Quality Feature — October 2016
By Jessica Martin
Tex Med. 2016;112(10:39-46.
Like many of his colleagues in the medical community, Corpus Christi family physician James Stefan Walker, MD, knows his practice will undergo a fundamental change in January 2017, but at this point, he has no idea exactly what that will entail.
"Highly individual-centric primary care is the best possible care that I have been privileged to provide, and I want to do everything I can to continue that form of patient care in the clinic," said Dr. Walker, a member of the Texas Medical Association's Ad Hoc Committee on Health Information Technology. “We are looking at many options, including the nuclear option — cash-based direct care.”
The necessary changes in Dr. Walker's practice stem from the proposed Centers for Medicare & Medicaid Services' (CMS') Medicare payment rules, which will replace the much-maligned Sustainable Growth Rate payment formula. CMS has designed a new Quality Payment Program that has two paths: the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs). CMS plans to finalize the rules under the Medicare Access and CHIP Reauthorization Act (MACRA) sometime this fall. (See "Quality Reporting Help From TMA.")
Nonetheless, CMS expects all physicians to begin complying with the new Quality Payment Program requirements in January 2017, giving clinicians only two short months to prepare. That simply isn't enough time, TMA contends in a 27-page formal comment letter sent to CMS in July. The letter lists TMA's 50 recommendations to improve the agency's draft rule implementing MACRA. For more information, read "MACRA: Fix or Folly?" pages 41–47, in the September issue of Texas Medicine.
In the meantime, Keller family physician Gregory Fuller, MD, chair of TMA's Council on Health Care Quality, says the only thing physicians can do is start preparing now, even in the absence of the finalized rule.
"There's a lot to learn," he said. "I think the main thing to do today is to learn as much as you can about MACRA and its different components. Right now, more than 50 percent of physicians don't know anything about MACRA, and that's worrisome."
The proposed rule's staggering 426 pages make wading through the entirety of the regulation untenable for most busy clinicians. Luckily, TMA has five steps physicians can take right now to prepare their practices for the transition to the new Medicare payment paradigm. (See "Register for MACRA Webinars Now.")
"It isn't going away, so learn as much as possible, and be as active as you can advocating for quality metrics that make sense," said Abilene family physician D. Allen Schultz, MD, a member of TMA's Ad Hoc Committee on Health Information Technology.
Step 1: Learn about MACRA, and decide if an APM is right for your practice. Otherwise, you'll be paid fee-for-service with incentives or penalties under the new MIPS program.
Two payment options exist under the MACRA Quality Payment Program: MIPS and APMs. "The majority of practices are going to end up doing MIPS," said Dr. Fuller, "but everyone should look into their options."
Before delving into APMs and MIPS, physicians should first consider whether they qualify as exempt from MIPS. The proposed rule currently exempts physicians from MIPS in 2017 if they are in their first year of Medicare Part B participation, are already part of an advanced APM, or are below the low-volume threshold of $10,000 or less in Medicare charges and 100 or fewer Part B enrolled Medicare beneficiaries annually. Although the list is not exhaustive, examples so far from the CMS Innovation Center include accountable care organizations (ACOs), patient-centered medical homes, bundled payment models, and other initiatives yet to be finalized.
If your practice is close to these numbers, it may be worthwhile to wait for the finalized rules. Dr. Fuller notes TMA recommended CMS increase the low-volume threshold to $250,000.
For those physicians who are not exempt and do not qualify for an APM, the next step will involve doing some serious cost-benefit analyses. The penalty fee or bonus compensation in MIPS begins at 4 percent in 2019 and increases to 9 percent by 2022.
"This is set up to be budget neutral. It's a zero-gain share. Some doctors will receive a bonus while some will receive a penalty, but the majority of doctors will likely be bunched up in the middle where they get zero. From that standpoint, we need to determine the time and personnel cost of quality reporting just to break even. At some point, it may be cheaper to take the 4-percent penalty," Dr. Fuller said.
To determine whether MIPS reporting will financially benefit or harm your practice, calculate whether the cost of compliance with quality metrics will be more than 4 percent of your annual Medicare payment. (In its MACRA Position Statement, TMA estimates the cost simply for quality reporting and electronic health record [EHR] maintenance at about $28,000 per year per physician.) Consider whether this will be worth it for you, your practice, and your patients.
If MIPS compliance and reporting is the right move for your practice, then it's time to prepare to participate in the new quality reporting program, which is broken into four weighted categories: quality (50 percent), advancing care information (25 percent), resource use (10 percent), and clinical practice improvement activity (15 percent).
Step 2: Assess your performance under Medicare's current quality programs.
Many aspects of MIPS are similar to the current, separate quality reporting programs — the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VM), and electronic health record (EHR) incentive program (meaningful use). As such, physicians should familiarize themselves with those programs and their performance in each category.
Under the proposed rule, physicians will receive penalties or bonuses in 2019 based on data from 2017. CMS plans to provide feedback on 2017 performance sometime in 2018. This means a lot of physicians will be operating blindly for the first year of implementation, unsure of their performance levels. The best tool physicians have at their disposal is past performance under PQRS and VM.
