The first two years of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP) are in the books and many organizations are wondering if their strong performances will ever be met with a significant upside adjustment.
Year 1 (2017) enjoyed very high participation levels, 95% of eligible clinicians, but very low upside adjustments. Between the Test Pace option, artificially low bar (3 points) for an upside adjustment, and numerous opportunities to score bonus points, only very few eligible providers (5%) were negatively adjusted.
As we work through 2019, including substantial changes to eligibility, performance requirements and removing the claims submission method from group practices of 16 or more, many hospitals and larger practices are beginning to understand MACRA as a business change and not just another quality reporting requirement asking for additional administrative resources and data submission. In other words, there is the realization that shifting from volume to value is not about compliance but about fundamentally changing how health care is reimbursed in the United States.
And as the saying goes, “but wait, there’s more!” in addition to a paradigm shift in reimbursement models, the Quality Payment Program continues to mandate expanding patient access and upgrading EHR technologies.
Taken together, the MACRA QPP is enforcing a health care reimbursement model that is designed to promote better outcomes, encourage greater technology utilization and manage/reduce the per capita cost of care.
Let’s dive a little deeper on the “how this is done” and explore a few important considerations for success in a post-MACRA value-based healthcare reality.
1. From CEO to part-time staff – MACRA impacts everyone
The Affordable Care Act revolutionized how Medicare reimbursements are determined and has irrevocably shifted the Fee-for-Service (FFS) paradigm and payer-to-provider relationship. This new reality compels successful health systems to understand the impact of these regulatory changes on each role in a health care organization.
QPP analytics solutions must have executive leadership in mind while providers must make sure they don’t lose the trees for the forest.
To effectively monitor and manage quality-to-cost ratios, a provider’s analytics solution should consist of an online dashboard that highlights all four MIPS reporting categories. Even if reporting via an Advanced Alternative Payment Model (APM), having a command of quality scores (Quality), cost scores (Cost), technology scores (Promoting Interoperability) and improvement ideas (Improvement Activities), is key to augmenting a company’s value-index. For example, nurturing better outcomes while managing costs, inpatient versus outpatient care, etc.
Providers must ensure that all members of their organization understand value-driven goals and are prepared for any imminent operational changes. Sophisticated analytics and meaningful reports are mission critical in this regard and will help to communicate the business needs and implementation considerations at each level across the organization.
Keeping constant communication with all stakeholders during these transition years to value is critical to mission success. Being prepared to educate the stakeholders, including IT support, will only make achieving this success that much easier.
It is not uncommon for IT staff to be wary of introducing new applications to “their” infrastructure or if the organization plans to develop analytics tools in-house, to be sensitive to resource strain, both in terms of system stress as well as staff availability.
2. Reporting as a group or individual
Depending on the size of your eligible reporting population and performance scores, the next consideration an organization needs to make is weighing the benefits of submitting as a group, i.e. TIN level, versus as individuals at the National Provider Identifier (NPI) level.
As a general guideline, unless there is specific reason not to, practices of all sizes should attempt to report as a group as this will better prepare the reporting entity for future APM reporting, as well as avoid the implications of a NPI being on the Physician Compare website, which ranks physicians with a one to five-star rating and posts these scores online. But having said that, individuals with strong independent scores and a total greater than their respective TIN, should consider submitting as an individual as well. Submitting as an individual will not preclude someone from being counted among their group if the group’s score is greater. On the other hand, if their personal score is greater, the Centers for Medicare and Medicaid Services (CMS) will use the individual’s higher score to determine his or her adjustment rate.
3. Your best path forward
In Year 3, individual eligible clinicians can submit measures via multiple collection types (MIPS CQM, eCQM, QCDR measures, and for small practices, Medicare Part B claims measures).
The most common submission mechanisms are through a Registry or QCDR (Qualified Clinical Data Registry) vendor, directly from an EHR, or through Administrative Claims – but this will change in the 2019 reporting year as organizations of 16 or more clinicians will need to submit via Registry (or EHR).
How you submit your data is important because the scoring thresholds for a given measure vary based on the submission method. For example, a Quality measure with a 90 percent performance score submitted through claims may award six points where that same performance score submitted via a registry would award 9.5 points out of 10.
4. Bonus points are available, get them wherever possible!
Leverage bonus points as another way to improve your MIPS final score. Two MIPS categories include bonus points – Quality and Promoting Interoperability (PI, formerly Advancing Care Information) – as well as high-risk care and year-over-year improvement.
