Physicians facing some changes in MACRA
Physicians caring for highly complex patients will receive some relief in Year 2 of the Quality Payment Program, established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In addition, say the feds, the program will offer:
- Meaningful measures and activities.
- A reduction in clinician burden (part of the Centers for Medicare & Medicaid Services’ recently launched “Patients Over Paperwork” initiative).
- New incentives for participation.
- Better care coordination.
- An easier way for clinicians to qualify for incentive payments by participating in Advanced Alternative Payment Models (Advanced APMs) that begin or end in the middle of a year.
Not all physician practice groups were pleased, however.
MACRA replaces the Medicare Sustainable Growth Rate (SGR) methodology for updates to the Physician Fee Schedule with a new approach to payment called the Quality Payment Program. The program was designed to encourage the delivery of high-quality patient care through two avenues: the Merit-based Incentive Payment System, or MIPS, and Alternative Payment Models, or APMs.
The Merit-based Incentive Payment System consolidates components of three prior programs: the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals.
For MIPS, physicians earn a payment adjustment based on evidence-based and practice-specific quality data. To show evidence that they provided high-quality, efficient care supported by technology, they must send in information in the following categories:
- Advancing care information, which replaces the Medicare EHR incentive program, also called Meaningful Use.
- Improvement activities, such as expanding practice access, improving care coordination and promoting patient safety.
- (New for 2018.)
Alternative Payment Models, or APMs, are payment approaches that provide added incentives to deliver high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population; and they allow the provider to earn an incentive payment for participating in an innovative payment model. Advanced APMs are a subset of APMs, and let practices earn more for taking on some risk related to their patients’ outcomes.
Year 2 changes
Released in November, the final rule for Year 2 of the Quality Payment Program offers up to five bonus points on the physician’s final score for treatment of complex patients, based on a combination of the Hierarchical Condition Categories (HCCs) and the number of dually eligible patients treated.
The final rule also weighs the MIPS “Cost” performance category to 10 percent of the total MIPS final score. The Centers for Medicare & Medicaid Services is including the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures to calculate practices’ cost performance scores for the 2018 MIPS performance period. CMS will calculate cost measure performance; no action is required from clinicians.
In addition, the final rule:
- Allows the use of 2014 edition and/or 2015 Certified Electronic Health Record Technology (CEHRT), and gives practices a bonus for using only 2015 CEHRT.
- Automatically weighs the Quality, Advancing Care Information, and Improvement Activities performance categories at 0 percent of the final score for clinicians affected by hurricanes Irma, Harvey and Maria, and other natural disasters. (In other words, clinicians in affected areas who do not submit data will not have a negative adjustment.)
- Continues a phased approach to public reporting Quality Payment Program performance information on Physician Compare.
To accommodate small practices (that is, groups of 15 or fewer clinicians), Year 2:
- Excludes individual MIPS-eligible clinicians or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries.
- Adds five bonus points to the final scores of small practices.
- Gives solo practitioners and small practices the choice to form or join a Virtual Group to participate with other practices. A Virtual Group is a combination of two or more Taxpayer Identification Numbers (TINs) made up of solo practitioners and groups of 10 or fewer eligible clinicians who come together “virtually” (no matter specialty or location) to participate in MIPS for a performance period of a year.
- Continues to award small practices three points for measures in the Quality performance category that don’t meet data completeness requirements.
- Adds a new hardship exception for the Advancing Care Information performance category for small practices.
APMs and Advanced APMs
CMS says that Year 2 offers more details on how the agency will incentivize clinicians who participate in APMs offered by payers other than Medicare, starting in 2019. This standard allows a non-Medicare payment arrangement to meet the financial risk criterion to qualify as an Other Payer Advanced APM if participants are required to bear total risk of at least 8 percent of their revenues from a given payer.
The agency has also updated its policies to further encourage and reward participation in Advanced APMs in Medicare.
Specific policies include:
- Extending the 8 percent generally applicable revenue-based nominal amount standard that allows APMs to qualify as Advanced APMs for two additional years, through performance year 2020.
- Exempting Round 1 Comprehensive Primary Care Plus participants from the 50-clinician limit on organizations that can earn incentive payments by participating in medical home models.
- Changing the requirement for Medical Home Models so that the minimum required amount of total financial risk increases more slowly.
- Making it easier for clinicians to qualify for incentive payments by participating in Advanced APMs that begin or end in the middle of a year.
