MIPS - Continuum Health · mips reporting started in 2017, with payment effects first hitting in...
Transcript of MIPS - Continuum Health · mips reporting started in 2017, with payment effects first hitting in...
®
Doctors need to act now — or risk losing ground
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MIPS: HOW PHYSICIANS
CAN WIN IN THE
NEW HEALTHCARE
ENVIRONMENT
Continuum Health Alliance, LLC402 Lippincott DriveMarlton, NJ 08053856.782.3300www.continuumhealth.net
CHANGES TO MEDICARE WILL SOON HAVE A MAJOR IMPACT ON PHYSICIANS’ BOTTOM
LINES. THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) IS FAST-TRACKING ITS
SHIFT TO VALUE-BASED PAYMENTS, WITH THE INTRODUCTION OF NEW REGULATIONS,
REPORTING REQUIREMENTS AND FINANCIAL CONSEQUENCES.
As a result, physicians could experience a substantial difference in their Medicare
Part B payments. Whether that change is positive or negative, though, depends
upon their preparedness.
For most private-practice physicians, the situation demands immediate attention.
That’s because each year’s reported data will affect payments two years later.
Moreover, Medicare is switching from an incentive-based system to one with
mounting penalties. Independent practices are especially vulnerable due to the
complexity of these changes. Even solo practitioners will be affected.
THE GOOD NEWS: Doctors can take incremental steps to address these changes.
But it’s vital to move forward now.
The United States will spend
nearly 20% of its gross
domestic product (GDP) on
healthcare by 2026, according
to an analysis from CMS1
Healthcare Costs as a Percentage
of GDP 2026
THE SOONER YOU ACT, THE BETTER YOU’LL PROTECT YOUR PRACTICE AND YOUR LIVELIHOOD.
Regardless of size,
it’s generally more
cost-efficient for private
practices to outsource
the management of this
multi-faceted transition.
Employer & Employee
Insurance Cost Increase
Employee and employer insurance
costs continue to rise with a 5.5%
increase expected in 20185
America ranks first in healthcare spending—
at $3 trillion annually3—but life expectancy
places 43rd worldwide4
2017
Healthcare Spendingin U.S. is
#1
U.S. Life Expectancy
Ranking:
#43
2018
C O N T I N U U M H E A LT H | 2
$ of today’s
healthcare
spending
A N E S T I M A T E D
i s W A S T E F U L
$2
20%
HOW did we get here?
The government and other stakeholders have realized that healthcare spending is on
an unsustainable path. Costs continue to rise significantly (though at a slower pace),
quality often lags, and excessive waste persists.
To solve this growing crisis, the federal government is leading a shift from “volume”
to “value.” It’s changing the old system that rewarded quantity of care to one that
centers on quality of care. The Medicare Access & CHIP Reauthorization Act
(MACRA) of 2015 provides the overarching framework for this transition.
Commercial payers are adopting similar models.
In fact, the transformation started approximately ten years ago with the introduction
of the Physician Quality Reporting System (PQRS), followed by Meaningful Use (MU)
incentives.
In 2010, the Affordable Care Act established the Value-Based Payment Modifier
(VBM or VM)—an adjustment to physician fee schedules that ties payment to
quality. CMS began phase-in of the VBM in 2015, based on 2013 reporting.
In 2017, CMS launched the Merit-Based Incentive Payment System (MIPS), a more
complex program that incorporates the VBM and other value measures.
While change is never easy, doctors must adapt in order to survive. Like it or
not, this new reality is here to stay: it has strong bipartisan support, the industry is
already heavily invested, and the technology now exists to enable it.
Moreover, greater transparency is coming for both price and quality—as increased
data collection, market competition and consumer demand converge.
“THERE IS NO TURNING BACK TO AN UNSUSTAINABLE SYSTEM
THAT PAYS FOR PROCEDURES RATHER THAN VALUE... THE ONLY
OPTION IS TO CHARGE FORWARD — FOR HHS TO TAKE BOLDER
ACTION AND FOR PROVIDERS AND PAYERS TO JOIN WITH US.”