The MACRA quality category will be similar to PQRS. CMS, however, proposes to score you on up to three population-based measures calculated from administrative claims in addition to the number of quality measures you are required to report. The resource use category will be similar to the VM program. CMS proposes to calculate and score resource use measures using administrative claims data only. The advancing care information (ACI) category will replace the meaningful use program.
If you participate in the PQRS and VM programs, and if you have not already reviewed your reports, get to know the type of feedback CMS provides and the data it uses to assess your quality and cost performance. For the PQRS program, access your PQRS feedback report; for the VM program, access your quality and resource use report (QRUR).
Feedback reports for 2015, planned for release in September, provide an opportunity to investigate your practice's strengths and weaknesses under PQRS and VM. Although quality metrics under MACRA will not be identical, it's a good place to start.
For some physicians, performance analysis under current quality programs has positively influenced their decision to participate in MIPS. Dr. Schultz says he plans to participate in MIPS "in part because I am already meeting meaningful use, and I am curious to see how it will all work."
TMA suggests identifying areas in PQRS, VM, and meaningful use where you already succeed and capitalizing on them for reporting under MIPS. This can be an option for many practices that have participated in quality reporting in the past.
Step 3: Review MIPS quality measures and reporting mechanisms.
The proposed MIPS quality category will make up 50 percent of the final score. To prepare, review the list of proposed quality measures in the MACRA proposed rule in Tables A, C, and E.
According to the proposed rule, physicians and groups will have to select their measures from either the list of all MIPS individual measures in Table A or a specialty-specific measure set in Table E (measures are the same in both tables). Make note of each quality measure's type and data-submission method. Keep in mind that this approach to the measure selection process may change in the final rule.
To receive credit for the quality category, data must first be reported through one of the approved reporting mechanisms. Reporting data on quality measures for MIPS can be done in the same way as your practice reported for PQRS, but CMS may reduce the required number of quality measures from nine to six measures, increase reporting thresholds, and require all-payer data for certain reporting mechanisms.
Determine which reporting mechanism will best fit your practice in 2017. Start by reviewing the existing reporting methods under the PQRS program: Medicare Part B claims, registry, qualified clinical data registry (QCDR), EHR, web-interface (for groups with 25 or more), and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Check out TMA's quality reporting tips.
Look through the proposed quality measures, and try to pick out high-performing areas for your practice. Once the final rule has been published, review each measure's benchmark, specifications, and documentation requirements. Align your care plans, and redesign clinical workflows if necessary so your practice can meet these quality measures.
While it may be easiest to report on quality measures your practice is already performing well on, it's also important to improve care plans in other areas.
Dr. Schultz is already working to implement changes to improve his performance in certain quality measures under MACRA. "I am adding work flows to satisfy the mental health screening and diabetic quality metrics while also reviewing how I screen for cardiovascular health. It's encouraging me to do a better job surveying my patients for mood disorder and substance abuse."
Finally, be prepared for a potential audit. CMS plans to selectively audit practices annually to validate data they submit under MIPS. Keep good patient records, and ensure EHR templates are properly filled out. Make notes of the patients who are reported on for each measure so you can track down medical information easily in case of an audit.
Step 4: Contact your EHR vendor.
Even though contacting your EHR vendor is the fourth step in TMA's list, Dr. Fuller says this is the first thing he will be doing. "We're talking to our EHR vendor to see what their status is and whether they're prepared for MIPS before anything else."
An EHR system is necessary to meet the requirements of the ACI category, which will replace meaningful use. If you already use an EHR, check with your vendor to ensure the product you use will be upgraded and certified to meet the metrics required under MACRA. If you do not currently use an EHR system, you will have to select, purchase, and implement one. Be sure the product you select is certified. TMA has numerous resources to help practices with selection.
Dr. Walker is part of a practice that is still considering all of its options, but he knows EHRs will be an important part of his practice moving forward. "Health data is the currency of the emerging transformed health care system," he said. "Don't run from it; dive in, and embrace it."
Dr. Fuller agrees and plans to capitalize on his practice's EHR as a rich source of health data he can use when deciding whether to participate in MIPS. "We have to find out what kinds of things we have in our EHR that we can collect data on, and then we are going to mine that data for all its worth."
Another important consideration is the sheer amount of data you will need to store safely and account for. If you're planning to participate in MIPS, be sure your computers and servers are capable of handling the data. As Dr. Walker's practice reviews its options under MACRA, he says one of the primary concerns is technological capability. "We are actively planning to upgrade our internet bandwidth in order to convert our practice management system to the one that our EHR offers online. In addition, we are looking at upgrades to our technology in terms of our computers, servers, and how we use our EHR."
Once you have spoken with your EHR vendor and have ensured that you are using a certified program, you should spend some time reviewing the meaningful use component of the current rules. While the new ACI component will not be identical to meaningful use, it is a good place to start.
