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.
By Matthew Fusan, director of customer experience, SA Ignite.
Although the Quality Payment Program (QPP) has been in effect for a year, there continues to be a lot of change in the program as CMS continues to evolve. The new year creates an ideal time to reflect back on what changes we have experienced to date as well as look forward and examine what could happen in 2018 and beyond.
2017: A Year of Regulatory Confusion
As the QPP rolled out, confusion still reigned supreme at both the CMS and HHS levels:
In 2017, CMS ramped up promotion and education for the QPP. Although these efforts have been more aggressive than previous programs, industry studies like the 5th Annual Health IT Industry Outlook Survey and the KPMG-AMA Survey show that clinicians are struggling to understand the program and what they need to do to be successful. In fact, many expect their employer to provide the information and solutions to manage and are not seeking to proactively educate themselves on requirements and improvement strategies.
While clinicians continue to experience confusion, the Department of Health and Human Services (HHS) has not done much to help clarify. CMS Administrator Seema Verma has continued to support the move away from fee-for-service and toward fee-for-value, but has also cancelled two mandatory bundled payment models – the Episode Payment Models and the Cardiac Rehabilitation Incentive Payment Model – and has also removed the mandatory requirement for the Comprehensive Care for Joint Replacement Model.
Although some bundled payment programs have been cut/reduced, the Centers for Medicare and Medicaid Innovation (CMMI) has put out a request for information (RFI) to gather input on patient-centered care and test market-driven reforms. The intent of the initiative is to empower beneficiaries as consumers, provide price transparency, and increase choices and competition. The RFI demonstrates that all models/programs will be watched closely and are subject to change.
2018: More Focus, More Models
While some programs are being cut/reduced, there is still pressure on CMS to accelerate new Advanced Alternative Payment Models (APMs) so they are exploring options during 2018.
The first option is to allow clinicians to use Medicare Advantage plans to meet the criteria for an Advanced APM. Even though this may require a change to the MACRA legislation, CMS has a demonstration project in the 2018 final rule to explore this option.
Another option is the second iteration of the Bundled Payments for Care Improvement (BCPI) program, Advanced BCPI. The risk levels for other Advanced APM options may appear to be too high for physician practices so this option may have wider appeal to physician groups.
Other models under consideration include Direct Primary Care, which is based on a non-insurance model, as well as collaborations with private payers.
While these models are all under consideration/in development, it will be interesting to see if the CMMI RFI will drive additional choice or will the changes proposed consume CMMI for 2018 and reduce the capacity to introduce new models. Either way, CMMI will look very different in 2018 and beyond.
2019: Change is Mandated
In 2019, critical components of MIPS are mandated, including:
The weighting of the MIPS categories is re-balanced so the Cost category becomes 30 percent of the total MIPS score. While organizations have struggled with optimizing cost for years with limited results, this increase in the Cost category means that 2019 will drive organizations to look closely at cost and create a strategy for measurable improvement.
The performance threshold that determines who receives an incentive versus a penalty will increase to the mean/or median of participants’ scores. In the 2018 final rule, CMS estimated that almost 75 percent of clinicians will earn a score greater than 70 points for 2018 so competition going into 2019 will be fierce, with healthcare organizations pitted against each other to earn high scores and financial incentives.
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.
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.