Big Help for Small Shops
By Joey Berlin Texas Medicine June 2017

TMF Health Quality Institute Wins Award to Help Small Practices 

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Quality Feature — June 2017

Tex Med. 2017;113(6):33-38.

By Joey Berlin
Associate Editor

Last year, Houston ophthalmology subspecialist Kathleen Archer, MD, found out how confounding Centers for Medicare & Medicaid Services (CMS) quality programs can be for a solo practitioner.

Dr. Archer performs oculofacial plastic and reconstructive surgeries, along with some general ophthalmology. She's been in private practice for 30 years and in solo practice for 25. Her ability to report for programs like the Physician Quality Reporting System (PQRS) has been limited in the past because she says CMS doesn't have reportable oculofacial plastic and reconstructive surgery codes. But Dr. Archer reported on the ophthalmology measures that she could, and she had been receiving bonus payments as a result.

Then, in October, she says, she received word from CMS that she had failed on her PQRS and Value-Based Payment Modifier program reporting measures for 2015. That meant she'd have to take a 2-percent penalty for each program this year — on top of the 2-percent Medicare sequestration cut already in place for all physicians. Dr. Archer says she looked at her reporting results and found that "for some reason, they applied 14 primary care measures to me and failed me on all of them."

"They failed me because I didn't screen and treat osteoporosis in women 65 and older," she said. "I wasn't doing flu vaccinations, pneumonia vaccinations. I wasn't doing colorectal cancer screening or breast cancer screening, advanced care assessment, falls assessment, clinical depression. I mean, these are things that a specialist wouldn't be doing."

She says she filed informal reviews — CMS' name for an appeal — for each program, but they resulted in denials via email. That combined 6-percent hit will stand, hardly chump change for someone in Dr. Archer's situation. This year, she's not allowing patients to use credit cards to pay for medical services because of the extra fee involved. And she says she's going to see "what happens to health care" between now and the expiration of her office lease in 2019 before deciding whether to continue practicing.

"I'm in my early 60s. I hadn't planned on retiring at this point," Dr. Archer said, "but I may be forced into retirement."

So when it comes to reporting, the stakes can be high. But after Dr. Archer went through that headache, she received help from the TMF Health Quality Institute, the Austin-based health care consulting firm operating as CMS' quality improvement organization for Texas and several other states. 

With the Medicare Access and CHIP Reauthorization Act (MACRA) bringing with it a fresh complication in the Quality Payment Program (QPP), smaller and solo practices like Dr. Archer's need the most help understanding the latest requirements. TMF is offering free assistance to small practices through its QPP-Small, Underserved, and Rural Support program with the help of a multiyear award from Medicare. 

Last February, CMS announced it would divide up to about $100 million over five years among 11 organizations nationwide, including TMF, to help educate and train practices of 15 or fewer clinicians on the QPP. CMS will distribute about $20 million among the organizations in year one of the program, then provide the rest over the following four years. 

For many of the smaller practices, much of the direct technical assistance they need revolves around making their electronic health record (EHR) system as optimized and tailored to their practice as possible, notes oncologist Ronald S. Walters, MD, a member of the Texas Medical Association Council on Health Care Quality.

"I think it is going to coalesce around a few key medical issues that represent the bulk of their medical practice on a daily basis, and the TMF can go to the practitioner and say, 'What would mean the most to you in your practice?' And it might be back problems, and GI problems, and blood pressure and diabetes and so on," said Dr. Walters, also a member of TMF's Board of Trustees. "That's OK; we just need to know what matters to them. And then, once you do that, you look at the systems they have and [say], 'All right, how can we make that easier?'"

TMF's Assistance

The Quality Payment Program offers physicians two participation tracks: the Merit-Based Incentive Payment System (MIPS) and an advanced alternative payment model (APM). According to CMS, physicians are part of the Quality Payment Program if they either are in an advanced APM or if they care for more than 100 Medicare patients per year and bill Medicare more than $30,000 in Part B-allowed charges each year. TMF's QPP technical assistance is free to all MIPS-eligible clinicians.

"The challenge of MIPS is that it's a very technical program," said Russell Kohl, MD, chief medical officer for TMF. "There are a lot of [check boxes] that have to be filled correctly in order for a practice to be successful. Although many physicians are able to avoid MIPS through participation in advanced alternative payment models, that's not typically an option for most of the small, underserved, or rural practices in Texas. In those practices, MIPS will be reliant on the practice itself to do most of the reporting work."

One of the MIPS categories is Improvement Activities. Among the ways physicians can get credit in that category is by working with a quality improvement organization like TMF. Elaine Gillaspie, project director for TMF's QPP support program, says TMF looks at a practice's overall readiness for participating in QPP.

