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MACRA considerations for physicians in 2017

Joncé Smith, Vice President of Revenue Cycle Management, Stoltenberg Consulting
Written by: Joncé Smith

Entering 2017 brings a huge degree of uncertainty amid major healthcare industry changes. In particular, the Medicare Access and CHIP Reauthorization Act (MACRA) holds several options for Medicare physician payment paths as healthcare providers interpret implications and exemption possibilities.

MACRA replaces the old sustainable growth-rate (SGR) formula for physician payment, shifting focus from the fee-for-service model to value-based care. Physicians must now pick from one of two reimbursement tracks: the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).

To help you better understand MACRA, we’ve outlined the program’s tracks below.

APM Breakdown: What you need to know

Advanced Alternative Payment Models (APMs) represent one path for physician reimbursement under MACRA, although it will likely be the path less traveled.

At this point, if your organization is still confused or working out reporting and interoperability capabilities, you’re likely not prepared for APMs for the first reporting period.

Models that qualify for the APM track include the Comprehensive ESRD Care Model (Large Dialysis Organization arrangement), Medicare Shared Savings Program (Track 2), Medicare Shared Savings Program (Track 3), Next Generation ACO Model, Comprehensive Primary Care Plus (CPC+) and Oncology Care Model Two-Sided Risk Arrangement.

APMs also include ACO or Patient-Centered Medical Home Models, such as the Medicare ACO Track 1+ for 2018, which offers lower risk than other ACOs. Recently, CMS added additional opportunities to join advanced APMs after the MACRA Final Rule passed, including a new voluntary bundled payment model, Comprehensive Care for Joint Replacement Payment Model (Certified EHR Technology track) and Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT track) in 2018. 

MIPS breakdown

Under the Merit-based Incentive Payment System (MIPS), reimbursement is based on success in quality metrics, resource use, clinical practice improvement and advancing care information categories. Performance tracking for MIPS begins January 1, 2017, with reported data submission due by March 31, 2018, for the 2019 adjustment payment period. In the 2017 performance year, physicians may earn or lose a potential four percent of reimbursements with payment adjustments made in January of 2019. The adjustment potential then grows to nine percent in 2022.

Within the first two reporting years, physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists are included under MIPS. These healthcare providers must generate at least $30,000 in Medicare Part B billing and provide service to at least 100 Medicare patients per year to participate. CMS is considering an expansion to the program by year three to include physical therapists, occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists and dieticians.

MIPS reporting

After a long period of industry feedback, CMS announced reporting flexibility under MIPS, which reduced the “Advancing Care” category measures from 11 to five. The change aims to help less-advanced providers meet requirements, while allowing payment adjustments for those with more advanced capabilities. Requiring at least 90 days of reporting, the Advancing Care category makes up 25 percent of performance consideration and includes security risk analysis (PHI protection), e-prescribing, providing patient electronic access, sending summary of care (Public Health and Clinical Data Registry) and requesting/accepting summary of care (Health Information Exchange). As opposed to the EHR Incentive Program (or “meaningful use” program), this category does not require all-or-nothing EHR measurement or quarterly reporting.

Additional MIPS performance categories include Quality (50 percent of performance consideration), Cost (10 percent), and Clinical Practice Improvements (CPI) (15 percent). Under the Quality category, clinicians may now choose to report six measures instead of the nine required under the Physician Quality Reporting System (PQRS). The Cost category score is based on Medicare claims, which requires no additional reporting from physicians. It uses more than 40 episode-specific measures to account for differentiations among specialties. Finally, under the CPI category, physicians are rewarded for activities like patient safety and care coordination.

Pick your own pace

CMS made additional reporting depth options under MIPS as well. Providers can essentially pick how much they would like to participate in MIPS for the 2017 reporting year. If submitting under a test pace, clinicians can submit some data after Jan. 1, 2017, for neutral or small payment adjustments. However, they must complete an option of one quality measure, one improvement activity or the required Advancing Care information measures. Physicians can also submit a partial year of reporting with 90-day data after Jan. 1, 2017, for small positive payment adjustments. For the more advanced participants, a full year can be reported for modest positive payment adjustments. If physicians choose not to participate at all, payment adjustment penalizes four percent.

Choosing a path and moving forward

With 2017 as the initial MACRA reporting year, CMS is offering flexibility with the test pace to avoid negative payment adjustment. Reporting on one clinical practice improvement activity is the easiest way to avoid payment penalty for many. However, if a practice can report on a full year, it will gain the full four percent payment increase, qualify for possible bonuses and be better prepared for the stricter full 2018 reporting requirements. Therefore, it’s in your practice’s best interest to consider if simply checking the box for 2017 reporting is right if your practice, in an effort to prepare for the future and maximize value.

Healthcare providers should optimize their data with metrics that clearly measure clinical outcomes, while specifically analyzing data trends instead of simply collecting data. Care coordination and interoperability will only increase in significance with MACRA, especially under APMs, so providers must look ahead. Continue to educate yourself on the changing reimbursement landscape, reporting requirements and coordination opportunities. Note when industry professional organizations, like CHIME, push back against MACRA Final Rule requirements and monitor how CMS responds. Spread understanding to clinicians across a practice, instead of siloing information with leadership.

Third-party advisors will serve as necessary resources for many organizations, considering the continued reporting confusion surrounding MACRA and already limited physician time due to EHR fatigue. Instead of missing out on reporting opportunities, proactively reach out to resources that can guide the best path forward.