MACRA – Keep Your Head and Stay Focused
In all the discussion about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and making the transition to the Merit-Based Incentive Payment System (MIPS), most of the dialogue has been about how much is going to change and how there is so much upheaval for physician payment under Medicare. Most of the conversations have focused on delay or moderation of the requirement. In all of this, is anyone pointing out how many Eligible Clinicians (EC) may be strongly positioned to begin participating in MIPS as early as 2017? It’s possible, if ECs have a good track record of participation in the value-based programs that preceded MIPS under the Physician Fee Schedule (PFS). Here are five key reminders to keep your head while others may be losing theirs.
1. Remember where MIPS came from.
It’s an established fact that three of the four measure domains under the MIPS composite measure come from existing CMS value-based programs under the PFS in 2016. To provide a short translation, these include:
If an EC is performing well in 2016 under these programs, the EC is in an excellent position to start 2017 for whatever comes. At any rate, the pedigree of these program requirements for MIPS is directly traceable, even given the changes in how things are measured under MIPS or how the specifics of domain weighting and measurement changes such as for ACI are structurally different. At their heart, the MIPS domains leverage a very significant amount of existing program elements that directly carry over. Particularly for selecting areas for Performance scoring under the ACI domain or for reporting quality measures for the Quality Measures domain, consider strongly emphasizing your strengths or familiar ground in selecting what you choose to do for meeting domain scoring in 2017.
2. The Clinical Performance Improvement Activities (CPIA) domain is new, but…
The CPIA domain of the MIPS composite measure is new, but it is not comprised of things ECs have never heard of. Of the 93 activities CMS proposes, practices may already be doing many of them, such as offering communication of abnormal test results to patients with timely follow up or using clinical decision support tools within their clinical practice. ECs should be looking at CPIA options through the lens of what they’re already doing to help them meet the full point values for the CPIA domain. Further, ECs should consider what existing activities support attainment of higher point values to provide the biggest bang for the buck.
3. Consider the Alternative Payment Model (APM) you may be participating in.
The MACRA statute provides significant support for EC participation in APMs. One of the greater leverage points is the value they can have for helping ECs meet multiple needs under physician payment reform of the PFS for Medicare. Perhaps of greatest value is the degree to which APM participation covers the point values associated with the CPIA domain. If you are participating in a qualifying medical home for Medicare, that can fully satisfy the point values associated with the CPIA domain. If you are participating in a Medicare Shared Savings Program (MSSP) or Accountable Care Organization (ACO), that may help meet half of the available points for the CPIA domain. Don’t forget to evaluate and consider the value of activities you’re already engaging or may engage in.
4. Your EHR may be worth something more to you.
The EHR should be considered a key point of reference for selection of activities from the proposed list of CPIAs. Consider what you use the EHR to do in your practice, for its ability to help you assess what activities you have the best opportunity to meet. Take the examples we noted before: The EHR can be used for provider notification of abnormal results that may merit communication to patients and be used to help track follow up activities. The EHR also can integrate clinical decision support interventions into clinical workflow or be used to help support the use of clinical checklists. The key is to consider selection of CPIAs based on what you already are using your EHR investment to do.
5. Consider how you already report to CMS as how you will report early in MIPS.
In its proposed rulemaking for MIPS, CMS proposed and requested comments on the use of a lot of different reporting mechanisms for reporting data on the MIPS domains for Quality, ACI and CPIA. From a policy perspective, CMS is out to stress the importance of reporting data in the most automated means possible that presents for the least administrative burden available. However, as a starting point, consider how you will report quality measures to PQRS and how you attest for meaningful use in 2016 as starting points to consider for how you report in 2017. You are not locked into one reporting method for the life of the program. You can transition to other means of reporting in future years, but consider staying with a consistent starting point if it makes sense.
You also will be expected to make a choice to report as a group or as individuals, and CMS proposes that this is the same choice across all four MIPS domains in 2017. If CMS adopts this in its final rulemaking, consider if it benefits you to remain with the same reporting approach that you may have made for reporting to PQRS in 2016.
The transition to MIPS will introduce new requirements over time, and there will be a significant amount of change if one looks back on things from the perspective of several years. In transitioning, take measure of what you can do to use your current experience and perspective as your point of departure in participating in the value-based programs under the PFS in 2016. Take careful stock of leveraging your strengths and current operational clinical practice focuses for selecting activities to report under the CPIA domain. For 2017, consider it a year to transition and adapt to what is changing under MIPS and plan for future years to be the time for more profound change. Do not lose your head. You may have a much better starting point than you think.
We had said to keep your head as you go through the transition into MACRA implementation for MIPS and APMs. Based on what Acting CMS Administrator Dr. Andy Slavitt indicated in his blog post from September 8, CMS is listening and reinforcing exactly that kind of thought. Dr. Slavitt shared a preview of what we should see in final rulemaking of four options for the 2017 performance period (impacting payment adjustments for 2019) to help Eligible Clinicians transition to full implementation of the MIPS composite measure scoring and APM related incentives by the 2018 performance period. ECs can do everything from what nearly amounts to status quo and conduct minimal reporting activities of the kind CMS has defined under MIPS, to choosing to report MIPS domains for a more limited reporting period than a full year with a more moderate payment adjustment effect to full scale with their 2017 efforts under MIPS or to even seek Qualified APM participant status. We do not yet know all of the details, but presume that other policies, such as the ability to use 2014 Edition CEHRT or 2015 Edition CEHRT to support MIPS ACI and to have alternative basis of measurement for a full adoption of MIPS in 2017, will remain in place. Some other details such as how the decision to participate using one of the options CMS will adopt at a group or individual level remain to be seen in the final rule. However, we applaud CMS for recognizing the need to provide for a smoother transition which will truly allow for ECs to be able to keep their head as MACRA’s provisions get fully implemented by 2018.