Experts offer tips on selecting measures, reporting data, and choosing the right improvement activities for your organization.
Even 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).
“If 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 Management Consultants.
But 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.
Providers 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.
A 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.)
Whether 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.
Create a MIPS Team
MIPS 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 Management Consultants.
Organizations 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 says.
In 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 says.
For 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 says.
Tackle the Reporting Question
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 says.
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.
Practices 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.
“As 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 says.
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.
Determine What—and How—to Report on Quality
Ideally, 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.
If 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.
“Don’t 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.
With 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 MIPS score.
Both 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.
“Even 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.
Still, 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.
For 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.
Select Which Improvement Activities to Complete
“Don’t 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.
When 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.
Prepare for the Future Cost Component
Although 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.
Using 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 improvement.
When exploring opportunities to maximize performance on the MIPS cost component, Douglass suggests reviewing the following questions:
- Do you have the right mix of primary care physicians and specialists at each site across the enterprise?
- Do you need to add advanced practitioners, such as nurse practitioners and physician assistants, at any sites to free up physicians to focus on patient care?
- Do you need to make IT investments to help improve care coordination and reduce costly avoidable care, such as hospital readmissions?
- Are there opportunities to offer virtual care, such as online provider visits, to improve access?
Experts 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 payer strategy. “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.
Once 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.”
Patients 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 score.
The APM Question
For 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 MACRA.
However, 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.
Such 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 you.”
Laura 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.