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though reporting requirements for 2017 and 2018 have been relaxed, many
physician practice leaders still feel unprepared as they continue to transition
to the Merit-based Incentive Payment System (MIPS), the default track for
physicians in the Quality Payment Program created by the Medicare Access and
CHIP Reauthorization Act (MACRA).
an organization hasn’t started laying out their MIPS strategy by now, they are
already behind the curve,” says John Redding, MD, senior manager at ECG
even organizations that have been slow to adopt a MIPS strategy still have time
to make key decisions and report the minimum amount of data to the Centers for
Medicare & Medicaid Services (CMS) before the end of 2017. That step would
allow them to avoid a 4 percent penalty on their Medicare Physician Fee
Schedule business in 2019.
who go the extra mile and submit at least 90 days of 2017 data to CMS could even
be eligible for an additional bonus—along with a base incentive of up to 4
percent—if they demonstrate exceptional performance.
high-performer’s share of the $500 million bonus pool is up to 10 percent of
allowable Part B charges. Figuring in the maximum base incentive, a potential
14 percent bonus could make a dent in many organizations’ shrinking margins. (Regarding
the maximum base incentive of 4 percent, it should be noted that because the
bonus payments are a zero-sum game, there have to be enough providers receiving
a 4 percent penalty to fund a 4 percent bonus.)
practices are focused on avoiding penalties or on earning a performance bonus,
the next few months are critical for laying the groundwork to maximize MIPS
scores. The following are some key strategies that organizations should implement
during this transition.
implementations require strategic leaders who can think beyond the reporting
logistics. “The financial implications of these decisions can be significant,
especially for large organizations, yet often, this kind of project gets
delegated to someone in IT,” says David Wofford, associate principal at ECG
would be better served by creating a multidisciplinary team or committee to
provide executive oversight of all value-based arrangements, including MIPS. These
teams should include physicians as well as leaders from IT, operations,
finance, strategy, and other areas.
Choosing a leader. In large integrated health
systems, MIPS committees should be led by a senior vice president or executive
with the employed physician group, with input from the chief strategy officer, Wofford
large independent group practices, leaders may designate a MACRA or MIPS
coordinator who has quality, medical home, or contracting experience, says
Martie Ross, principal at PYA. Part of the coordinator’s role is to identify
data analysts for reporting as well as provider relations staff to help educate
physicians on MIPS requirements.
Other important members of an
organization’s MIPS team include clinical documentation improvement specialists
who can help the practice maximize its MIPS execution. Performance improvement
staff also may be recruited to roll out MIPS-driven improvement activities,
such as the implementation of an antibiotic stewardship initiative or a fall-screening
and assessment program, Ross says.
Allocating resources as needed. “Organizations should look at MIPS
as an opportunity to prepare to succeed in value-based care across payers and
make wise investments that can be utilized across different contracts,” Redding
example, organizations may decide to invest in data analytics so they can track
their performance in both MIPS and commercial-contract measures. Or they may add
care management personnel or patient engagement tools to improve treatment
compliance and reduce hospitalizations. “The important point is to make
investments that can be used across the breadth of your payer mix,” Redding
One of the most difficult steps in
a MIPS implementation plan is determining whether an organization should pursue
individual reporting, which is submitted under individual National Provider
Identifiers (NPIs), or group reporting under a single Taxpayer Identification
Number (TIN) or multiple TINs. “For many practices, the question comes down to
whether they have the capacity and capability to do individual reporting,” Ross
Weighing the options. Vickie Monteith, RN, managing
director at Deloitte & Touche, LLP, says there are two main philosophies
for organizations with multiple TINs. Organizations may want to utilize a
separate TIN for their high-quality, low-cost physicians in anticipation of
moving out of MIPS and into an advanced alternative payment model (APM). As
part of this strategy, they keep their other physicians under a separate TIN or
multiple other TINs, hoping that their performance will earn a neutral or small-positive
payment adjustment under MIPS.
Other organizations have chosen to
keep all providers in either a single TIN or in their respective separate TINs
to help drive better performance across the board, recognizing that it may take
a few years to earn a positive payment adjustment.
reporting under the same TIN also have some tough decisions to make, usually
around which quality measures to select. A quandary can arise when the MIPS
measures that are best for most of the primary care providers do not apply to a
specialist who is under the same TIN. But for many practices, concerns over the
financial impact of such decisions are unwarranted, Monteith says.
long as the TIN’s performance is within plus-or-minus one standard deviation
from the TIN’s mean on the total composite scores from their Quality and Resource
Use Reports (QRURs), they will probably have measures to report on that will
allow them to be neutral on their payment or earn a positive adjustment,” she
Leveraging QRURs. Though often ignored by providers
in the past, QRURs can help practice leaders determine whether their providers
are better off reporting individually or as a group under MIPS. This fall, CMS
will release 2016 QRURs by TIN for every group practice and solo practitioner
subject to the Value Modifier. The QRURs detail providers’ 2016 performance on
the quality and cost measures that were used to calculate the Value Modifier
(which was terminated with the implementation of MIPS, although payment adjustments
continue in 2017-18 based on 2015-16 performance).