"That could be various things — looking at engaging practices in quality improvement activities, looking at their practice flow, looking at their EHR system, so assessing and maybe optimizing their health information technology. And then we go into working with practices on supporting them in maybe strategic planning, change management that affects their practice flows."

TMF's technical assistance includes developing and distributing educational materials, including fact sheets, toolkits, and monthly webinars with national speakers who home in on various QPP categories. Ms. Gillaspie says TMF's quality improvement consultants work directly with clinicians on aspects of QPP.

Most of TMF's assistance is remote, as opposed to on site. CMS views a physical "boots on the ground" presence for QPP assistance as an extreme circumstance, Ms. Gillaspie notes. Referencing his own experience as a solo practitioner in rural Oklahoma, Dr. Kohl says the key to success for any assistance program is "helping practices figure out what they actually need and then getting it to them."

"A lot of folks like to think that having someone on site to help is always the best option, but that wasn't always best in my rural practice experiences," he said. "Between limited space to meet with people and long drives for them to reach me, a lot of times I would rather just have a quick phone or Skype discussion where we get through what's needed, and I can get back to seeing my patients."

For more information on TMF and joining its Quality Payment Program network, visit the TMF QPP website.

What Makes It Difficult

Ms. Gillaspie says the biggest challenges smaller practices face is the question of resources. Practices in rural areas might have only one or two clinicians and often don't have an office manager. The smaller practices require more intense technical assistance.

"It's a question about HIT optimization — 'Why is this important for me, why should I invest the monetary resources in optimizing my EHR, and also, do I need more resources in my office, like an office manager?'" Ms. Gillaspie said. "Those are all questions we cannot answer for a practice, but we do try to lay out the benefits.

"Something that we've learned is, a lot of it is just a lack of knowledge initially on the intricacies of the program, but also the benefits: 'Well, if I invest in my EHR, that's going to help me down the road. It's not just for the QPP. That is helpful for my patients, that's helpful for my practice flow, and it's ultimately helpful for my bottom line.' So it's really about education," she said.

Along with Texas, the TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) region includes Arkansas, Missouri, Oklahoma, and Puerto Rico. For its work helping small, underserved, and rural practices with the CMS award, TMF's reach is also extending to Colorado, Kansas, Louisiana, and Mississippi.

TMA has partnered with TMF on some of the association's quality improvement tools and public health programs. Austin internist Ghassan Salman, MD, newly appointed chair of TMA's Council on Health Care Quality and a former member of TMF's Board of Trustees, says TMF can help physicians improve their quality capability from a knowledge and a systems perspective. It also educates patients on how they can contribute to improving quality.

Although quality programs are well-intentioned, Dr. Salman says, they add the burden of documentation and reporting. The nature of their complexity can put a physician practice at risk of not complying, he says.

"Understanding what is being required from the physician practice is step No. 1, and TMF and TMA, both of them do a great job of educating the physicians," Dr. Salman said. "The second is to get the right people on board to help them comply with these rules and regulations and submitting the data."

Practices in Texas, Arkansas, Missouri, Oklahoma, and Puerto Rico that don't qualify for the Small, Underserved and Rural Support program can get separate assistance from TMF through the QIN-QIO. 

Quality improvement help, including on-site assistance, is also available through TMA Practice Consulting. TMA's practice consultants can conduct a MACRA-readiness assessment focusing on clinical processes, EHR optimization, and opportunities to improve your workflow. (See "MACRA Help From TMA.") 

"That's Why I'm in This Business"

After her issue with 2015 reporting led to the 6-percent penalty, Dr. Archer contacted TMF last November for guidance. She says TMF helped steer her to additional measures she could report on that differed from what she had been reporting. For her 2016 reporting, Dr. Archer used the American Academy of Ophthalmology's IRIS Registry and manually entered the data, "so hopefully I won't be penalized for 2018. I don't know."

For 2017 data, she says it's going to be a matter of "seeing what the academy puts forth as far as reporting, so that hopefully I won't get a penalty for 2019. And of course, 2019 is the year when my lease is up, and I'll have to start figuring out ahead of that time if I can stay in business."

"I've tried to do things all along," she added. "I've tried to be compliant, tried to give excellent patient care, and I end up spending about 60 percent of my time on administrative things — on paperwork, time with the insurance company, input into the electronic record. It's a time pit."

