This article was originally published in the March/April 2017 issue of “Billing,” The Journal of the Healthcare Billing and Management Association.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is driving healthcare delivery and payment reform across healthcare provider organizations, Medicare, and other government and commercial payors. On October 14, 2016, the U.S. Centers for Medicare and Medicaid Services (CMS) published the final rule for the Quality Payment Program (QPP) that implements key features of this law.
What is the Importance of the MACRA Quality Payment Program?
MACRA legislation is expected to drive care delivery and payment reform across the US healthcare system for the foreseeable future and presents both opportunities and risks for healthcare organizations. Consequently, the healthcare system is developing new strategies and models for practice improvement and reimbursement.
New policies under MACRA encourage a stronger focus on quality and total cost of care. Although MACRA retains the Medicare Physician Fee Schedule (PFS) as the basis for Part B payments to healthcare professionals, it establishes two separate payment tracks: Advanced Alternate Payment models (APM) and Merit-Based Incentive Payment System (MIPS) that will adjust reimbursement through measures of quality and cost.
MACRA sunsets three programs: PQRS, Value Modifier, and Meaningful Use for Eligible Professionals and merges them into MIPS, as well as introduces Advanced APMs. Collectively, these two paths are referred to as the Quality Payment Program (QPP).
What Does MIPS Look Like?
The first MIPS performance period began on January 1, 2017. Payment adjustments based on 2017 performance will take effect in 2019. MIPS has four performance categories; the scores in each category are weighted and contribute to a composite final score. Based on the final score, providers will receive a positive or negative adjustment. The weighting and adjustments will change in succeeding years.
|Advancing Care Information (ACI)||25 percent|
|Clinical Practice Improvements Activities (CPIA)||15 percent|
|Resource Use (Cost)||0 percent|
MIPS 2017 Performance Categories and Scoring Weights
The Quality category is similar to PQRS and the Quality Measures of the Value Modifier. Clinicians under MIPS will provide information on quality of care, with some measures chosen by the providers and some measures calculated by CMS. A major difference is that the program is no longer pass/ fail, but allows providers to get credit for reporting based on a series of points for performance. Measures in each category will be awarded a number of points based on benchmarks established for each measure according to how organizations scored on the measures in prior years.
The Advancing Care Information performance category looks very much like Meaningful Use (MU), without the requirement to report Clinical Quality Measures, thus removing the redundancy between PQRS and MU. Other improvements include: A group practice reporting option; elimination of threshold performance levels; provider performance specific to the practice, and no longer needs to be tracked historically or across practices; and practices can excel while focusing efforts on a limited set of functionality that makes the most sense to the practice and its patients.
Clinical Practice Improvement Activities are a new category for reporting. Providers will attest from a list of over 90-plus activities in which they are participating to improve their delivery of care. Many of these activities are things already being done.
The Cost category will not contribute to the final score in 2017, but in future years will contribute up to 30 percent of the final score. The measures in the Cost category will be calculated by CMS.
All APMs, sponsored by the Center for Medicare & Medicaid Innovation (CMMI), figure prominently in the QPP. However, Advanced APMs are payment models that include requirements for the APM Entity to bear risk for monetary losses of a more than nominal amount, or be a Medical Home Model.
Advanced APMs have their own requirements for measuring cost and quality, and are exempt from participating in MIPS. Examples of Advanced APMs are Medicare Shared Savings Plans (MSSP) Track 2 and 3, Next Generation Accountable Care Organizations, and CPC+.
What Are the Uncertainties Under QPP?
The QPP has a decided emphasis on pushing providers toward APMs in general, and Advanced APMs specifically. Health systems and physician practices must choose which QPP model is the best fit for their goals and figure out how to navigate the complexities of each model. A qualified registry can be of assistance in making these choices and succeeding under the QPP.
The MIPS and APM models under QPP are new, experimental, and certain to evolve. In the final rule, the first year of the program—2017—is acknowledged as a “transition year,” and presents simplified options to avoid a 4 percent penalty. However, the reporting requirements will become more stringent, and the potential penalties, incentives, and bonuses steadily increase to 9 percent and above through the 2020 reporting year.
APMs are relatively unproven. Requirements, penalties, and incentives for each model will change over the next several years as CMS adjusts old models, and new models are rolled out. Providers can count on participation churn and pressures to shift among the APM offerings. There will likely be steady migration from the MIPS path to APM and Advanced APM and back as new models fail to perform and designs evolve. Despite the uncertainties ahead, a highly capable registry can help a practice, regardless of its chosen payment model.
How Do Clinicians Participate in MIPS?
Clinicians can report as an individual MIPS-eligible clinician or as part of a group. Data may be submitted through the CMS Web Interface, third-party entities, including Qualified Registries, health IT vendors, Qualified Clinical Data Registries (QCDR), and CMS-approved survey vendors.
How Can a Capable Qualified Registry Help Practices?
A capable registry can provide a strategic resource under MIPS and APM as practices of all sizes invest in technology and develop practice optimization plans. CMS requirements are certain to change over time, and so must practices and their vendor partners. Under MIPS, practices will need to analyze and regularly report on quality and resource-use performance against national benchmarks, and, if needed, change practice patterns to avoid payment reductions due to substandard performance. Performance will be publicly reported on the CMS-sponsored Physician Compare website. Advanced analytics from a highly capable Registry can point to high-cost areas and suboptimal measure performance for the enterprise, group, or individual, and take them on a path to improve quality and reduce cost.
How Can a Capable Registry Assist Practices to Plan and Manage for Success?
Some practices using a registry for PQRS may be unaware of the heightened importance of a registry’s role under QPP. PQRS was a pass/fail, pay-for-reporting program. The Value Modifier introduced the concept that “performance counts.” MIPS continues the legacy of the Value Modifier, but with as much as 9 percent penalty under MIPS, the stakes are significantly higher.