Ultimately, the decision to report
as one or multiple TINs can have ripple effects across payers. “If you change
TINs, it changes TINs for every payer,” says Claudia L. Douglass, FACHE, PMP, managing
director at Deloitte & Touche, LLP. Changing TINs requires re-credentialing
every physician under those plans, which takes time. “If you change TINs, it
can delay your accounts receivable, so you really have to analyze the
downstream effect,” she says.
Finding your TINs. Providers can enter their NPI
number on the Quality Payment Program (QPP) website and see all of the TINs to which
they have been assigned. They also can see whether they would fall below the low-volume
threshold, and thus be exempt from MIPS reporting requirements, if they report
individually or as a group for each listed TIN.
organizations should choose the full-reporting option, which for 2017 means reporting
all of the required measures for at least 90 continuous days. Full reporting not
only makes providers eligible for a 4 percent positive payment adjustment, Wofford
says, but it also serves as a dress rehearsal for future years.
full reporting is not feasible in 2017, practices should pursue partial
reporting, which requires reporting one quality measure, more than one
improvement activity, or the required Advancing Care Information (ACI) measures
for at least 90 continuous days.
let 2017 slip through your fingers by failing to report because if you do,
you’ll take a 4 percent hit needlessly,” Wofford says. “We’re halfway through
2017, and a lot of organizations are still dragging their feet on MIPS. If you
can push hard to do full reporting in 2017, there may be some financial upside.
But the main benefit is that doing so will put you in a better position for future
years, when full reporting is expected.”
Finding out which measures are
available through which reporting mechanisms. Practices have a lot of options when it comes to
reporting, but the right choice hinges on an organization’s administrative and
IT capabilities, says Graham M. Fox, consulting senior manager, PYA. Consider
three of the main reporting mechanisms: an electronic health record (EHR), a
registry, and claims data. For each reporting method, the benchmarks can
differ. For example, a practice might be set up for smooth EHR reporting but
may find more favorable benchmarks for its selected measures through registry
reporting. Almost all measures are reportable by registry, Fox says, whereas a
smaller number are reportable through EHRs or claims.
271 possible MIPS quality measures to choose from, practices need to determine
which ones will help them maximize their quality score, which accounts for 60
percent of their overall MIPS score. Fox says organizations that were participating
in the now-defunct Physician Quality Reporting System (PQRS) as of 2016 should
review their most recent performance to determine their strengths. They also
should search the QPP website
to uncover which quality measures are reportable through the various data
submission methods, as well as how the benchmarks may differ by reporting
method. From there, they can determine the opportunities to get the highest possible
Fox and Ross urge practices to study the benchmarks carefully this first year.
“If you have a very slight variation in practice for some reason, and you miss even
just a handful of patients, you might earn only three of the 10 available points
for a particular measure,” Ross says.
Going GPRO. Groups of at least 25 practitioners
may have an advantage if they met the June 30 registration deadline to report
through CMS’s Group Practice Reporting Option (GPRO). GPRO requires groups to
report 15 quality measures, compared with a maximum of six through other
reporting mechanisms. Yet a major benefit is that CMS prepopulates each measure
with approximately 250 attributed beneficiaries.
though groups are reporting on 15 measures instead of six, it becomes a lot
easier because they are reporting on a smaller population of just Medicare
patients,” Ross says. Compare that with providers that elect to report through
claims data, EHRs, or registries: They must report on half of their patient population, regardless of payer. Having a
smaller population not only simplifies reporting, but it also helps
organizations focus their performance improvement efforts on Medicare
beneficiaries rather than their entire panel.
Wofford cautions that leaders need to determine whether GPRO measures—the same
measures reported by accountable care organizations (ACOs) participating in the
Medicare Shared Savings Program—provide the best opportunity for organizations
to maximize their MIPS score. “These measures tend to be focused on primary
care, which may not apply to a practice with a lot of specialists,” he says.
Choosing measures in multispecialty
practices. As they
transition to MIPS, multispecialty practices have to decide whether to continue
to focus on measures that hinge on the performance of their primary care
providers (e.g., breast cancer screening) or instead to adopt specialty
measures based on the strengths they have developed.
example, practices may be confident that their oncologists have implemented
streamlined processes to meet the benchmarks for the general oncology measure
set, which includes 19 measures spanning chemotherapy use, tobacco screenings, and
documentation of medications in the medical record.
ignore this category, because it is 15 percent of your score,” Ross says. Of
the 92 eligible improvement activities, 78 are medium-weighted measures worth
10 points and the rest are high-weighted measures worth 20 points. To maximize
their score, most providers need to reach 40 points.
Preparing for potential audits. This past spring, CMS released the
validation standards that it will use to audit measures
for the improvement activities. Ross urges practices to check these standards
to ensure they have the proper documentation—which they will need if they are
subject to an audit—before they attest to their improvement activities.
Providers can attest directly through the QPP website or through a registry.
