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.
Guest post Ken Perez, vice president of healthcare policy, Omnicell.
On October 14, the Centers for Medicare & Medicaid Services (CMS) released a 2,171-page final rule for the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS had issued a proposed rule on April 27 and in the intervening period, more than 100,000 physicians and other stakeholders attended outreach sessions and CMS received more than 4,000 public comments on the proposed rule, with many of the expressed concerns pertaining to the start date for MACRA’s first performance period.
MACRA’s Quality Payment Program replaces the unpopular sustainable growth rate formula and defines how physicians in physician practices—not hospitals—will be reimbursed by Medicare. It features two alternative, interrelated pathways: the Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). MIPS is designed for providers in traditional fee-for-service Medicare, while the advanced APMs are for providers who are participating in specific value-based care models, such as accountable care organizations (ACOs).
Small physician practices with less than $30,000 in Medicare charges or that see fewer than 100 Medicare patients per year are exempt from MIPS. According to an analysis by the American Medical Association, 30 percent of physicians are below one or both of these thresholds. In addition, providers new to Medicare in 2017 are also exempt (though just for the first year).
The proposed rule specified Jan. 1, 2017, as the start date for the first performance period under MIPS, which would drive calendar year 2019 payment based on performance in 2017 across the four MIPS categories: Quality, Advancing Care Information, Clinical Practice Improvement Activities, and Cost/Resource Use. The final rule allows providers to start collecting performance data anytime between Jan. 1 and Oct. 2, 2017, with data due to CMS by Mar. 31, 2018.
Under MIPS, physicians can earn in 2019 a payment adjustment that is neutral, up to 4 percent positive, or up to 4 percent negative, depending on their level of participation, the amount of data submitted, and the length of the performance period reported. The adjustment increases to plus or minus 5 percent in 2020, plus or minus 7 percent in 2021, and plus or minus 9 percent in 2022. CMS projects that 592,000 to 642,000 clinicians will submit data for MIPS during the first performance year.
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
A new complex rule is about to change the entire US healthcare industry. It will replace the Sustainable Growth Rate (SGR) and streamline the three programs. The NPRM for MACRA was passed in 2015 and after the comments and feedbacks from numerous healthcare experts, the final rule with comment period has been released by CMS.
In the final rule, CMS has responded to more than 4,000 comments in a document which is more than 2,300 pages long. Some of these comments have been implemented in the law. As a result of this feedback friendly approach, substantial changes have been made.
The New MACRA after changes
The law aims to bring in unified policies that will add greater value to the healthcare system through the new Quality Payment Program (QPP). The program rewards for value in two ways:
Merit-based Incentive Payment System (MIPS)
Advanced Alternate Payment Models (Advanced APMs)
Chance to adapt
To help the physicians get used to the program CMS has declared the first year — 2017 — as “transition” year. There will be four options available to physicians in the transition year:
Clinicians can choose to report one measure in the quality performance category; one activity in CPIA or report the measures in ACI to avoid the negative adjustments. Alternatively, if they choose to report none, they will receive negative adjustments of 4 percent.
Report for minimum 90 days more than one quality measure, more than one CPIA or more than the required ACI to avoid negative adjustments and qualify for possible MIPS positive adjustments.
Ideally, report for a year or more than 90 days and maximize the chances to receive higher positive adjustments.
Participate in the Advanced APMs program, and if can to see ‘sufficient’ portion of the Medicare Patients, they will be able to qualify for 5 percent bonus incentive payment to be paid out in the year 2019.
Merit-based Incentive Payment System
Under this program, eligible clinicians will get payment adjustments based on the quality, cost and other measures related to care. This program will see the “sunset” of three existing programs namely:
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
According to a survey almost 50 percent of the physicians do not understand MACRA. With less than five months to full implementation of MACRA, are we ready to embrace one of the most elaborate laws of US? And, most importantly, will it produce the needed positive outcomes? The program is expected to improve the current standards, sort the most persistent problems and create opportunities to rework and revise Medicare. How will all this happen?
With MACRA in place, there won’t be two digit payment cuts like in the current Sustainable Growth Rate (SGR) formula. Besides enhancing the use of electronic health records, MACRA is expected to increase the relevance of Medicare to the real world and reduce the administrative burden from physicians’ shoulders.
MIPS stands for Merit-Based Incentive Payment System. It will streamline the three independent programs Physician Quality Reporting System (PQRS), meaningful use, and value-based modifier to ease the burden on the clinicians. The three components in MIPS will replace these programs. Besides this, one more component will be there to bring improvements in practice. Namely following components will be there in MIPS:
1.) Quality: This component will replace the Physician Quality Reporting System (PQRS). Under MIPS the methods of reporting and the various quality measures have been adopted from the old programs PQRS and VBM. There are some changes in the reporting methods and for the registry, EHR, and Qualified Clinical Data Registry (QCDR) reporting methods, a clinician can select minimum six measures which could be a combination of any quality domain. If the clinician faces patients, then he has to select in such a way that one of these measures is cross-cutting measure (cross-domain-cutting), and one is outcome-based measure. If there is no outcome-based measure, then a high priority measure has to be selected.
Besides these six measures, CMS will calculate two or three more measures depending on the size of the group of physicians. For instance, if there is an individual physician or a group less than 10 then two measures and if more than that then three measures. Additionally, for QCDR and registry reporting methods, the “data completeness” standard has been changed. The number of patients to be reported within a measure denominator has been raised from 50 percent to 90 percent.
2.) Advancing Care Information: According to MIPS the meaningful use program will see a lot of changes. Currently, the meaningful use program is everything-or-nothing; i.e., if one clinician achieves a performance rate of 20 percent on meaningful use measures and another achieves 90 percent then they both get rewards in a similar fashion. However, under ACI the latter one gets 10 out of 10 points, and the former gets three points.
More than 100 ACI performance points have been defined out of which base 50 are base points given for reporting either “yes” or a non-zero numerator. The performance scores are up to 80 points based on the performance on eight measures. Rest bonus points are awarded for reporting any other public health registry.