Seeking greater flexibility, MACRA's MIPS could be more confusing for clinicians in 2018
On June 20, CMS released its much-anticipated 2018 Quality Payment Program proposed rule, aimed at simplifying reporting requirements for year two of the program implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and beyond.
MACRA will eliminate the sustainable growth rate formula and replace it with a 0.5% annual rate increase through 2019, after which physicians are encouraged to shift to one of two Quality Payment Programs: 1) Merit-Based Incentive Payment System (MIPS) or 2): Alternative Payment Model (APM). The new proposed rule would amend some requirements for both tracks and includes policies to increase participation.
Notably, the 2018 proposal exempts an additional 134,000 clinicians from MIPS by raising the low-volume threshold to $90,000 or less in Medicare Part B charges or 200 or fewer Medicare patients a year. The original threshold, established in last October’s final rule, was $30,000 in Part B charges or 100 Medicare patients. The proposal continues CMS’ approach in allowing for the flexibility of MACRA onboarding.
The broader exemptions don’t surprise Jeff Coughlin, senior director of federal and state affairs at HIMSS. “Directionally, this is where we thought the rule would head,” he tells Healthcare Dive, adding that HHS Secretary Tom Price has a unique lens to look at reporting and regulatory burden given his background in medicine. “I think the focus is not going to go away in terms of ensuring that there is some flexibility for clinicians, but that the underlying push [for value-based care] is still there,” he says.
Too much wiggle room?
Not everyone is happy about providing even greater flexibility. “MACRA in its original form was extremely flexible, maybe even more flexible than it needed to be or than was actually wise,” says Michael Abrams, managing partner at Numerof & Associates. “If the point is to minimize the burden on physicians, keep it simple.”
Rather than easing the administrative burden, Abrams worries that physicians will be forced to spend even more time trying to understand and comply with the 2018 requirements, or hire outside consultants to provide guidance.
He also questions the message the administration is sending about the urgency of getting to higher quality and better value versus not making members of the medical community uncomfortable. “[HHS Secretary Price is] very sympathetic to the imposition of accountability where it has never been imposed before," Abrams says. "The point is to find a smart way to minimize the burden without undercutting the point of the whole effort, which is what I think we’re potentially doing here.”
Making sense of data
The prospect of more and more physicians being able to opt out of MIPS raises questions about how useful the data that are collected will be in achieving MACRA’s goals. CMS itself has said this a concern. “When you’re going to have large blocs of providers who would not have to participate, it’s going to mess up your benchmark data for quality measures and it’s going to mess up the overall trends,” Naomi Levinthal, practice manager for research at Advisory Board Company, tells Healthcare Dive.
On the bright side, the exemptions are not likely to last forever. A stated goal of the QPP is to create additional pathways for people to be able to participate in MIPS and Advanced APMs, so the overall number of participants is expected to keep growing. Experts should have a better sense of how many providers ultimately have nothing to do with MIPS by years three, four and five, Levinthal says.
Three types of providers to watch are those newly enrolled in Medicare who will never have an adjustment; those who make it onto the APM track; and clinicians that fell short of qualifying for the APM threshold that can choose to participate in MIPS or stay out.
Virtual group reporting a positive sign for VBC continuation
For 2018, CMS is also introducing the concept of virtual groups. Under the proposal, a virtual group is defined as a combination of two or more solo practitioners or a group of 10 or fewer clinicians joining up with another solo practitioner or group for purposes of reporting. The new option shows CMS’ sensitivity to providers’ concerns about readiness for QPP and the reporting burden.
“It’s another positive sign for the entire push to value-based care,” says Coughlin. He adds that HIMSS will be reviewing the option closely as it prepares its comments on the proposed rule.
But while virtual groups might mitigate overhead costs and the administrative effort involved in MIPS reporting, the reality might not be so easy, warns Abrams. “When you factor in the necessity for these cooperating solo or small groups to draft up contracts between them about their respective responsibilities and the possibility that delays or deficits by some of the players can impair the results for the rest of the players, you’ve got to wonder whether the net-net of this effort can actually come out that way,” he tells Healthcare Dive.
Cost measures are looming
While CMS will continue weighting cost at 0% for 2018, MACRA requires that it increase to at least 30% by year three of the program. For hospitals that are subject to MIPS, that could be a game changer because most hospitals have little idea about utilization and how utilization varies by physician, says Coughlin. “For most hospitals, this is a black box.”
Levinthal points to the Value-Based Payment Modifier Program, which QPP sunsets, as an indication of how providers might perform on cost measures. Most providers clustered around the mid-range of performance with few hitting high or very low marks. “What that suggests is that people do basically just average on those measures, and it’s difficult to figure out how to change sometimes because it has a lot to do with the types of codes that are used to characterize your patients,” she says.
EHR technology requirements could be different for clinicians, providers
The proposed rule also relaxes the timeline for clinicians to implement 2015-certified EHR technology, allowing them to continue using EHRs certified to the 2014 Edition for the 2018 performance period. The delay is CMS’ nod to physician concerns that not many EHR vendors have products certified to 2015 specifications.
While physicians can continue to use 2014-certified EHRs for 2018, CMS makes clear its goal to have all providers transition to 2015-certified software with APIs and greater interoperability. To encourage that move, the agency is offering physicians who report Advancing Care Information objectives and measures using 2015-certified EHRs for the entire year a bonus of up to 10 percentage points.
“It is a great compromise of not requiring the use of 2015-certified software, but incentivizing those providers who are able to use it,” says Coughlin.
It also marks the first time that CMS would have differing EHR timelines for upgrading EHRs for providers subject to the ACI requirements than hospitals, notes Levinthal. CMS could address hospital's timelines in August when it is set to finalize the 2018 Medicare Inpatient Prospective Payment Systems rule (the proposed rule was released in April).
Does it all make a difference?
Ultimately, the performance scores that providers end up — both on cost and quality — could mean the difference between rising or falling patient volume. CMS plans to post composite scores for providers on a website capable of being searched by consumers, and with the trend toward greater consumerism in healthcare, it’s likely that more people could use the website to shop for providers who rate high on quality and performance while keeping costs low.
Providers have expressed concern about the data being published and the implications for purchasing behavior in the future, says Levinthal. “It’s very important for medical groups and health systems to be aware of the ratings that are published about their providers,” she adds.
And the impact might not end with consumers. Abrams believes MIPS scores could also influence commercial payers’ decisions about which providers to include in their networks.
MACRA/QPP no doubt will change the operations and efficiencies of many clinicians. As the program continues, it will be important to track exactly who and how.
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