MIPS Implementation: What Healthcare Stakeholders Need to Know

December 19, 2016 9:55 am

A healthcare policy expert says choosing the best measures to report on is one of the key early steps that will help providers succeed in MIPS.

Billy Wynne, JD, (pictured at right) is a managing partner with the Washington, D.C.-based government relations firm TRP Health Policy. Wynne has expertise developing and implementing federal healthcare policy focused on Medicare, Medicaid, and the Affordable Care Act (ACA).

In this article, he talks about the Merit-based Incentive Payment System (MIPS), one of two payment tracks of the Medicare Access & Chip Reauthorization Act (MACRA). Wynne outlines how MIPS implementation will affect provider organizations beginning in 2017, the first performance year under MACRA, and what healthcare organizations need to know to get ready for the new system.

How prepared do you think providers are overall to adapt to MACRA generally and MIPS in particular?

In 2006, Congress enacted the Tax Relief in Healthcare Act, which introduced the physician quality reporting initiative. That was the first time that Medicare asked physicians to report on quality measures. It’s been somewhat of a steady march for at least 10 years.

So, I think that no one should feel entirely surprised by where MACRA is going. Many physician advocacy groups and specialty societies have been preparing for this for some time. Primary care practitioners, for example, have been a little more progressive in engaging with these quality measurement programs—developing good measures, submitting them for inclusion in these programs, and putting out guidance for their members on how to comply. Very generically speaking, more specialized sectors of the clinician cohort have been more resistant and have not necessarily been forthcoming in establishing measures by which they might be evaluated.

Do you expect some providers to be more challenged than others to report quality measures?  

Arguably, there’s a broader array of potential measures that a general practitioner or primary care physician could choose from compared to a more highly specialized provider, though it’s going to vary by specialty—some have plenty of measures that they can choose from.

One good thing about having a broader range of measures to choose from is then you can take into account things like how the measures are reported and figure out what’s easiest for you to do. Once you pass that minimum threshold of having a good set to choose from, then you can be a little more picky about considering what each does for your practice. 

In the first year, CMS [the Centers for Medicare & Medicaid Services] has basically said if you can report on one measure, then you’re not going to pay a penalty. I think everyone is going to be able to do that if they try.

How can practices begin to prepare for MIPS and choose which measures they’ll capture and report on?  

The first thing I would do if I were starting from scratch is find the list of measures, which is in the regulation and probably available through your local specialty society. Read it and see if there are items that are going to work for your practice. I think part of the problem is that physicians hear rumors and they read negative articles about how it’s going to be complicated and burdensome. But it’s not as scary as it might seem if you just go and look at some of the primary materials.

In terms of what measures to choose, some specialties have registries that they sponsor. Those registries have their own predetermined measures. In that sense, the society is basically dictating to the physicians at least the universe of measures they can choose to report on. At the end of the day, though, it’s up to the practice and physicians.

If you have a certified electronic health record (EHR), then I think the likely recommendation is to look for measures that are reportable through EHRs.

Everybody files claims, so if there’s nothing else, claims-based reporting can be used for those measures that qualify for claims-based reporting.

If you’re in a group practice, reporting on an aggregated group level is almost definitely the way to go, as the per-person administrative burden will be much less.

What are the big pitfalls you see coming for healthcare organizations? Are you hearing about any that are causing the most concern?

Probably the biggest pitfall is the administrative burden for a practice to take this on. The financial consequence of not participating in MIPS becomes greater over time, so they need to take additional steps to comply and avoid any adverse payment consequences. The administrative burden of that is profound. I don’t know a lot of offices that feel like they have much extra time—certainly not primary care practices. It’s a real problem.

Do you worry about unintended consequences associated with reporting on certain quality measures?

Yes, that is a concern. For example, it used to be that for hospital outpatient departments’ value-based purchasing programs, CMS wanted patient experience measures related to pain management. What they found, at least anecdotally, is that it was incentivizing providers to give patients opioids. Patients would come to the doctor’s office with pain, and they’d want an opioid. If the physician didn’t give it to them, the patient reported that the physician didn’t do a very good job of managing their pain.

That would be a pitfall not just for providers, of course, but for patients as well.

The Clinical Practice Improvement Activities domain of MIPS is a brand-new component of practice performance measurement. What do we know about it at this point?

Under this new category, most physicians will choose just four measures that “improve clinical practice” out of more than 90 activities within nine subcategories. This bucket seems pretty vague at this point. I think this will evolve and probably get more specific over time.

Realistically, will it be difficult for physicians to avoid losses under MIPS?

