Robert A. Dowling, MDThe Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) establishes the Merit-Based Incentive Payment System (MIPS) to measure quality and resource use and adjust payments to providers based on performance in these and other categories. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for implementing MACRA, and while the details are not final, they give a clear indication that most urologists will be subject to MIPS payment adjustments (see “MACRA pay models: What you can expect")
and will need to understand the basics of the incentive program in order to thrive.
In this second installment in a series, I will address who is covered by MIPS, how and when you will be measured, and how and when you will receive your payment adjustment.
Who is covered by MIPS?
MIPS is the default incentive program, and everyone is in MIPS unless they meet one of three exceptions: first year of participation in Medicare, do not exceed a low volume threshold of Medicare payments or patients, or qualifying participation in an advanced alternative payment model (as defined by CMS). CMS estimates that over 85% of urologists in the Medicare Part B program will be in MIPS.
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The proposed rule further clarifies that physicians, physician assistants, nurse practitioners, and clinical nurse specialists will be subject to MIPS at the outset, and in subsequent years physical therapists and almost every other type of health care professional who bills Medicare will be measured and paid under MIPS. Finally, the proposed implementation will allow clinicians in groups to participate in MIPS as individuals or as a group.
How and when will you be measured under MIPS? MACRA stipulates that the first payment adjustments will occur as positive or negative fee schedule adjustments in 2019 (payment year). The proposed rule clarifies that, as with all previous payment adjustment programs under CMS, the performance period will begin 2 years earlier and be an entire year (with a few exceptions).
CMS expects to have issued a final rule by fall 2016 and has clearly signaled an intention to implement MIPS performance measurement in January 2017. For example, the proposed rule outlines alternative paths forward through the first 2 years of MIPS measurement (2017 and 2018) that roughly map to the existing meaningful use stages—which MIPS would replace.
Next: The composite performance score
The composite performance score
MIPS creates a composite performance score to measure and benchmark all eligible clinicians with a complicated formula. The MACRA-defined categories (and their relative weight) that comprise this composite score are Quality Performance (50% decreasing to 30% in year 3), Cost (also known as Resource Use) (10% increasing to 30% in year 3), Advancing Care Information (25%), and Clinical Practice Improvement Activities (15%).
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Each of the categories has its own measurement complexity, but the simplest way to think about MIPS is this: The Quality Performance category will inherit the framework of Physician Quality Reporting System (PQRS) measures and replace that program, the Cost category will inherit the framework of and replace the Value-Based Modifier (VBM) Payment program, and the Advancing Care Information category will inherit objectives and measures from and replace the meaningful use program. The Clinical Practice Improvement Activities category, which is a new area that I hope to discuss in a future article, involves attesting to activities or processes (from a large menu and only for a 90-day period) that have been widely recognized to improve the health of patients or populations such as care coordination, patient engagement, or patient safety. The individual category scores are multiplied by their weight to arrive at a single MIPS composite score for the performance period for each eligible clinician (or group).
This is the primary determinant of the MIPS composite score at program inception. CMS proposes to require six measures chosen from a menu of existing and new PQRS measures (some existing measures are proposed to be deleted). A clinician’s score on each quality measure is determined by actual performance compared to a historically derived benchmark for that individual measure. Urologists who have participated in the PQRS program to date can find their historical performance on measures in their quality and resource use report (QRUR) downloadable from the CMS website, and begin to understand how they will be scored under MIPS.
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While the proposed measures and specialty sets do include some new options for urologists, from a practical perspective, the measures available for Quality Performance reporting under MIPS will be determined by which measures are actually reportable via one of several methods. For example, if a clinician elects to submit quality measures through “EHR reporting,” that EHR would have to be certified for each measure so reported; many EHRs are currently certified for only a limited number of measures. Some EHRs may send information to a third party such as a qualified clinical data registry (QCDR), which in turn calculates the measures; that QCDR could not report on measures for which the baseline data is not available. Finally, MACRA calls for new measures to be added each year; it will take EHR vendors weeks or months to develop, implement, and certify new measures.
Next: Cost, Advancing Care Information
Clinicians will be measured on cost as they are today under the VBM program. Historical results are also available on the QRUR report. CMS will attribute the costs and calculate the score based on claims data and require no reporting by clinicians for the three measures: total per capita cost, Medicare spending per beneficiary, and episode measures if applicable. There are three episode measures that could be triggered by a urology care event: prostatectomy for prostate cancer, transurethral resection of the prostate for BPH, and kidney and urinary tract infection. Urologists should examine their QRUR reports and determine whether costs under the VBM have been attributed by one of these episodes to better understand their exposure under MIPS.
Advancing Care Information
. This replaces and simplifies the meaningful use program. There is a path defined with options for providers who were planning to attest for Stage 2 or 3 in 2017, and Stage 3 in 2018. The score in this category involves a qualitative score for participating in six activities, and a quantitative score for performance in three of those areas: patient electronic access, coordination of care through patient engagement, and health information exchange.
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All of the proposed objectives and measures map to the current Stage 3 requirements, and several Stage 3 requirements have been eliminated or made optional (for example, reporting to a specialized registry is now optional). As with the current meaningful use timeline, clinicians and their EHR vendors will need to upgrade to the 2015 certified EHR edition by Jan. 1, 2018 to report under MIPS.
Next: Pay adjustments will be begin in 2016
Pay adjustments will begin in 2019
MIPS payment adjustments will begin in 2019, when the physician fee schedule is adjusted up or down based on 2017 MIPS composite score performance compared to the average: A clinician who is below average will receive a negative adjustment, and a clinician who is above average will receive a positive adjustment. The maximum adjustment is +/–4% in the first year, and this increases to +/–9% in subsequent years. Clinicians with exceptional performance are eligible for positive adjustments up to three times the maximum, and clinicians scoring under the 25% negative percentile receive the maximum negative adjustment (see table
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CMS estimates that in urology, there will be more winners (clinicians with positive adjustments) than losers under MIPS in year 1.
Bottom line: Absent any major legislative reform, MACRA is the law of the land and will be implemented and in effect by Jan. 1, 2017. The major theme is payment linked to quality and cost, and most urologists will start in MIPS. Urologists can begin to prepare now by reviewing their PQRS feedback reports and their annual QRUR for the most recent available year. In addition, practices should develop a strategy for monitoring performance on Quality Performance, Cost, Advancing Clinical Information, and Clinical Practice Improvement Activities now—and deciding whether it makes sense to report as individuals or as a group. Some additional investment in tracking mechanisms may be necessary to maximize reimbursement in the new world of MIPS.
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