Thinking Strategically About MACRA and MIPS: Will it Be Sink or Swim in 2019?

Thinking Strategically About MACRA and MIPSIn Part One of this two-part article exploring the implications of MACRA for healthcare providers, healthcare leaders and health IT experts discuss why it’s critical for clinicians to think strategically, rather than tactically, about MACRA compliance.

Numerous industry surveys have highlighted that U.S. physicians, by and large, remain unprepared for managing and executing Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) initiatives. In fact, an exclusive survey conducted by Healthcare Informatics and SERMO found that just one in five practices (20 percent) with 15 physicians or fewer and approximately one in four practices (28 percent) with 16 to 50 physicians report that they are “ready to go” to meet the core requirements under MACRA.

For that survey, Healthcare Informatics surveyed 2,045 U.S. physicians in SERMO across various specialties—revealing that most practices still need MACRA help, with many still stuck in fee-for-service environments. The goal of the joint research was to gauge providers’ readiness for MACRA, a newly-implemented law that will fundamentally change how eligible Medicare physicians will be reimbursed.

Tom Lee, Ph.D., founder and CEO of Chicago-based consulting and software firm SA Ignite, says he is not surprised by survey results indicating that physicians continue to be unprepared to meet the core requirements under MACRA. “Given the level of complexity of the program, and how quickly things have come, I’m not surprised, and I’m sure there are also folks who were trying to follow the repeal and replace activity, which was another distraction,” he says. “Those organizations that don’t have enough dedicated effort to towards understanding the regulations and how to operationalize them, and that will tend to skew toward smaller organizations, those are the types of organizations that the lack of awareness and preparedness will likely have the greatest implications.”

Joncé Smith, vice president of revenue cycle management at Stoltenberg Consulting, a Pittsburgh-based healthcare information technology consulting firm, also is not surprised by news about physicians’ lack of preparedness for MACRA. “I think a lot of people felt that a program of this magnitude, size and complexity would ultimately be delayed, but it was not, so I think that has caught people pretty unprepared. And, this program is replacing three of the previous physician reimbursement incentive programs, yet it’s so unlike the pieces and parts of those programs, so I think there’s a very large education curve that’s going to have to take place.”

MACRA, which was passed with bipartisan support in Congress, launched its first reporting period in January 2017 in which eligible Medicare clinicians will be reporting to a Quality Payment Program (QPP) that determines a physician’s reimbursement based on the high quality, efficient care they provide that’s supported by technology. MACRA includes two payment tracks that eligible Medicare clinicians can take part in that will determine their payment adjustments in future years. Early on in the program, most of these clinicians are expected to participate in the less risky Merit-Based Incentive Payment System (MIPS) track as opposed to the Advanced Alternative Payment Models (APMs) track.

Mark Miller, M.D., an independent family medicine physician who practices in Fayetteville, Arkansas, says that independent practices are struggling with the complexity and aggressive timing of the rule. “There’s a lot of uncertainty. I have talked to my colleagues and they have heard of it, and for those who are employed physicians, they are trusting that their office manager is going to take care of reporting, but as far as the independent doctors, they are going have to do it themselves,” he says, adding that at a recent American Medical Directors Association conference, when the 150 physicians in the room were asked if they were already actively engaged in MACRA, only two raised their hands. “I think physicians as a whole know very little about it and will be blind sighted by it.”

Preparation Strategies

The Quality Payment Program combines the existing Medicare Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-Based Modifier (VBM) programs into MIPS, starting with the 2017 performance year. MIPS payment adjustments are applied to Medicare Part B payments two years after the performance year, with 2019 being the payment adjustment year for the 2017 performance year.

MIPS defines four categories of eligible clinician performance, contributing to an annual MIPS final score of up to 100 points. The four categories are Quality; Advancing Care Information (ACI, renamed from Meaningful Use); Clinical Practice Improvement Activities (CPIA) and Resource Use (which will be weighted for 2018 and beyond).

Miller recommends that physicians first educate themselves on MACRA and MIPS requirements using the QPP portal developed by CMS— On that site, CMS offers an online lookup tool that enables clinicians to determine whether they have to participate in MIPS this year.

More strategically, Lee recommends a number of preparation strategies for physician practices in order to comply with requirements for the 2017 reporting year, as well as to work out the “reporting kinks” to better prepare for future reporting. “The part of the education that is most critical is for the leadership of provider organizations to understand what all the impacts are, and just generally get a sense for where the complexity is and where can they have the best opportunity to improve,” he says.

As a next step, many provider organizations and clinicians are focused on determining their current MIPS score, Lee says. “So, if they had to report MIPS right now, how many points out of 100 are they on track for and what kinds of decisions do they need to make in order to optimize that score? There’s definitely ways that providers can go through that exercise; it starts with education and then it’s using a lot of year-to-date or historical Meaningful Use and quality data, particularly for the PQRS program, to determine what their score is. And of course there are some tools out there to help them with that.

The third step, Lee says, is for practices to analyze where their practice is performing well and is likely to succeed under MIPS, but more importantly where performance is lacking and where opportunities for improvement exist. “And the focus shifts to ‘I want to get to a certain score by the end of the year,’ and it’s about identifying multiple paths that can get you to the maximum number of points so you can maximize your incentive.”

“The final piece is operationalizing on what those low hanging fruit opportunities are. For example, if it turns out that you are underperforming on certain measures and the real reason if your electronic health record (EHR) is not optimized, then what resources, time and people do you need in order to optimize that? Or if it’s a training issue with your clinicians, or if it’s some other aspect that you’ve got to shore up interoperability, and do better on some of the ACI measures. So, you repeat that whole cycle as many times as you can throughout the year to continually improve as the MIPS program continues to become more difficult year over year.”

As reported by Healthcare Informatics Managing Editor Rajiv Leventhal, the Trump administration is currently reviewing potential 2018 updates to MACRA that would especially ease the burden the new legislation puts on small physician practices. Leventhal reported that previous federal officials under the Obama Administration dubbed 2017 as a “transition year,” meaning that as long as Medicare-participating doctors did at least the minimum reporting, they wouldn’t get dinged with negative payment adjustments. In the first performance year, CMS allows physicians to “pick their pace” of participation. It’s expected that new Health and Human Services (HHS) Secretary Tom Price, M.D. will extend that flexibility, Leventhal reported. The proposed rule from Price is expected to drop in the coming weeks, if not sooner.

However, even if CMS does extend that flexibility, the MIPS score performance threshold will eventually increase, and Lee says provider organizations need to be prepared in order to “keep up with a treadmill that is going faster and faster.”

To this point, Lee says many forward-thinking physician practices are focused on taking actions to not only avoid payment reductions, but also to improve performance on MIPS measures in order to earn incentive payments.

“It’s not just about avoiding a one-year penalty; that’s not strategic, that’s shortsighted. This is not a tactical decision for one year then you put it in a box and maybe look at it again next year. You’ve got to think about it strategically, ‘What long-term implications does this program have for you?’ You need to think about ‘What is your long-term strategy for Medicare period?”  He adds, “We are seeing physician practices that are concerned about the immediate and annual reimbursement impacts regarding the payment adjustment, but they are even more concerned about the reputational impact. The winners get richer and the losers get poorer, and then you get to a point where you are not going to be being able to catch up.”

Part Two of this article, to be posted next week, explores the operational and reputational implications of MIPS reporting and the technology investments that will be vital to success.

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