— Alex Azar, Health and Human Services Secretary,
speaking at a March 2018 hospital convention
Medicare’s QualityGoals: + +
BETTER CARE SMARTER SPENDING HEALTHIER PEOPLE6
$
C O N T I N U U M H E A LT H | 3
TODAY’S IMPERATIVES: FOR PHYSICIANS, IT’S SINK-OR-SWIM TIME. THE
WATERS OF THIS PARADIGM SHIFT CONTINUE TO RISE EACH YEAR. VIRTUALLY ALL DOCTORS
WILL BE AFFECTED BY THESE CHANGES, WHICH INCLUDE SUBSTANTIAL PENALTIES FOR THOSE
WHO UNDERPERFORM ON QUALITY AND COST MEASURES IN COMPARISON TO THEIR PEERS.
On the plus side, physicians who perform well under the new rules will receive
additional reimbursement from Medicare. And commercial payers are starting to
create similar opportunities.
If you’re just starting to address these changes, prioritize the Merit-Based Incentive
Payment System (MIPS). But first, it’s helpful to understand MIPS’s predecessor—
the Value-Based Payment Modifier (VBM)—which has been wrapped into MIPS.
VBM had its final reporting period in 2016, and 2018 is its final payment year.
Reporting has now shifted to the more complex, higher-stakes MIPS.
PQRS
The Physician Quality
Reporting System
requires physicians
and other eligible
professionals (EPs) to
report quality data in
order to avoid Medicare
payment penalties. This
program is replaced by
MIPS reporting in 2018.
VBM
The Value-Based Payment Modifier applied additional payment incentives and penalties based on a com-bination of PQRS perfor-mance data and Medicare cost data. VBM could also consider claims-based outcomes measures and patient surveys (CAHPS —Consumer Assessment of Health Providers and Systems). VBM reporting ended in 2016, but its mea-sures are now part of MIPS.
MU/ACI
Meaningful Use (MU)
is providers’ use of
certified electronic
health record (EHR)
technology in ways
that measurably
improve quality and
value. This has been
replaced by Advanc-
ing Care Information
(ACI) measures.
CMS evaluates practices
as a group if they share
a single tax ID number.
Therefore, all practice
members must perform
strongly to ensure the
group’s success.
VBM: A Quick ReviewCMS began using the VBM in the 2015 payment year,
starting with groups of 100-plus eligible profession-
als (EPs), and expanding to smaller practices and solo
practitioners by 2017. The amount of potential payment
adjustments was linked to the size of the group: larger
practices could have greater swings than smaller
practices. As with MIPS, the adjustments are required to
be budget-neutral; in other words, the national totals for
penalties and incentives must cancel each other out. For
the 2016 reporting year (2018 payment year), payment
adjustments will range from -2% to +6.6%.7
C O N T I N U U M H E A LT H | 4
MIPS: Getting Started
The Merit-Based Incentive Payment System (MIPS) is a new algorithm that
encompasses the previous models—MU,* PQRS and VBM—and adds “Clinical
Practice Improvement” activities. Created under MACRA, MIPS replaces Medicare’s
troubled physician reimbursement model, known as the Sustainable Growth Rate
(SGR) formula. (*MU has been replaced by Advancing Care Information (ACI),
which includes measures related to patient engagement, patient electronic
access, and use of certified electronic health record technology.)
This table shows the four components of MIPS and their relative weights:
COMPONENTS OF MIPS (MIPS score: 0 – 100 points)
“TECHNOLOGY IS UNLEASHING LOTS OF WAYS TO
MAKE CARE ACCESSIBLE, MORE PATIENT-CENTERED,
MORE EFFICIENT AND LESS COSTLY.”