Physicians who don't participate either in the advanced APM or MIPS paths this year will receive an automatic 4-percent per-claim cut to Medicare Part B payments in 2019. However, there are easy, bare-minimum steps you can take in 2017 and avoid the penalty in two years. (See "Do the Minimum, Avoid a Penalty.")

In presentations on the QPP, Dr. Kohl says he has tried to stress the pick-your-pace element of the program. CMS allows practices that weren't ready for QPP at the dawn of 2017 to begin anytime through Oct. 2, 2017.

"It's not that overwhelming of a program. It's just there's a lot of very precise things that have to be done, and if you can take the time to do it and build the processes, it's not that bad. But if you're trying to implement all of this at once by yourself, it's completely overwhelming," he said. "The pick-your-pace program, which is really valuable yet under-recognized, lets us help practices ease into MIPS so they don't have to jump right into the deep end and start swimming. By starting small and advancing your abilities over the next year, we can help achieve success without that overwhelming feeling."

At press time, CMS was mailing letters to physicians through May to inform them of their MIPS eligibility and exemption status, and had also added a tool on its website to help physicians determine whether they fall below the low-volume threshold to make them exempt from MIPS in 2017. 

TMF's goal, Ms. Gillaspie says, isn't just to train practices on QPP; it's to educate them on quality improvement.

"And honestly, I think we've seen quite a shift there, that practices are understanding the overall benefit is much more than [their] monetary [penalties]," she said. "[It's] really, 'I can make my practice better.' Because what clinicians always tell us is, 'I want to focus on my patients. That's why I'm in this business.' And I think we've been able to really help them understand that it is about overall quality improvement for better patient care."

Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.



TMA Practice Consulting can help prepare physician practices for the transition under the Medicare Access and CHIP Reauthorization Act (MACRA). TMA's practice management consultants can conduct a MACRA readiness assessment of your practice and provide customized on-site assistance to help you with your practice's specific needs. The assessment will focus on clinical processes, electronic health record optimization, and workflow improvement opportunities to help increase your Merit-based Incentive Payment System scoring. TMA is dedicated to working with you and your practice to earn an incentive payment, not just avoid the penalty. To learn more, email TMA Practice Consulting, call (800) 523-8776, or visit the TMA website.

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Do the Minimum, Avoid a Penalty

The Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program has two paths: the Merit-Based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). If you are not in an advanced APM and are not exempt from MIPS in 2017, you must complete at least one of the following requirements to avoid the 2019 Medicare payment penalty. Here are the categories with their submission deadlines for the 2017 performance period and the bare-minimum requirements:   

  • Quality category (deadline: Feb. 28, 2018): Report data on one quality measure for one patient for any point in time in 2017. The most affordable and easiest way to submit the bare minimum for the quality category is through claims-based reporting. Access the TMA guide for step-by-step guidance on this method.
  • Improvement Activities category (deadline: March 31, 2018): Report that you completed one improvement activity for a minimum of 90 days in 2017. The most affordable and easiest way to submit data on improvement activities is by attesting to participation via the Centers for Medicare & Medicaid Services MIPS portal. This portal is not yet ready but will be made available by January 2018.
  • Advancing Care Information category (deadline: March 31, 2018): Attest to meeting the four or five measures that are required for the base score for a minimum of 90 days in 2017. The number of measures will depend on your electronic health record (EHR) edition. Contact your EHR vendor to inquire about these requirements and whether you will be able to meet them through your EHR system, and to discuss fees for MIPS reporting.   

See more details on the bare-minimum requirements. 

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TMA's MACRA Engagement Continues

As physicians adjust to the rollout of the Medicare Access and CHIP Reauthorization Act (MACRA), TMA continues to make recommendations on its development and help members adjust to and understand the law.

TMA's MACRA Task Force is in constant contact with key U.S. representatives from Texas — including U.S. Rep. Kevin Brady, chair of the House Ways and Means Committee, and Rep. Michael Burgess, MD, chair of the House Energy and Commerce Subcommittee on Health — on practice implementation issues and MACRA feedback. 

In early March, TMA sent recommendations on more than 20 specific areas of Medicare regulatory reform to U.S. Health and Human Services Secretary Tom Price, MD, in an effort to promote simplified reporting and prevent harm to small practices.

In addition, the MACRA Task Force is assisting with feedback to the Washington, DC-based consulting firm Healthsperien, which the Physicians Advocacy Institute has hired to produce MACRA educational materials.

TMA urges physicians to evaluate their practice's readiness to participate in MACRA and to take steps to comply now if they intend to participate. For resources to help you do so, visit the TMA MACRA Resource Center

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Last Updated On

June 01, 2017

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Joey Berlin

Associate Editor

(512) 370-1393

Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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