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.
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.