MIPS: All You Need to Know About It

Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.

Abhinav Shashank
Abhinav Shashank

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.

Decoding MIPS

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.

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The Dream of Learning Healthcare Systems: How We Think It’s Doable

Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.

Abhinav Shashank
Abhinav Shashank

The digitization of healthcare was a much-needed change brought after years of hard work and effort. One might wonder how could one justify the expenditure of $10 billion in a span of five years just on digitization. The problem intensifies when after several studies we find out that EHRs only reciprocate around 30 to 35 cents on a dollar and sometimes the figure dips to 15 cents.

Why have we digitized healthcare when the efforts required to get the desired result is still too much? I think we haven’t used the available technological aids appropriately. It is like driving a car at midnight and not knowing that you have headlights. You can have a clear view of your path, you can get to your destination fairly fast but can’t because you don’t know what is going to help you and in what way, your performance is reduced to a great extent to be able to achieve what you desire

Justified use of EHR could create the needed ecosystem

According to a report, 10 percent to 20 percent of savings are possible if a value-focused healthcare organizations capitalize on EHRs and interact with their patients better through technology. The amount that could be saved annually per bed is in between $10,000 and $20,000.

Meaningful Use

There are incentives for meaningful use of EHRs, but the truth is that the return through meaningful use incentives is somewhere around 15 or 20 cents on a dollars. There have been implementation, stabilization and optimization problems that have made it hard for healthcare organizations to extract the best out of EHRs. Practices will have to start using data as a source of innovation and come up with solutions that’ll not provide them better incentives but assist them in providing even better patient-centric care.

There are certain key points one can work on to make their healthcare ecosystem more efficient and patient-centric. Only judicious data usage from data disparate sources can help in so many ways, imagine what else is possible with advanced solutions. The integration of EHR with different disparate sources could be really beneficial in understanding the factors that drive value-based care. For instance, with the help of various data one can perform:

Population Health Management: With the help of data collected from different sources, impact at a population could be created and analyzed. Once you have the data of millions of patients, imagine all the things that are possible. Identification of at-risk patients, stratification of patients on the basis of various disease registries, better decision making, and a lot more. According to a study, due to disease management programs the cost of care were reduced by $136 per member per month because of reduction in admission rates by 29 percent.

Variations in Care Delivery: Efficient analytics and data management can help answer many questions. The medication process could be streamlined on the basis of past cases, and identified opportunities could be capitalized. Also, a thorough data-driven analytics could provide substantial insights on the performance of various facilities and how they differ when it comes to care delivery process.

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Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.

Abhinav Shashank
Abhinav Shashank

Currently, one of the most discussed topics in the healthcare industry is MACRA; a complex 962-page document that is supposed to redesign the entire healthcare industry. Know all about MACRA in six questions.

What is MACRA?

MACRA stands for Medicare Access and CHIP Reauthorization Act. It’ll repeal the current Sustainable Growth Rate (SGR) Formula and extend CHIP for two more years. Extending CHIP for two more years (in total four years now) will help tens of millions of kids in retaining their insurance.

SGR was introduced in 1997, as a method to curb the Medicare expenditures. Under SGR the physician payments were cut if the overall expenditure was above the benchmark. This payment cut system turned out to be a major reason for significant losses incurred by physicians. Fearing payment cuts, many physicians started denying services to Medicare beneficiaries.

In 2015, “Doc Fix” or MACRA was proposed, which as the name suggests fixed the unprecedented payment cuts. If it weren’t for “Doc Fix,” physicians would have faced 21 percent payment cuts in 2015.

The Notice for Proposed Rulemaking (NPRM) was issued on Apr. 27, 2016, and the final rule will come in November. MACRA’s full implementation will begin from 1st January 2017.

What will MACRA change/replace?

The idea behind implementing MACRA is to create something that works and is enduring. MACRA would bring changes through its unified framework called “Quality Payment Program,” which has been further divided into Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APMs).

All those who will be eligible for MIPS are called Eligible Clinicians. The term has expanded from “Eligible Provider” to “Eligible Clinicians.” It will include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and groups of such clinicians. This expansion has increased the number of people who will receive payments from Medicare. CMS might expand to Medicare part B after two years, which will include therapists, clinical social workers, clinical psychologists.

To keep health information flexible and user-centric, and bring all these changes with better care opportunities, MIPS will evaluate eligible clinicians on four measures namely: Quality Category to replace PQRS; resource use category to replace value-based modifier; Advanced Care Information (ACI) to replace meaningful use; Clinical Practice Improvement Activities (CPIA).

How will the four categories measure the performance?

