Starting in 2019, Medicare's push toward value-based reimbursements will be within reach of the finish line. "It can sound terrifying," says Joni Wyatt, MHA, MHIA, CPHIMS, FHIMSS with Kassouf & Co. "But most practices have already done the work."
Resulting from passage of the Medicare Access and CHIP Reauthorization Act (MACRA) last year, the new system will present Medicare providers with two payment options. The Alternative Payment Model (APM) covers providers involved in CMS-approved programs, such as Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMH). "APMs are not common here," Wyatt says. "One of my concerns is physicians thinking they're part of an APM and exempt from reporting, when they're not."
In Alabama, most Medicare physicians will only qualify for the second payment option -- the Merit-based Incentive Payment System (MIPS). This program bases the reimbursement percentage on how well each provider scores in multiple areas in relation to their peers. "CMS will apply risk adjusters to make it an apples-to-apples comparison," Wyatt says, such as accommodating for cost disparities in equipment based on geography or patient acuity.
The data used to determine the MIPS scores for 2019 will be reported by providers throughout 2017. "The final rules from CMS aren't expected until this November, so dates could change," Wyatt says.
But waiting on final dates before taking action could be a costly mistake, warns Tammie Olson, CPC, CPCO, with Management Resource Group (MRG). "We saw with the other incentive programs -- and even ICD-10 -- providers who waited until the last minute suffered penalties and revenue loss because they were not prepared."
Wyatt adds that MACRA, and especially MIPS, should not be alarming. "It may be new in name, but the concept is not new. Penalty versus incentive is not new, and performance compared to peers is not new."
"The only thing that surprises me about MACRA is how fast the program is being implemented," Olson says. "This can cause problems, as we have seen in some of the other incentive programs started by Medicare."
Fortunately, MIPS not only replaces other current incentive programs, but mimics them, which could smooth its implementation.
Made up of four components, which are each weighted differently, MIPS combines those four scores to produce a provider's overall composite score. "So the good news is that if you've been doing the work for the other incentive programs, then you're likely 75 percent ready," Wyatt says.
Half of a MIPS score depends on quality. "Quality measures are very similar to the Physician Quality Reporting System (PQRS) measures previously submitted to Medicare," Wyatt says. "So the pieces are in place, but you'll still have to pay attention to the details that will come with the final rule." EHRs will likely be able to provide the data so it will hopefully only be a matter of learning what to report to fulfill this section.
Another 25 percent of the score derives from the Advancing Care Information (ACI) component, which resembles Meaningful Use (MU) metrics. "Under MU, it was all or nothing," Wyatt says. "But under ACI, practices receive credit for any completed measures."
The only component with no direct relation to any previous programs counts for 15 percent of the overall score. Called Clinical Practice Improvements, it covers nine categories filled with 90 activities that can each help a provider boost their score. For instance, offering weekend hours gains points under Expanded Practice Access. Other activities cited include telehealth services, coordination of care, and diabetes screening for patients with bipolar disorder. "The biggest obstacle is going to be how to overcome the administrative burden of collecting the data needed for the metrics," Olson says.
"All of these activities are proposed at this point," Wyatt says, adding that some sort of confirmation is due in November. "The silver lining is that these activities may already be implemented, and this will give you a chance to get credit for them."
The last component, called Resource Use, requires no reporting. Because it is an assessment of how much the provider spends, CMS can pull the data straight from each provider's claims.
"The best thing for providers to do now is an internal gap analysis," Wyatt says. This can be done by visiting the CMS portal. "The QRUR [Quality Resource and Use Reports] will show you your gaps in PQRS, what measures you're reporting and how your reporting matches the benchmark." Providers can also see their indicators on cost, and should already know whether they are meeting MU. "Even though the QRURs are from a previous reporting period, practices will get a good idea of where they might be under MIPS," she says.
Olson says providers need to evaluate the source of any penalties under PQRS and MU. "And use your professional societies as a resource. Attend their meetings about MACRA," she says. "This is a huge move and will have a definite impact on providers' payments. You need to start now."
She also warns that politics will not stop the implementation of MACRA. "The biggest misconception is that this will go away with a new administration," Olson says. "Because it is law, MACRA can only be abolished if Congress votes to repeal it. That is unlikely, since it received bipartisan support when it passed."
Wyatt agrees. "It's not going to cease to exist altogether," she says. "Value-based reimbursement is now in play."