— Margaret O’Kane, President, National
Committee For Quality Assurance (NCQA)
Key Terms ACI: advancing care information
ACO: accountable care organization
APM: alternative payment model
CHIP: Children’s Health Insurance Program
CIN: clinically integrated network
CMS: Centers for Medicare &
Medicaid Services
EP: eligible professional
MACRA: Medicare Access &
CHIP Reauthorization Act
ACI (successor to MU)
25%
VBM Cost 10% in 2018
30% in 2019
Clinical PracticeImprovement
15%
PQRS/VBM Quality
50%
25%
30%
10% 15%
50%
MIPS: Merit-Based Incentive Payment System
MU: meaningful use
NCQA: National Committee for Quality Assurance
PQRS: Physician Quality Reporting System
VBM: Value-Based Payment Modifier (a.k.a. VM)
C O N T I N U U M H E A LT H | 5
MIPS reporting started in 2017, WITH PAYMENT EFFECTS FIRST
HITTING IN 2019. THE IMPACT CAN BE EXPONENTIAL: IN MIPS’S FIRST YEAR, ADJUSTMENTS
TO A PRACTICE’S MEDICARE PAYMENTS CAN RANGE FROM -4% TO ABOUT +19%. BY 2020,
THOSE FIGURES COULD SPAN FROM -9% TO +27% OR MORE. (THE SCALING FACTOR “X,”
SHOWN IN THE TABLE BELOW, IS CAPPED AT 3.0. THEREFORE, THE MAXIMUM BASE INCENTIVE
FOR THE 2020 PERFORMANCE YEAR COULD, IN THEORY, BE +9% * 3.0 = 27%.)
Exemptions and AdditionsIf you do little Medicare billing, you may be exempt from MIPS. CMS has expanded
the low-volume threshold to exclude providers with less than $90,000 in Medicare
Part B charges or less than 200 Part B beneficiaries annually.
PerformanceYear
2017
2019
2018
2020
2019
2021
2020
2022
-4%
-7%
-5%
-9%
+4%X
(CMS predicts X = 0.86)
+7%X
+9%X
+5%X
(CMS predicts X = 0.30)
+10%Y
(CMS predicts Y = 1.52)
+10%Y
+10%Y
+10%Y
(CMS predicts Y = 1.75)
PaymentYear
Max.Penalty
MaximumBase Incentive*
Max. ExceptionalPerformance
Bonus**
MIPS Maximum Payment Adjustments8
However, small practices—those with 1 to 10 physicians—can band together vir-
tually (regardless of their geographic locations or clinical specialties) to report
on MIPS measures. As a group, they are assessed and scored collectively.
In addition, non-physician EPs will be subject to the VBM component of MIPS
starting in 2018. These include physician assistants, nurse practitioners, clinical
nurse specialists, certified registered nurse anesthetists and anesthesiologist
assistants.
MIPS can have an enormous effect on a practice—growing or shrinking its
Medicare reimbursements substantially.
* A scaling factor (X) may be applied to maintain MIPS’s budget neutrality.
** Top performers also qualify for an “exceptional performance bonus” on top of their base incentive. A scaling
factor (Y) may be used.
C O N T I N U U M H E A LT H | 6
TIPS for succeeding under MIPS
With MIPS under way, there’s no time to waste. Physicians must dedicate
themselves to being “quality champions” and make sure they have the data to
prove it, in order to receive rewards and avoid penalties under MIPS. Doctors
need to score high on quality measures while keeping the overall cost of care low.
If you’ve participated in VBM, you have a head start. Understanding how you’re
measured under VBM will help you address MIPS requirements.
THE FOLLOWING STRATEGIES CAN HELP YOU ACHIEVE THESE GOALS:
n Focus on patient attribution. CMS attributes each patient annually to a physician
based on the majority of primary care utilization. Yet, if your patient sees other
doctors, the quality and cost of that care—good or bad—will be attributed to
you. Make sure to communicate with these other physicians to improve care
coordination and avoid duplicate services.
n Improve patient access. Ensuring your patients receive the right care in the right
place at the right time is critical to keeping costs down. Provide a way for patients
to reach your practice 24/7—by phone, online portal or mobile app, for instance—
to help avoid unnecessary emergency-room visits and other inefficiencies. Reach
out to complex patients to proactively manage their care.
n Enhance MIPS participation. All non-exempt physicians must report MIPS
data or face Medicare penalties. However, each practice chooses which quality
measures to report on (within certain parameters)—and can emphasize
measures that reflect the highest levels of quality. For example, if 98% of your
diabetic patients had their annual foot exam this year, you’ll want to report on
that measure. To best make such determinations, physicians must have an
electronic health record (EHR) and use it meaningfully. In essence, the EHR must
be able to capture the appropriate data and report it back. For that to happen,
the EHR must contain the right fields, and doctors must be trained to enter the
data properly.