The Improvement Activities (IA) category can earn 10 bonus points for Promoting Interoperability by completing at least one of the specified activities using a CEHRT, with the maximum number of bonus points allowed in the Promoting Interoperability category maxing out at 25.
As of Year 2, the 2018 performance year, MIPS-eligible clinicians are awarded five bonus points for the treatment of complex-care patients based on the Hierarchical Condition Categories (HCCs) definition and the number of complex patients treated by a practice. Needless to say, practices must ensure they are properly documenting/coding risk identifiers and including this information with their claims.
Small practices with 15 or fewer eligible clinicians (ECs) that submit data for at least one performance category will receive six bonus points on top of their MIPS Quality score.
5. Review your Quality Resource Use Report
Every organization and practice should ensure it has an Enterprise Identity Management (EIDM), informally known as a CMS user login. The EIDM is used to review annual Quality Resource Use Report (QRUR) – which highlights how a practice has scored in the areas of Cost and Quality – and review Quality Payment Program feedback reports.
6. Transform “data” into actionable “intelligence”
True value only comes from reliable data that has been cleared of duplication, reviewed and corrected from errors, while accurately mapped to support comprehensive analytics to create meaningful dashboards. The importance of actionable data creates the need to audit reports every few months to ensure the practice’s analytics data is reliable and maintains the highest trust with its consumers.
There is a natural tendency to manage MACRA as a matter of compliance, similar to the regulatory change from ICD-9 to ICD-10. But moving to value-based care is larger than a procedural change and will take years to define and longer yet to master.
7. Utilize resources found on the QPP website
Visit the QPP website at qpp.cms.gov to check participation status.
CMS continues to improve their technology and the resources available to participants monthly. Providers should stay current on the latest releases and software updates from CMS as they regularly develop and release tools to make quality reporting easier.
8. Capture quality codes now so you won’t have to backfill them later
Imagine automating 80 percent of your quality reporting tasks! Getting to this point could be as simple as adding one to three additional codes to a patient encounter. Once an organization captures those additional codes, CPT II for example, they should ensure that their data is accurate and that they are capturing enough information to enable add-on analytics and monitoring tools to streamline quality reporting and performance analysis directly from the data in the EHR.
A complete dataset is fundamentally important to streamline quality reporting and will move an organization from a position of ‘did you put those codes in?’ or ‘where can we find that information?’ to ‘where can we go from here?’ and ‘what strategic analysis can we draw from this information?’
A relatively small change in coding practices can significantly move an organization towards realizing their organizational goals and automate their value-index reports on a regular basis, sometimes in real-time!
9. Remember that the proposed rule is NOT the final rule
Be flexible. CMS continuously receives feedback on regulations and measure definitions that will inevitably result in differences between the proposed rule and the final rule. In other words, practices should not assume what the final rule is going to say and absolutely avoid hard-coding a solution based on the proposed rules. A practice’s development and data team(s) should anticipate spending time towards the end of the year to react to what the final rule ends up being.
10. Show me the money!
The multimillion-dollar question is “What do organizations need to do to successfully navigate MACRA and stay on top of the QPP curve?” If your practice is providing great quality but at an above-average cost, start exploring cost management solutions such as bundled payments and risk-based contracting. If your costs are competitive but your patients are “getting what they paid for” then you need to investigate improving outcomes and incorporating best practices.
If you’re not sure what your exact issues are, or where to improve, or how to identify the root cause of some issues, then you need to find that out, and fast! The value-guided healthcare train has left the station and if you’re going to thrive under these new models then you need to align your organization for success. Get in front of your data, identify your Value-Index Position (VIP) and begin to take the steps necessary to improve your VIP ASAP.
Clinicians reading this article demonstrate that their heads are in the right place. The next step now is to ensure that your technology is sound and that development is underway for a business-wide MACRA education and value implementation strategy.
About Moshe Starkman
Moshe Starkman is the Senior Director, Value-Based Reimbursement at nThrive, specializing in value-based reimbursements with an emphasis on MACRA and bundled payments. He is an accomplished small business owner and popular public speaker. He has over 20 years of experience as a software architect and has developed solutions for several medical societies, the United States Postal Service, a team of former FBI investigators, and two leading presidential campaigns. Between his knowledge of the industry and his technology savvy, Moshe is a sought-after leader in the transition to value-driven health care throughout the U.S.