Leveraging the EHR. The validation standards also include
the criteria that the agency will use to audit the MIPS ACI performance
category, which replaces the Medicare EHR Incentive Program and builds on the
meaningful use incentive.
selecting improvement activities, organizations should consider those that
overlap with the ACI category (which represents 25 percent of the MIPS
composite score). For example, use of a certified EHR to capture patient-reported
outcomes is an improvement activity that also can earn bonus points in the ACI
category, as is use of decision support and standardized treatment protocols.
cost/resource utilization is not included in the MIPS score calculation in 2017
and, according to a proposed rule, in 2018 as well, CMS plans to eventually use
claims data to assess two total-cost-of-care measures: Medicare spending per
beneficiary (MSPB) and total per capita costs. The government also will assess
performance on 10 episode-based efficiency measures.
2017 and 2018 as MIPS transition years can help organizations turn their
attention toward cost containment and waste reduction. “Preparing well for MIPS
can help you get started on your move to value, especially if you are trying to
get into an upside-only APM like [Medicare Shared Savings Program] Track 1 or
an upside-downside model like MSSP Track 1+,” Douglass says. Organizations should
review their past performance in the Value Modifier program and PQRS, which the
MIPS cost and quality components replace, to determine potential areas for
exploring opportunities to maximize performance on the MIPS cost component, Douglass
suggests reviewing the following questions:
offer the following suggestions for organizations as they move forward with
their MIPS implementations in the latter half of 2017.
Look at MIPS as part of a larger
“You can spend a lot of time and money trying to manage your ACO, Medicare
Advantage, and commercial value-based programs separately without having an
idea of how these programs align and how to best select the measures and
activities that will cut across multiple programs,” Wofford says. A dashboard can
help organizations align their measures, track their performance, and develop a
more coordinated strategy across all value-based payer arrangements.
Get your medical home certified if
the cost-benefit analysis makes sense. A certified medical home allows organizations to
attain 100 percent compliance in the improvement activities category, Redding
says. Certified medical homes automatically receive full credit for this
category, negating the need to report on this component.
Make sure your clinical support
staff is trained on any new workflows designed to improve performance. Some well-worn processes, like
tobacco screening, can present opportunities for improvement and better MIPS scores.
In this example, leaders should make sure all clinical staff understand new
workflows being implemented to improve screening rates and ensure proper
documentation of the activity.
Share performance data with
physicians now so they will be better-prepared when quality and cost outcomes affect
their income in the future.
Redding suggests gradually improving the transparency of performance data over
time. This approach might entail blinding physician performance data initially
and ensuring that data are valid and accurate before they are shared widely.
practices align physician compensation models to MIPS measures, they should be
able to alleviate any issues that may arise when lower performers benefit from
the scores of higher performers. Ultimately, this approach should help drive
the entire practice’s performance higher, Redding says.
Consider the reputational impact of
MIPS. “It’s not
just about the dollars,” Fox says. “These scores are going to be available to
the public through Physician Compare and will follow physicians when
they join a new TIN. It’s going to be important for health systems to pay
attention to those MIPS scores because everybody else will, including payers and
professional-liability insurance providers.”
will take interest in these scores as well. “We’re going to know the good, the
bad, and the ugly from a physician standpoint, and that is definitely going to
drive how consumers choose who they select for their care,” Monteith says.
Consider moving to the Medicare
Shared Savings Program (MSSP) as a defensive strategy. “Being a Track 1 MSSP accountable
care organization will not qualify you as an advanced APM, but it will simplify
MIPS scoring for your group because the APM scoring standard within MIPS is
much more straightforward,” Ross says. In these ACOs, providers’ quality scores
are based on the MSSP measures, and everyone in the group receives the same
many organizations, MIPS will be the training ground before they choose to join
or create an advanced APM, the other QPP track available to providers through
some organizations may decide that MIPS offers greater rewards than the APM
track. “If you’re a primary care practice that doesn’t have the size and scope
to create your own ACO, you may need to partner with organizations that are
lower-performing, which can drag down your scores,” Wofford says.
organizations may fare better in MIPS depending on local market dynamics,
Wofford says. “If you are a high-performing organization that expects to max
out on your MIPS incentives, you may decide that the upside opportunity in MIPS
is more attractive than even some of the APM models that may be available to
Ramos Hegwer is a
freelance writer and editor based in Lake Bluff, Ill.
Quoted in this
article: Claudia L. Douglass, FACHE, PMP, managing
director, Deloitte & Touche, LLP, Charlotte, N.C.; Graham M. Fox, consulting senior manager, PYA,
Atlanta; Vickie Monteith, RN,
managing director, Deloitte & Touche, LLP, Charlotte, N.C.; John Redding, MD, senior manager, ECG Management
Consultants, Chicago; Martie Ross, principal,
PYA, Kansas City, Mo.; David A. Wofford,
associate principal at ECG Management Consultants, San Diego.
This article is based in
part on presentations at the 2017 ACHE Congress in Chicago.
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