CMS says that it worked with more than 100 stakeholder organizations and over 47,000 people, and reviewed over 1,200 stakeholder comments to finalize its Year 2 rule. But not all of those stakeholders are pleased with the result. The Medical Group Management Association is one. MGMA represents more than 40,000 medical practice administrators in more than 12,500 organizations.
In response to the association’s 2017 Regulatory Burdens survey, more than half of respondents reported they were participating in MIPS in 2017, and 72 percent said they planned to exceed the minimum reporting requirements, says Jennifer McLaughlin, senior associate director, government affairs, for MGMA. “However, 73 percent view MIPS as a government program that does not support their practice’s clinical quality priorities, and the vast majority are very concerned about the clinical relevance of MIPS to patient care.
MGMA supported the MACRA legislation, but the association believes that, as implemented:
- MIPS is burdensome and incompatible with the intent of Congress to improve the quality of and reduce the cost of healthcare.
- Physicians have limited opportunities to move into an eligible APM, in large part because the regulations establish a restrictive risk standard.
- The Center for Medicare & Medicaid Innovation – a part of CMS charged with supporting the development and testing of innovative healthcare payment and service delivery models – has taken a top-down, government-driven approach to developing APMs.
“MACRA was implemented seemingly to reduce physician practices’ regulatory burden, but MIPS is largely a continuation of … legacy programs,” that is, the Physician Quality Reporting System, or PQRS; and Meaningful Use (of certified electronic-health-record technology), says McLaughlin.
MGMA also takes exception with CMS’ decision to limit the pool of APMs to those developed by the Center for Medicare and Medicaid Innovation. “There is a much larger pool of innovative alternative payment models out there,” including those in the Medicare Advantage program and the Patient-Centered Medical Home care delivery model, says McLaughlin.
MGMA expressed disappointment with CMS’ decision to measure cost in 2018 even though that information is still incomplete, she continues. “CMS has yet to extensively test new episode-based measures, reform the patient attribution methodology, and implement risk- and specialty-adjustment to avoid penalizing physician practices who treat the country’s most vulnerable patients,” says McLaughlin. “We are also concerned CMS will not provide feedback about costs and patients who are attributed to groups during the performance period, so groups will have no way to track their resource utilization.”
Editor’s note: For an easy-to-read chart pointing out the differences in Year 2 of MACRA, go to this CMS website: https://www.cms.gov/Medicare/Quality-Payment-Program/resource-library/QPP-Year-2-Final-Rule-Fact-Sheet.pdf
Cardiologists are ready for MACRA
The American College of Cardiology is confident its members will fare well under MACRA’s pay-for-performance approach.
“We expect positive quality measure performance to carry through under MIPS and help many of our members not only avoid a penalty, but potentially also have a shot at the payment incentives available to high performers,” says Christine Perez, associate director, Medicare payment and quality policy, American College of Cardiology.
In the College’s 2017 practice census, over half of practices surveyed stated that they have in place an implementation plan for the Quality Payment Program, says Perez. “We believe that this number may be higher, as there are many practices where clinicians may be unaware that their administrative team, quality team, or clinical leadership [are] taking the lead on MIPS and APM activity on behalf of the group.
“Historically, cardiologists have performed well in reporting quality measures under [the Physician Quality Reporting System], so we expect this to carry over under MIPS. We have heard of several practices aiming for a full year performance this year since they have already established much of the reporting infrastructure and expertise with measure reporting under the previous Medicare programs.”
“The ACC agrees that quality should be a major part of new payment methodologies, as long as it is measured appropriately,” says Perez. And ACC believes MACRA is headed in the right direction.
“Unlike PQRS, which was pay for reporting, MIPS is now pay for performance, so we have been encouraging our members that it is not only important to participate, but also to continue to review their performance and continuously improve the quality of care they provide to patients.
“Looking to future and more robust years of the program, the ACC will continue to advocate that CMS allow cardiologists to report measures that are clinically meaningful to the patient population they treat.”
Most ACC members plan to report their performance measures via ACC’s qualified clinical data registry, EHR, or a qualified registry, says Perez. “We have heard concerns regarding the availability of CMS’ attestation portal for Advancing Care Information and Improvement Activity reporting. There were hopes that this portal would be available earlier in the year so practices would have a chance to become familiar with it and know that they had a solution available for reporting these categories.”