A capable registry can address the need to not just make a qualifying submission, but through analytical tools, identify trends, and compare performance at every organizational level. This enables a practice to compare current status in comparison to goals, objectives, benchmarks, peers, and competition, and identify areas for improvement before their yearly submission to Medicare.
A highly capable registry provides services beyond its solution for measuring performance reporting. The registry can assist practices with services to aid in understanding the rules and reporting requirements, followed by guided development of a strategic plan and ongoing practice improvement methodologies. Registry consultants can guide advance planning among all affected stakeholders while providing resources for data-driven milestones and objectives. Ultimately, it is all about advance planning and tools to measure and progressively improve performance.
MIPS success ultimately equates to performance optimization. A capable registry can help maximize the opportunities to achieve that.
What Should a Practice Look for in a Registry for QPP?
The process begins by matching registry capabilities to organizational needs, including:
- Reporting and measurement tools
- Capability to provide “Measures that Matter” through existing measures and specialized measure development
- Actionable data to guide understanding and improvement, including benchmarking, trending, and comparative data by specialty stratification Automated data flow
- Consulting services for planning/ training Educational programming
- Ability to report through all submission mechanisms:
- CMS-Qualified Registry, Qualified Clinical Data Registry (QCDR), Data Submission Vendor (DSV), and CMS Web Interface
What Questions Should a Practice Pose to a Registry Under Consideration?
Making the correct choice in choosing a QPP registry involves more than comparing features listed on a spec sheet. There must also be a cultural fit:
- Depending on whether an organization wants to report as an individual, group, or APM, the submission mechanism will vary, and, over time, participation in APMs will change. Is the registry sufficiently flexible to help with any submission mechanism?
- Will your data be secure with respect to all HIPAA requirements and best practices?
- Does the registry provide support for understanding the rules, accessing data, and selection of “Measures that Matter”?
- The benchmarks will move higher every year; the practice needs to operate in an environment of continuous improvement. What evidence can the registry provide to support its expertise in areas such as analytics and practice improvement?
- A continuous flow of data will provide the best opportunity for remediation. What is the registry’s experience with flexible data exchange and auto mated data flow? How is data captured?
- What provisions are in place for measure remediation, including updates to policies, documentation programs, and training for patient encounters, reporting templates, EHR configuration, and performance reports?
- Does the cost of the registry’s service match its value proposition? Assuming the solution delivers the desired value, is it also affordable? As the old sayings go: “You get what you pay for,” and, “Beware of being penny wise and pound foolish.”
- Does the registry have a track record of successful submission and a high level of customer retention?
What Are the Essential Capabilities for a Registry Under QPP?
A registry should be able to analyze and submit data for all QPP performance categories.
|QPP MIPS Categories|
|Analysis and Reporting||
|Practice decision drivers||
|Registry advantage vs other reporting mechanisms||
*Source: CMS 2014 Experience Report (Issued: April 2016)
What Are the Essential Features of a Highly Capable Registry Under QPP?
It is no longer enough to be or have just a qualified registry. Your qualified registry vendor should be constant and reliable when the rules and programs are not. As you change programs and submission mechanisms, you should not also have to change your vendor.
Hallmarks of a Highly Capable Registry Under QPP
- Knowledge of the Rules
- Experience with PQRS
- History of Success
Able to accommodate submissions for:
- Practice Groups (GPRO)
MULTIPLE AND FLEXIBLE DATA INPUTS
- Manual online entry forms, spreadsheet, and flat file uploads for quality data
- Manual online attestation forms, spreadsheet uploads, and flat file uploads for Advancing Care Information Manual online attestation forms and spreadsheet uploads for Practice Improvement Activities
- Manual Inputs from paper or EHR chart abstraction Quality
- Multiple options for automated data flow, including:
- Direct connections to leading EHR systems
- EHR-specific Application Program Interface (API)
- HL7 standards-based data exchange using files compliant with Clinical Data Architecture (CDA)
- Traditional interface connections
MULTIPLE AND FLEXIBLE SUBMISSION SERVICES
- MIPS Qualified Registry
- Qualified Clinical Data Registry
- EHR submissions including Data Submission Vendor and EHR Direct capabilities
- Web Interface Automated Submissions
- Claims submission remediation and reformatting for Qualified Registry resubmission
WIDE VARIETY OF MEASURES
- All MIPS Measures
- All ACO/APM Measures
- Collaborative development of specialized measures for QCDR reporting
- All ACI Measures
- Measure Analysis: From claims or comparable data including CPT and ICD codes, what measures do you have eligibility to submit?
- From vendor data, knowledge, and experience, in what measures do providers of your specialty typically excel?
- Reliable performance analysis that stays up to date with changing specifications and adjusts to submission mechanism
- Comparisons to benchmarks and trending of your data:
- to Medicare benchmarks
- to your peers
- to your own historical data
FREQUENT AND ON-DEMAND REPORTING
- As often as you submit data, you should have access to refreshed performance reporting
- In the Quality Payment Program, you need ample warning of mal-performing measures to be able to find and correct what could be multiple problems in the data value stream
- Client support: Help when and how you need or want it (e.g. Online FAQ, Online chat, email, phone)
- Educational programming (e.g.: webinars, published articles, presentations at meetings and conferences, blog articles, white papers, written instructions, and guides)
- Practice Improvement activities
- Learning opportunities using your data and your peers
- Cost improvement programs (Value-Based Modifier experience and use of CMS cost reports for client guidance)
- Consulting services for issues including: advanced planning, practice improvement, measure remediation, EHR configuration and optimization, cost containment
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