The “Clinical Practice Improvement” component of MIPS offers
more than 100 options to choose from, including such activities as:
• Being an NCQA-designated patient-centered medical home
• Providing expanded practice access, such as same-day
appointments
• Conducting population health management activities
• Providing care coordination, including patient
engagement activity
• Providing self-management training to patients
C O N T I N U U M H E A LT H | 7
n Track performance. Practices can assess quality in several ways. Your EHR should
be able to run reports on quality. You can also obtain Quality and Resource Use
Reports (QRUR) from CMS; these provide feedback on quality, which can help
you estimate how you will fare under MIPS and where you need to improve. A
well-qualified enablement partner can provide additional tools, analysis and
advice to monitor and improve quality.
n Reduce overall costs. Although costs cannot be tracked because this data is
not available across providers, practices can help minimize costs of care. Key
strategies include providing enhanced patient access (as previously noted),
engaging patients in their own care, enhancing work flows to increase efficiency,
making referrals to like-minded (value-driven) physicians, and becoming clinically
integrated—such as by joining a clinically integrated network (CIN) or
accountable care organization (ACO). CINs are described in more detail later.
n Button down your data. CMS requires practices to provide data, and they may
audit your practice. Determine how you will document quality. Make sure you
can prove the information you report.
n Stay informed. MIPS quality measures will be updated annually, and the
program’s requirements are subject to change.
Unique Insight Into Costs Unlike other enablement
partners, Continuum has access to physician cost data
through its collaboration with CMS and commercial
payers. This data allows Continuum to provide physi-
cians with high-quality, lower-cost provider options.
MIPS requires investments of time and resources.
The right enablement partner can do the heavy
lifting—freeing doctors to be
doctors, and ensuring the
practice’s continued success.
®
C O N T I N U U M H E A LT H | 8
New MIPS Challenges & Improvements
CMS will continue to revise and update MIPS. For instance, providers must now
report a full year of data, and the completeness requirements have increased.
CMS also plans to remove measures considered “topped out” or “too easy”
over a four-year period, and it has reduced the possible earned points for
these measures.
On the plus side, CMS has added 21 new Clinical Practice Improvement Activities
to choose from. And it’s considering new, “episode-based” cost measures for 2019,
which could present a new opportunity to providers.
For more on recent changes to MIPS, download our white paper titled Value-
Based Care in Uncertain Times: Navigating the Quality Payment Program.
Go to: https://www.continuumhealth.net/insights/white-papers/
An Alternative to MIPS
Beginning in 2019, physicians can avoid MIPS by participating in an advanced
alternative-payment model (advanced APM), such as certain ACOs, medical homes
or bundled payment models. Advanced APM participants could earn higher
payments in exchange for greater financial risk, compared to MIPS participants.
In fact, MACRA’s long-term objective is to shift more clinicians to Advanced APMs
and away from the MIPS program. In the meantime, MIPS participation can help
prepare practices for that step.
For more information on advanced APMs,
download our white paper titled “The
New Gold Standard in Quality Payments:
Alternative Payment Models.”
“WE’RE AT THIS MOMENT OF OPPORTUNITY TO REALLY LOOK
AT HOW WE DELIVER CARE AND HOW WE PAY PHYSICIANS.
WE’RE NOW TRYING TO START WITH A CLEAN SLATE AND
ENABLE A PAYMENT SYSTEM THAT SUPPORTS OUR GOALS …”
— Margaret O’Kane, President, NCQA
®
Should your practice reach for the gold?
®
APMs: The New Gold
Standard in
Quality Payments:
Alternative
Payment Models.