Step 5: Explore the list of clinical practice improvement activities (CPIAs).
The new performance requirement under MACRA is the CPIA category, designed to promote expanded access, patient engagement, and practice assessment, among other metrics. CPIA requirements vary based on the size, location, and model of your practice.
For a full overview of the CPIA category, physicians can look at Table H in the MACRA proposed rule. Fortunately, many of the CPIA requirements are simple; you already may have implemented some of them.
For starters, participation in a nationally recognized, accredited patient-centered medical home (PCMH) automatically qualifies a practice for full credit. Although certification can be a significant undertaking in terms of time and cost, it has many benefits, as Dr. Walker knows. It is one of the many options that his practice is considering. "PCMH designation enables practices in either the MIPS or APM model. In MIPS, it enables data reporting and collection, as well as improves reimbursement contracts with private insurances. In the APM model, PCMH designation would also help us become a leader in an ACO [accountable care organization] arrangement."
Physicians participating in APMs also automatically receive half of their CPIA credit. Once again, look into whether an APM is an option for you and your practice before making further decisions.
For those clinicians who will not qualify for automatic CPIA credit, the next step will be to look through the different activities and decide on a few to pursue. The highest potential CPIA score is 60 points. CMS proposes that high-weighted CPIAs are worth 20 points while medium-weighted CPIAs are worth 10 points. To get full credit, physicians will need to complete three high-weighted CPIAs (24/7 practice with access to patient medical record, provision of same-day or next-day access to providers), six medium-weighted CPIAs (engaging patients and family caregivers in developing a care plan and care priorities, documented in an EHR), or some combination thereof. Full credit for the CPIAs will be awarded only if they are performed for at least 90 days under the proposed rule.
"Many of the population management categories are relatively easy, and many physicians are doing those things already," Dr. Fuller said. For example, one of the medium-weighted population management activities is to use reminders and other outreach to proactively manage chronic and preventive care in patients. For many clinicians, this would be an easy 10 points.
Come January, reporting in the new system will be easier if you've already started to prepare. If you're close to the cut-offs for exemptions, you'll want to double-check those numbers in November. After that, if you still qualify for reporting under MACRA, you'll want to review all requirements for MIPS and APMs.
Although he has some daunting tasks ahead of him to prepare for MACRA, Dr. Walker says he does believe MACRA is a step in the right direction. "Remember that if health care was ideal already, then there would be no need for the recent push to reform the system. Pay for performance is intended to reward you for doing the right kind of care. The vehicle of health care may change from generation to generation, but the act of providing compassionate, excellent health care has not and will not change."
Jessica Martin, owner of Martin Medical Writing, LLC, is an independent science and medical writer based in St. Paul.
Quality Reporting Help From TMA
If you are new to the current quality programs and would like to participate in them in 2016, visit TMA's resource centers for information on how to get started.
In addition, TMA Practice Consulting has quality improvement services to prepare physician practices for the transition to MACRA. Learn more by visiting the TMA website, calling (800) 523-8776, or emailing TMA Practice Consulting.
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Register for MACRA Webinars Now
TMA offers on-demand webinars, presented by TMA staff experts, to educate you on the Medicare Access and CHIP Reauthorization Act (MACRA). Courses, available for continuing medical education credit, include:
- MACRA Participation: Pick Your Method covers what MACRA is and the pros and cons of participation options.
- MACRA: Quality Reporting Options for the Merit-Based Incentive Payment System (MIPS) features information on the reporting mechanisms and selection of the MIPS quality measures.
- CPIAs and Identifying Medicare Services to Bring in New Revenue teaches you about MACRA's new scoring element using clinical practice improvement activities (CPIAs) and how to identify additional billable services.
- How IT Can Help You Succeed Under MACRA educates you on the new advancing care information category and the new information technology (IT) requirements. It also features questions to ask your electronic health record vendor, information on selecting certified health IT solutions that can help you collect and report data, and guidance on assessing key quality program reporting implications.
Visit the TMA Education Center to register for the webinars. For the latest information on MARCA, visit the TMA MACRA Resource Center.
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Explore Your Options With TMA PracticeEdge
TMA PracticeEdge, formed by TMA in 2015, helps physicians with the transition to value-based care. The company specializes in network development and contracting, and offers products and services that help physicians meet quality metrics, such as delivery of behavioral health care and preventive screenings.
Beginning in 2019, the Medicare Access and CHIP Reauthorization Act (MACRA) requires physicians to participate in one of two payment structures: the Merit-Based Incentive Payment System or eligible alternative payment models (APMs). Though the majority of Medicare Shared Savings Program and commercial accountable care organizations (ACOs) in Texas do not yet qualify for APM bonuses under MACRA, care coordination, patient engagement, and other value-based care activities used by these organizations can help physicians report on and improve their MIPS scores.
If you're thinking about starting or joining an ACO, or want to optimize how your practice responds to current and upcoming payment rules, TMA PracticeEdge can help you explore your options.
Email TMA PracticeEdge to learn more about TMA PracticeEdge services.
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