Christopher StanleyBy now, healthcare organizations are well aware that the Medicare Access and CHIP Reauthorization Act (MACRA) has big changes coming for Medicare payment in 2019. However, multiple surveys have shown that the majority of providers are unprepared for the changes and aren’t sure how they’ll be affected. (See for example the 2017 survey by Healthcare Informatics, MACRA: How Ready Are U.S. Physicians?, and The Physicians Foundation’s 2016 Survey of America’s Physicians: Practice Patterns & Perspectives—with the latter’s finding that only 20 percent of physician respondents were familiar with MACRA.)

By the latest Centers for Medicare & Medicaid Services (CMS) estimates, more than 800,000 physicians will be exempt from the Merit-Based Incentive Payment System (MIPS) and its reporting requirements for 2017. These physicians are those with less than $30,000 in Medicare billings or fewer than 100 unique patients, physicians new to practice, and physicians participating in a qualified Advanced Alternative Payment Model (APM) program.

Still, it’s imperative for providers to understand that if they are not exempt based on the official criteria, they will be placed in the MIPS program and subject to payment reductions. Like taxes, MIPS participation is not optional, and lack of awareness or knowledge won’t save providers from being penalized.

MIPS: What Providers Need to Know

For physicians who are in MIPS, a key deadline is looming on the horizon. By July 1, they should decide which quality metrics to collect for 2017 to allow for data collection in the second half of the year. Likewise, providers should realize that transparency is a key tenet of MACRA; thus, their data will be made available on the CMS compare website for all to see.

For some, selecting a minimal amount of high-quality data is the proper approach to avoid a penalty. But submission of data for an entire year, along with clinical practice improvement and advancing care information, positions providers to receive a significant increase in payment in payment year 2019. In other words, with some risk comes the opportunity for substantial reward, and appropriately positioned providers should consider taking the extra step to reap future payment increases.

Providers aren’t required to submit quality data until March 31, 2018, but they should take action now, including determining which metrics to track for 2017 and collecting data to ensure they are ready to report after the close of this year.

The Quality Question

Under MACRA, healthcare quality is defined by objective clinical process or outcome metrics for the Medicare patients treated. For MIPS, physicians can choose at least one of roughly 200 different metrics, some specialty-specific and others primary care or population-based. Providers must submit at least one metric for 2017 to avoid penalties.

These key considerations can help healthcare organizations as they choose metrics:

  • First, organizations should pick a metric for which they have data readily available. Organizations can get some credit (and possibly avoid a penalty) even if their results are not as strong as they’d like; simply submitting data in the first year is acceptable.
  • Organizations should choose metrics that make sense for their practice scope and in which they are particularly invested. Diabetes metrics, for example, are a relatively easy choice because they cross multiple specialties and most physicians can influence rates within their practices.

Getting to the Top of the Class

MIPS physicians who want to maximize Medicare payments (4 percent increase in Year 1, escalating to 9 percent in Year 4 and beyond) should take the following steps:

  • Track and submit at least six quality metrics for the full 2017 calendar year (see additional details and requirements at qpp.cms.gov/learn/qpp).
  • Implement and report under Advancing Care Information all base score and performance score elements, such as e-prescribing, health information exchange connections, electronic access for patients, and coordination of care through electronic means.
  • For Clinical Practice Improvement, become a recognized patient-centered medical home (if applicable) or select and complete approved improvement activities (qpp.cms.gov/measures/ia).
  • Prepare for 2018 success when resource utilization (amount and cost of services for defined conditions and episodes) will be included in the composite performance score.

The transition to value requires physicians to track their results, report to external organizations (such as CMS), and make adjustments as the rules of the game change. Some physicians are embracing this new reality, but others are falling behind.


Christopher Stanley, MD, MBA, is a director, Navigant, Denver.

Publication Date: Friday, June 09, 2017