Continuum Health Alliance, LLC402 Lippincott DriveMarlton, NJ 08053856.782.3300fax 856.782.3526
C O N T I N U U M H E A LT H | 9
One leading solution is to form a clinically integrated
network (CIN), which enables physicians to join together
to improve quality, reduce overall costs, and earn more
revenue through MIPS. CINs can also facilitate larger
payments from commercial insurers, as more payers
follow CMS’s lead and adopt value-based reimbursement
programs. (Similarly, doctors can form an accountable care
organization [ACO]—a type of CIN specifically designed
for Medicare.)
An enablement partner can help design, set up and manage the CIN, providing the
necessary personnel support, technology and expertise for a successful network.
A Better Future
Medicare’s transition to value-based reimbursement will ultimately drive a higher
quality, more sustainable healthcare system. While the changes can be daunting,
physicians need to recognize these shifts and embrace them—for the benefit of their
patients, society and themselves. Doctors must understand how their performance
will be judged and apply this knowledge.
Physicians who adapt will also benefit from the greater levels of transparency
coming to the medical profession. In fact, if you see Medicare patients, some of
your quality data may already be online at medicare.gov/physiciancompare. Greater
access to such information will further reward quality and raise the bar for the entire
medical profession.
New Opportunities: AS STATED EARLIER, PRIVATE-PRACTICE PHYSICIANS
MUST ALIGN WITH OTHER PROVIDERS IN ORDER TO SURVIVE AND THRIVE IN THE NEW
HEALTHCARE ENVIRONMENT. HOWEVER, MANY ARE WONDERING HOW THEY CAN DO
THIS WHILE REMAINING INDEPENDENT.
THIS IS “A HISTORIC OPPORTUNITY TO FINALLY MOVE TO A
SYSTEM THAT PROMOTES QUALITY OVER QUANTITY AND
BEGINS THE IMPORTANT WORK OF ADDRESSING MEDICARE’S
STRUCTURAL ISSUES.”
— Congressman Fred Upton, Chairman,House Energy
and Commerce Committee
C O N T I N U U M H E A LT H | 1 0
IMPROVE QUALITY
REDUCE OVERALL COSTS
EARN MORE REVENUE
CLINICALLY INTEGRATED NETWORKS CAN:
ABOUT Continuum Health
As a physician enablement company, Continuum Health delivers managed
solutions to provider groups and aggregators, helping foster self-sufficiency
by maximizing fee-for-service payments, transitioning them to value-based
programs and preparing them for risk. Continuum also collaborates with payers
to help drive value-based adoption among providers and improve the health
outcomes of patients. The company optimizes performance through value-based
care, practice management services, revenue cycle management, and specialty
care solutions. Thousands of physicians, specialists and nurse practitioners caring
for millions of patients depend on Continuum’s business and clinical experts to
help achieve their goals. Learn more at www.continuumhealth.net.
Related white papers:
n Value-Based Care in Uncertain Times: Navigating the Quality Payment Program
n The New Gold Standard in Quality Payments: Alternative Payment Models
Go to: https://www.continuumhealth.net/insights/white-papers/
Disclaimer: CMS rules and regulations are subject to change over time.
Sources1 National Health Expenditure Projections, 2017–26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth Cuckler, Sisko, Poisal, et al.; Health Affairs 2018 37:3, 482-492
2 http://www.dartmouthatlas.org/downloads/press/Skinner_Fisher_ DA_05_10.pdf - page iii
https://khn.org/morning-breakout/iom-report/
3 https://www.cms.gov/research-statistics-data-and-systems/statistics-trends- and-reports/nationalhealthexpenddata/downloads/highlights.pdf
4 https://www.cia.gov/library/publications/the-world-factbook/rankorder/ 2102rank.html
5 https://www.shrm.org/ResourcesAndTools/hr-topics/benefits/Pages/ employers-benefits-costs-rise.aspx
6 Medicare’s Quality Goals (GRAPHIC): www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/ MACRA-MIPS-and-APMs/Draft-CMS-Quality-Measure-Development- Plan-MDP.pdf - page 13
7 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ PhysicianFeedbackProgram/2016-QRUR.html
8 https://www.saignite.com/industry-expertise/quality-payment-program/ mips-education/10-faqs-about-mips/
Continuum Health Alliance, LLC402 Lippincott DriveMarlton, NJ 08053856.782.3300www.continuumhealth.net
®