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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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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The Stunning Rise of the Medicare Part B Value-Based Payment Modifier

Guest post by Tom S. Lee, Ph.D, CEO and founder, SA Ignite

Tom Lee, Founder and CEO, SA Ignite
Tom Lee

The Value-Based Payment Modifier (VBM) is one of the most impactful yet least understood components of the portfolio of value-based programs under Medicare Part B. Provider organizations widely know that their Physician Quality Reporting System (PQRS) quality measures must be reported to CMS in order to avoid significant VBM penalties. Yet, few organizations understand the value-based payment modifier rules well enough to know how to improve their value-based payment modifier quality and cost scores, which directly impact Part B reimbursement. And, the stakes are high as the 2015 VBM can have a +/-4 percent or greater impact on Part B, and starting in 2017, value-based payment modifier comprises 60 percent of the reimbursement impact of the newly-passed Merit-Based Incentive Payment System (MIPS). MIPS rolls up value-based payment modifier, meaningful use and other value-based programs into a single score for each provider that can impact Part B reimbursement up to approximately 30 percent based upon cost and quality performance relative to peers.

One way to understand the growing importance of VBM is to compare the rules and metrics of the 2013 program to those of CMS’ proposed 2016 program. The rise is stunning and reminiscent of the rapid expansion of other game-changing programs, such as meaningful use, but where the financial and reputational impacts are even greater.

The growing number of providers subject to VBM penalties

VBM penalizes providers falling into the lowest tier of quality performance among peers nationally, as determined by PQRS and other quality measures. In 2013, approximately 30,000 providers were subject to value-based payment modifier quality-performance penalties. In 2016, CMS projections and proposals taken together indicate that 1.25 million providers will be subject to such value-based payment modifier penalties, representing a 40-fold increase in the span of 4 years.

Why the growth? It’s all about regulatory change. In 2013, this quality-performance penalty only applied to groups with more than 100 providers, which opted into quality tiering, and it excluded organizations in the Medicare Shared Savings Program (MSSP), Pioneer ACO Model, or the Comprehensive Primary Care Initiative (CPCI). Furthermore, penalties were only applicable to Part B payments to physicians (MD, DO), not payments to non-physician providers (nurse practitioners, physician assistants, etc.) In 2015, CMS cast the net wider by expanding quality-performance penalties to apply to all groups down to only 10 providers in size and including participants in MSSP ACOs, Pioneer ACO Model and CPCI. For 2016, CMS is proposing that the size threshold be removed entirely such that all groups and solo physicians be subject to quality-performance penalties and that the penalties should be applied to Part B payments to non-physicians as well, not just physicians.

The amplification of VBM incentive and penalty dollars

The sizes of the maximum incentives and penalties in 2013 were 9.8 percent and -1.0 percent, respectively. The national incentive pool is set to be equal to the national penalties assessed in order to keep value-based payment modifier as an overall budget-neutral program. Hence, the “winners take from the losers,” where “losers” also include those providers who simply did not meet the minimum PQRS reporting requirement imposed by value-based payment modifier. This non-reporting percentage was about 30 percent of eligible providers in 2013, and CMS projects about the same percentage for the 2016 performance year. Hence, assuming that the proportion between winners and losers remains about the same in 2016 as compared to 2013 (about 13 percent), and factoring in the proposed 2016 value-based payment modifier rules, the maximum value-based payment modifier performance-based incentive could rise to as high as 20 percent, while the maximum penalty would be -4 percent, respectively representing 2 times and 4 times increases from 2013. As mentioned above, MIPS further increases the potential financial impact to 30 percent or even more of Part B payments.

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Participation Rises in Medicare Physician Quality Reporting System and Electronic Prescribing Incentive Program

The Centers for Medicare & Medicaid Services (CMS) today released the 2012 Physician Quality Reporting System and Electronic Prescribing (eRx) Experience Report, showing a significant increase in participation in two key programs that allow eligible professionals to earn incentive payments through voluntary participation.

“Our physician and other clinician quality programs reached new records this year with over 430,000 professionals participating in the Physician Quality Reporting System and over 340,000 e-prescribing,” said Patrick Conway, M.D. deputy Administrator for innovation and quality and chief medical officer at CMS. “Clinicians are actively measuring and reporting on quality, and CMS is in the beginning stages of adding this information to the Physician Compare website, which can be viewed by patients. Measuring, transparently sharing, and improving quality performance is key to a better health system.”

The full report can be found at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2012-PQRS-and-eRx-Experience-Report.zip

The Physician Quality Reporting System (PQRS) has been using incentive payments, and will begin to use payment adjustments in 2015, to encourage eligible health care professionals to report on designated quality measures. The Electronic Prescribing (eRx) Incentive Program used a combination of incentive payments and payment adjustments to encourage electronic prescribing by eligible professionals.

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Sustainable Growth Rate Reform: An Indication of the Broad Strategic Intent of CMS

Ken Perez
Ken Perez

Guest post by Ken Perez, vice president of healthcare policy, Omnicell.

Years ago, I worked in a business unit of a large technology company that was involved in mergers, acquisitions and partnerships. In the course of our work, even when some proposed deals would fall through and some partnerships would not come together, the strategic intent of the company remained clear to us. It was like a beacon that we kept pursuing no matter what.

With healthcare-related legislation, all too often we can lose sight of the strategic intent of CMS. We immerse ourselves in the debate over details, but often fail to step back and reflect on the “end game” that one can hang their hat on. What is CMS signaling to healthcare providers?

Currently, there is bipartisan and bicameral support for permanent repeal of the unpopular, annually overridden sustainable growth rate (SGR) provision, a formulaic approach intended to restrain the growth of Medicare spending on physician services. The SGR threatens to impose a 24.4 percent reduction to the Medicare physician fee schedule (PFS) effective April 1, 2014.

Lawmakers from the House Ways and Means, House Energy and Commerce, and Senate Finance committees have worked together to consolidate separate bills that their respective committees passed toward the end of 2013. The result is H.R. 4015, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, which was introduced by Rep. Michael C. Burgess, a Texas Republican and physician on Jan. 6, 2014.

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