After years of incremental change, MACRA represents the largest transformation in a generation to how Medicare providers are paid. The law requires most Medicare clinicians to choose one of two major value-based tracks, which together are termed the Quality Payment Program (QPP):
• First, the Merit-based Incentive Payment System (MIPS) will annually rate providers on clinical quality, information technology use, clinical practice improvement and resource use. MIPS combines elements of the familiar Meaningful Use (MU), Physicians Quality Reporting System (PQRS) and Value-Based Modifier (VBM) programs. However, MIPS scoring and related payment impacts are drastically different. Even a one-tenth of a point difference in clinician performance can influence Medicare Part B reimbursement under MIPS.
• Second, the Advanced Alternative Payment Models (Advanced APMs) will include other value-based programs, such as Medicare Shared Savings Program Accountable Care Organizations (ACOs) and Qualifying participants in Advanced APMs – which will carry their own advantages and disadvantages – will be exempt from MIPS.
Performance in one of these programs, most likely MIPS for the majority of clinicians, could deliver positive – or negative- impact to an organization's Medicare revenue and public reputation. While provisions of the MACRA proposed rule may change when the final rule is published in November, it is unlikely that major changes will occur.
With 2017 rapidly approaching, healthcare organizations should treat 2016 as a MIPS "rehearsal" year by following these four steps:
1. Educate the organization particularly the C-suite, as soon as possible – Understand the financial, reputational and operational impacts of MIPS and Advanced APMs. (Particularly MIPS as it will likely affect the vast majority of Medicare Part B clinicians.) To learn more, organizations can leverage tools such as the MIPS Financial Calculator, MIPS FAQs and other educational resources. Recommend documents to review from CMS include the QPP Fact Sheet and a CMS presentation on the MACRA proposed rule.
2. Estimate your MIPS score – Gather historical or year-to-date MU, PQRS and VBM measures and benchmark values and attempt to estimate what your MIPS CPS would be in 2016 were the first performance year under MIPS. While formulating the estimated score, organizations should conduct sensitivity analyses on unknown variables to see how they might affect the CPS.
3. Optimize MU, PQRS and VBM quality to maximize MIPS – Next year, for instance, the MIPS quality category score will be based on six measures – instead of nine currently under PQRS – and will span any combination of quality domains, instead of just three currently under PQRS. However, one of the MIPS quality measures must be applicable to multiple quality domains, and one must be an outcome-related measure. In light of complications related to PQRS measure selection and other MIPS rules, organizations should use the 2016 PQRS performance year as a test-run for their MIPS quality performance by selecting the six measures, in light of the MIPS rules, that will ideally help the organization score the most points in 2017. With 10 MIPS quality points available for every measure contributing to a total possible 60 points ensuring these performance indicators will be applicable under MIPS and getting them as high as possible is crucial.
4. Evaluate staff, resources and organizational structure – Organizations should use 2016 to estimate clinicians' scores under MIPS and consider strategies and deploy resources that would increase their points for 2017. For example, under MIPS, organizations can report collectively as a group of clinicians instead of individually. Evaluating clinical staff's projected performance on the MIPS quality and ACI metrics should help organizational leadership determine if they want to report those metrics next year as a group or invest the time in improving individual clinicians' performance so they are prepared for MIPS. Organizations should also consider how it will collate and disseminate quality data on a regular basis and identify staff who would work directly with clinicians to change habits to increase performance. Determining how consolidating MIPS performance tracking and reporting to a single leader would impact the organization would also be a positive time investment for the remainder of 2016.
Federal regulations frequently change or face delays. The Sustainable Growth Rate and ICD-10 implementation are just two recent examples. Yet substantial revisions to the MACRA proposed rule are not likely to occur – even in the current political climate. The law is based on bipartisan legislation and has already faced a lengthy comment period, so the final rule is expected to be very similar to the proposal.
That's advantageous news for healthcare organizations. For once, there is no need to wait and speculate about what will happen. Rather, hospitals and health systems can prepare now to achieve success under MIPS or Advanced APMs. More preparation today will translate to fewer surprises and greater confidence as the new MIPS era unfolds.
Tom S. Lee, Ph.D., is the Founder and CEO of SA Ignite.
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