Quality Category: Instead of reporting on nine measures, Clinicians will have the choice to pick speciality-specific measures. They can choose six measures to report to CMS that suits them the best reflecting their practice. But one of these measures must be an outcome measure or a high-priority measure and one must be a cross-cutting measure. Clinicians can also choose to report a specialty measure. Clinicians can report through Claims, Electronic Health Record (EHR), Clinical Registry, Qualified, Clinical Data Registry (QCDR) or Group practice reporting web portal.

For the year one, quality category will have 50 percent weight in the performance scoring procedure.

Resource Use: Clinicians are not required to report for this, CMS will calculate these measures based on claims and “availability of sufficient volume.” To account for the differences among specialties, CMS has proposed to add 41 episode-based measures. These episode groups have potential to provide more actionable insights on measure resource use than the various cost measures.

For the year one, resource use category will have 10 percent weight in the performance scoring procedure.

Advancing Care Information: Clinicians can report on the measures that suit their practices the best and reflect how the EHR technology is being used for daily needs, with particular emphasis on the interoperability and information exchange. The performance score does not use threshold and allows physicians to receive partial credits on measures.

For the year one, advancing care information category will have 25 percent weight in the performance scoring procedure.

Clinical Practice Improvement Activities: In this category, clinicians would be rewarded for activities that improves overall care delivery such as care coordination, beneficiary engagement, and patient safety. Clinicians can choose practices’ goal from a list of 90 plus activities. This category does not require a full year reporting. CPIA activities need to be performed for at least 90 days during the performance period.

For the year one, CPIA Category will have 15 percent weight in the performance scoring procedure.

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MACRA Anticipation: What a Delay Might Suggest

Guest post by Cheri Bankston, director of clinical advisory services, Curaspan.

Cheri Bankston
Cheri Bankston

As physicians across large and small practices struggle to prepare for the many payment reforms under the Medicare Access and CHIP Reauthorization Act (MACRA), Centers for Medicare and Medicaid Services’ (CMS) Acting Administrator Andy Slavitt recently suggested that MACRA could be delayed from its intended Jan. 1, 2017, start date. He also proposed that reporting requirements may be adjusted to ease the burdens on physicians. For example, data and measurements could be potentially submitted through an automated method.

MACRA is expected to greatly transform how Medicare pays for physicians and other clinicians who participate in the fee-for-service program. Under MACRA, payment changes will be split into a two-track system for Medicare reimbursement:

Merit-based Incentive Payment System (MIPS) is for providers who operate using fee-for-service reimbursements. This new program combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM), and the Medicare Electronic Health Record (EHR) incentive program into one single program for participants.

Alternate Payment Model (APM) is for physicians who take on a significant caseload of patients. New payment models enable health care providers to be paid by Medicare. From 2019 to 2024, CMS may pay some participating health care providers a lump sum incentive payment.

How This May Impact You

Working with physicians and understanding their business model is the core of transition management, especially for physicians who are providing care to patients in the Fee-for-Service program. With a deeper understanding, it is easier to foster a more collaborative and effective relationship. Hospitals have been paid a lump sum since the early ‘80s, but it is important to recognize that some physicians and physician groups do have patients enrolled in bundled payment models and others who are not. So how important is it for case managers to know how a physician is paid?  For a case manager to properly perform their job, they must know how the business of health care functions.

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Will Meaningful Use Flatline in 2016?

Guest post by Emily Tyson, director of emerging markets, Curaspan.

Emily Tyson
Emily Tyson

On the cusp of many important changes currently impacting major healthcare policies, Andy Slavitt, acting administrator at the Centers for Medicare & Medicaid Services (CMS), made a striking statement to the audience at the J.P. Morgan Health Care Conference earlier this year: “The meaningful use program as it has existed will now be effectively over and replaced with something better.” This remark created a stir within the healthcare community, which has long lamented the burdensome documentation and lackluster results most often associated with the Meaningful Use (MU) program, and left many providers and healthcare organizations wondering what that really meant for the future of reimbursement, along with healthcare technology and EHR regulation.

What do we know today?

Slavitt’s comments reference a transition – not a replacement – to a new payment program. The government is making a concerted effort to lessen the burden associated with its programs and push the industry toward value-based care. Last year Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA). The Act made three notable, high impact changes to Medicare reimbursement:

With the recent release of the proposed MACRA ruling, the Act and associated rules may take effect on January 1, 2017 and will offer healthcare providers two options for participating in quality programs: (1) Fee-for-service (FFS) combined with greater incentives through a new Merit-Based Incentive Payment System (MIPS), or (2) Alternative Payment Models (APMs). The current payment adjustments associated with the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VBPM), and MU will be phased out and replaced with a consolidated approach. MIPS will provide payment adjustments based on four weighted performance categories: Quality (30 percent), Resource Use (30 percent), Meaningful Use of Certified EHR Technology (25 percent), and Clinical Practice Improvement Activities (15 percent). APMs include reimbursement models, such as ACOs, patient centered medical homes, and bundled payments.

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