I think that’s a big concern for CMS. That’s why they watered things down considerably in the first year. This is not some sort of punitive, cost-saving vehicle. This is intended to be good for the healthcare system, and it is intended to be doable and maybe even a positive experience for participants. I don’t think it’s their goal to penalize physicians.

In the first year they made it about as easy as they possibly could under the law as it was written by Congress for physicians to avoid a penalty. Again, in the first year you need to report on just one measure for part of the year. It’s going to be really hard to miss that.

Even then, however, no doubt there will be a significant proportion—I don’t know what it is—of physicians who will simply choose not to qualify or not to participate because they don’t want to make the necessary investment. Or, they may simply be unwilling to go down this path at this point. And some may try but won’t be ready. 

In future years, CMS’s estimates of participation go up, but the criteria to qualify for bonus payments also gets more stretched, at least as it’s contemplated currently. That may change later. While it makes sense to raise the bar over time as providers get more acquainted with the system, it cuts both ways. Physicians will have more time to get ready to participate, but at the same time, what were initially very minimum standards become more stringent down the road. That’s going to diminish success.

One thing about MIPS that is making people a little wary is that it is zero-sum game. So, for all the physicians who get a 4 percent bonus, there is theoretically at least an equal number who get a 4 percent cut. Congress did put an extra $500 million into the piggybank to dole out as additional incentive payments, so that will be the net surplus of the program. But otherwise, it will be budget-neutral—there are always going to be losers. That doesn’t sit well with people.

But it’s worth remembering that MIPS is a component of MACRA, which repealed the SGR, which dictated cuts in perpetuity for physicians. There were trade-offs. The AMA [American Medical Association] and others accepted these. It’s not just supposed to be hunky-dory. There are some challenges, and that’s part of the deal for having the SGR repealed.

What is the potential long-term impact on the industry of the zero-sum nature?

There are some who argue it will promote consolidation, and not just physician-to-physician, but hospitals acquiring physician practices. Or, that it will prevent physicians from accepting Medicare, or from practicing at all. It’s challenging these days, so I think there’s some cause for concern. Yes, there could be some adverse, maybe unintended consequences of diminishing access because of consolidation in the workforce. I think that’s a bona-fide concern.

On the other hand, the trend of consolidation has been going on for some time. There are a lot of factors that are contributing to that beyond MIPS—it’s just getting more complicated to be a provider. And if you’re thinking about lifestyle and other aspects outside of your professional life, then being employed by a hospital might seem like a really attractive option pretty soon.

Are there any changes that you believe need to be made to MIPS?

I think the breadth of the measures will need to improve. The EHR-based or least-administratively burdensome means of reporting measures needs to be enhanced. The resource-use measures and the value-based measures need a lot more sophistication. That just takes time and some learning before that’s going to occur.

One thing I would note is that the ballgame is the advanced APMs, the alternative payment models. That’s really where I think CMS believes the answer is. MIPS is intended to be a bridge to getting practices into those structures. But in those advanced APMs, there’s an even greater need for more options and more sophistication and refinement. So this is in some ways the foundation and the first step, and advanced APMs are the vision for five or 10 years from now.

Does health care stand to benefit from the widespread implementation of MIPS?

I think it does. Patients are starting to get better information about the quality of the care their provider delivers and about their options. But for the most part today, there’s not a very scientific way to judge the quality of care you’re going to get.

We’re moving toward informing consumers. Most people seem to think if we have more empowered consumers in health care, it’s going to get the system to deliver higher-quality care and perform better. I do believe that.

When we ask, ‘Is the healthcare system going to be better?’ the answer comes down to a balance between improving the process of measuring quality, its administrative cost, and the level of provider disgruntlement associated with it. Is it worth it?

Finally, do you anticipate any big changes to MACRA in the foreseeable future under a Trump administration and Republican-dominated Congress?

MACRA passed on a bipartisan basis, and no prior congressional ACA repeal initiatives speak to it directly. House Speaker Paul Ryan’s plan, the most recent version of which was announced this past summer, does suggest reforms to the health IT meaningful use criteria and would repeal CMMI [the Center for Medicare and Medicaid Innovation], which is the pipeline for the advanced APMs that are so critical to MACRA’s long-term success. Regardless, with ACA repeal, 23 million covered lives, and countless other complex and controversial policies at stake, I suspect amending MACRA will be a pretty low priority for Congress next year.

Lisa Zamosky is a healthcare journalist who covers health insurance, healthcare policy, the Affordable Care Act, Medicare, Medicaid, and consumer health and finance concerns.

Interviewed for this article: Billy Wynne, JD, managing partner, TRP Health Policy, Washington, D.C.


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