of health information from one system to another, avoiding the alteration and promoting the security of data.
3) Semantic: Semantic interoperability is the third tier, and at the top of the communications pyramid. The highest level of interoperability, it provides the systems the ability to exchange data and make use of the information. The message is received in an encoded format and which is later normalized. This normalization of data pushes health IT systems to close in on the technology gaps and create a common platform for secure, uninterrupted machine-to-machine communication.
Scope of Interoperability
There has been a dramatic increase in population, and with that came the need to manage population health. The amount of information increased exponentially with the use of EMRs. They helped in storing the increasing information, but sharing was still doubtful.
In 2005, only about 30 percent of the entire group of office-based physicians and hospitals used basic EHRs which increased to 75 percent for hospitals by the end of 2011. The state of Indiana now connects more than 10 million patients across 80 hospitals, and about 18,000 physicians use this data.
How long until 100 percent interoperability?
It has been accepted that health care, as a single entity, faces challenges in the exchange of information. Even the pioneer EHR vendors admit that although they have some complex connections established, not all of them were successful. According to a report, less than half the providers were satisfied with the way their information exchange was taking place. Stakeholders involved have always been concerned that EHRs, even the ones for Meaningful Use 2, are unable to share data effectively.
In the latest ONC report, it was mentioned that if all the providers were to come down to a common consensus, there happen to be two barriers on the road to complete interoperability. One, discord on how data should be transmitted. Second, a lack of proper infrastructure which is equipped enough to transmit data nationwide. It is very critical that the technology being used is updated and standardized to ease the flow of patients’ vital information to avoid any probable mishap.
Persisting Problems in the Path of Interoperability
1) Inadequate Standards
More often than not even after collecting patients’ data, it cannot be passed on to the members of the healthcare community because of lack of the appropriate standards. Most of the times it happens that two systems trying to exchange data are using a different version of standards. This is because there are varying standards and numerous version for which providers aren’t equipped.
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
The picture of healthcare industry is changing rapidly and still continues to evolve, with technology playing a huge role and the other factor being the government. With a new administration in the White House, the Senate and the House of Representatives, there ought to be numerous changes in healthcare, modifying ACA being one of them. Come January, what will be the effect of the new policies of the GOP have on health IT?
In his victory speech, President-elect Donald Trump emphasized on restoring and improving infrastructure and calling healthcare and hospitals an integral part of that plan. The Trump administration even after a session is less likely to remove its focus from IT investments and developments in healthcare; the Republicans believe in leveraging technology and healthcare experts are confident that healthcare-related initiatives like Cancer Moonshot and Precision Medicine Initiative will continue to speed up.
According to a recent ONC report, 96 percent of hospitals and 78 percent of physician offices were using certified EHRs to maintain patient data.
With digital initiatives developing, the hassle in prescribing medicines, scheduling appointments and access to vital records have reduced.
Making the consumer the center of the healthcare system and empowering them has been favorable. According to a survey conducted on 13,000 users, it was revealed that 28% changed their providers based on data made available online – implying that patients wish to be a part of the decision making.
A substantial number of digital health startups have emerged, and their revenue in 2015 was over $4.5 billion – and continues to grow.
Health IT developments to look ahead
Although Donald Trump has his healthcare plan for the country under the covers, some significant advancements are coming our way and following is a slice of what’s coming:
Value-Based Care: One of the most important thing Trump has asserted on in his plan is that he wants to ensure that “no one slips through the cracks simply because they cannot afford insurance.” With U.S. healthcare accounting for 17.1% of the entire nation’s GDP, it’s important to back this transition towards value-based care.
Advancements in Interoperability: In ONC’s latest report to Congress, interoperability was tagged as an essential priority. There are still a lot of factors getting in the way of free flow of data between providers, topped with the inability on patients’ part to access their medical information freely. There are many initiatives on the block: the Sequoia Project’s Care Quality programs, the development of FHIR standards that will be backed by Trump and will pan out impressively.
Banking on Digitization: In sustaining the momentum of this transformation, digitization would be the cornerstone. The use of data analytics, machine learning, patient-centered technology developments and the Internet of Things will unleash their forces under Trump administration and fuel further developments and investments.
Changing the Dynamics of the Marketplace: Donald Trump plans to allow insurance companies to sell their plans across the state lines which may result in an increase in competition and making their plans value-focused. Allowing a free market for drug import could also prove critical in reducing the cost of healthcare: he said in one of his speeches that Medicare could save as much as $300 billion every year, if drug prices were negotiated.
Health IT will stay because the need is to continue to work on making healthcare industry interoperable. Major value-focused programs on healthcare by federal government, such as MACRA won’t see significant changes. However, there is a possibility that the Quality Payment Program could be “enhanced.”
Guest post by Richard Loomis, MD, chief medical officer and VP of informatics, Practice Fusion.
If you bill Medicare, changes are coming in 2017 that may affect your reimbursements. Existing programs such as the electronic health record (EHR) Incentive Program (meaningful use) and the Physician Quality Reporting System (PQRS) are being replaced by a new payment system called the Quality Payment Program (QPP), which is a complex, multi-track program that will adjust payments from -9 percent to +37 percent by 2022. The Centers for Medicare & Medicaid Services (CMS) recently released the final rule that will implement the QPP as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
While the 2,300-page final rule outlining the new program is complex, successful participation in 2017 doesn’t have to be. Here are some tips on how to participate in the QPP starting January 1, 2017 to minimize the risk of any negative adjustment to your Medicare Part B payments beginning in 2019.
Step 1: Check if you qualify to participate
CMS has expanded the range of clinicians able to participate in the QPP compared to Meaningful Use (MU). Eligible clinicians now include physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. However, you’re excluded from participating in 2017 if:
You’re a clinician enrolling in Medicare for the first time. You’re exempt from reporting on measures and activities for the Merit-Based Incentive Payment System (MIPS) until the 2018 performance year.
Your practice meets the low-volume threshold. This means your Medicare Part B allowed charges ? $30,000 OR you see ? 100 patients covered by Medicare Part B during the 2017 calendar year.
Step 2: Choose your participation track
Although the QPP will begin January 1, 2017, there will be a ramp-up period with less financial risk for eligible clinicians in at least the first two years of the program. CMS designated 2017 as a transition year to help providers get started in either of the two participation tracks: MIPS or the Advanced Alternative Payment Models (Advanced APMs).
MIPS streamlines current Medicare value and quality program measures — PQRS, Value Modifier (VM) Program and MU — into a single MIPS composite performance score that will be used to adjust payments. All eligible clinicians who are not participating in an Advanced APM should report under MIPS in 2017. Conversely, you’re not required to participate in MIPS if you’re participating in an eligible Advanced APM, as described below. Some APMs, by virtue of their structure, are not considered Advanced APMs by CMS. If you participate in an APM that doesn’t qualify as an Advanced APM, it will increase your favorable scoring under the MIPS participation track.
APMs are new approaches to paying for medical care through Medicare that provide incentive payments to support high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. The main difference between the MIPS and Advanced APM programs are that Advanced APMs require practices to take on more financial and technological risks.
They receive a five percent lump sum bonus payments for the years 2019-2024.
They will receive a higher fee schedule update for 2026 and onward.
It’s important to note that if you stop participating in an Advanced APM during 2017, you should make sure you’ve seen enough patients or received enough payments through an Advanced APM to qualify for the five percent bonus. If you haven’t met these thresholds, you may need to participate in MIPS reporting to avoid a negative payment adjustment.