The implementation of MACRA is purposely paced to allow providers the time to understand what is required of them and what choices they should make to comply, but with changes this large, many in the industry remain concerned about their readiness — and their colleagues'.
Monday marked the deadline for clinicians opting to only submit 90 days of quality data to start collecting performance data for the Quality Payment Program's (QPP) Merit-based Incentive Payment System (MIPS). The data must be handed over to the CMS by March 31, 2018.
While some clinicians have been collecting data since the start of the year, many are still struggling to understand the program’s requirements and what they need to do to comply. According to the American Medical Association, fewer than one in four physicians feel they are prepared to meet QPP requirements. CMS has committed $100 million over five years to assist smaller practices in meeting MACRA requirements, but some wonder if that's enough.
Lots of clinicians are still trying to understand the whole alphabet soup of MACRA, QPP, MIPS and more, says Michael Abrams, co-founder and managing partner of Numerof & Associates. “They need help figuring out if they’re exempt and, if not, where to go from there.”
For data collection in 2017, clinicians must participate in QPP if they are part of an advanced payment model (APM) or bill Medicare Part B more than $30,000 and care for more than 100 Medicare patients annually. Under MIPS, eligible clinicians need to select six metrics, including one outcome measure from three performance categories — quality, advancing care information (ACI) and improvement activities.
Clinicians don’t need to do much this year to keep their heads above water, notes Abrams. It’s mostly a symbolic effort. Those that submit a full year's worth of data could earn a positive adjustment, depending on what the data show.
May the metrics be ever in your favor
The choice of metrics is important because it will determine what questions providers ask, what data they collect and, ultimately, changes in clinical practice behavior. But with over 300 options, the task of selecting metrics can be daunting. In the clinical improvement category, there are over 90 options, some of them specialty specific. For a multi-specialty practice, the number of possibilities can be exponential.
Beginning in 2019, a fourth category kicks in and 30% of participants’ scores will be tied to costs. “Where we see a lot of work is really trying to get ahead of what that cost score is going to be,” says Tom Lee, CEO of SA Ignite, a Chicago-based health IT company that provides comprehensive solutions for MIPS.
For larger organizations with lots of specialists who have a lot of Part B payments, “preparedness means getting a running start on 2018 with 2019 in mind,” he tells Healthcare Dive. “It’s not just about doing the bare minimum for 2017.”
Providers need to consider long-term impacts to their business
Lee notes that not all providers will follow his advice. A lot of clinicians are just trying to avoid a penalty for this year without having a long-range strategy for managing MIPS.
Clinicians that score above the MIPS performance threshold get increasing incentives; those that fall short are penalized. Organizations that realize MIPS is a competitive program, because everything is benchmarked, will want to pick the best measures to optimize their score on an ongoing basis, Lee says, especially since the scores will eventually be publicly reported by CMS.
It’s not just about short-term reimbursement from CMS. Beyond being publicly reported to both consumers and parties, including commercial insurers, the score stays on the permanent resume of every clinician. “I think there’s a wide lack of knowledge about really the game that they’re playing and how deep and far-reaching and how long-term the impacts are,” Lee says.
Lee says demand for digital solutions has picked up “big time” as the October deadline approaches. “The C-suite is very charged up about this,” he says, “This is not a year-by-year check the box program that you can wash clean year after year. The effects are pretty lasting … and it has got big strategic implications.”
Digital solutions are evolving for consumers' needs
For now, Munson Healthcare in Traverse City, Mich., is relying on tools provided by the state — via the federal government — that allow providers to calculate MIPS scores and do some analysis. “We have not really looked for any other products outside of what our EHR vendor is providing and what the state is providing,” says Randi Terry, director of information services at Munson.
All of the major EHR vendors offer MACRA solutions. Cerner began providing guidance and resources to its customers on how best to leverage its solutions to meet QPP requirements in mid-2016. The company has tools that allow clinicians to verify their eligibility for the program, calculate their composite performance score by compiling measurement data from the EHR for the ACI and quality categories for MIPS, and manually input their improvement activities, says Sam Grefrath, director of regulatory compliance practice for the EHR vendor. Cerner has also enhanced reporting capabilities of its systems to support program requirements where necessary.
“We’ve seen an increase in demand for analytics to monitor eligible clinicians’ performance in the program and efficiency in data capture for clinicians in their workflow,” Grefrath tells Healthcare Dive.
He says providers remain focused on finding EHRs that can provide the most efficient data capture for their clinicians while not losing sight of the patient story and clinical care.
Epic, too, has developed products in response to the program, including tools for monitoring QPP performance for both MIPS and APM tracks.
“So far, our users tell us they feel prepared for submission this year and anticipate scoring well,” says Sasha TerMaat, a director at Epic. “What they want for MIPS specifically is to understand how CMS is going to apply the algorithm to score them, which we show them in dashboards and scorecards.”
Other health IT companies offer a combination of products and services to meet MIPS requirements. SA Ignite’s MIPS platform helps users decide which measures will optimize their quality score and which improvement methods will support that goal, predict their quality scores under different scenarios and monitor performance against benchmarks.
Any tool the marketplace may want needs to be able to analyze not just the current year’s data but prior years’ data as well, says Abrams. “Once they have the tools that support rational decisions about which metrics to use, what comes next is … reports that provide insights on how to move forward improving quality of care and reducing costs,” he tells Healthcare Dive.
Providers need to pay attention to what the data look like and what their response is. If there are outlier clinicians in an organization, there needs to be some action to improve the overall score, he says.
Yet with all the IT solutions and efforts to help clinicians prepare for MACRA and MIPS, the road ahead could be bumpy.
“We don’t believe the hurdles are too high, but the complexity of the program undercuts the potential for better care and lower costs,” says Greg Carey, senior government and regulatory affairs manager at athenahealth.
“Even with the increase in potential for exemptions, the relationship between CMS’ value-based programs and physician burnout grows stronger every day,” he tells Healthcare Dive. While clinicians will be rated on the cost and quality of care they deliver, access to CMS cost and quality data remains largely out of reach.
CMS has been sensitive to providers’ concerns about readiness for QPP and MIPS and the reporting burden, and included new options like virtual groups in its 2018 QPP proposed rule. The agency also allowed for more exemptions from the program by raising the low patient volume threshold to $90,000. After all the exemptions, CMS expects just 36% of clinicians will be eligible for MIPS, though that share represents 58% of Part B charges.
However, Lee cautions providers not to reach too quickly for that exemption. Many MIPS improvement goals align with improvements practices already are making with respect to quality and reducing cost, and not having a MIPS score could hurt if a local competitor is scoring 95 or 100.
“If you’re going to do the work anyway just to survive as a healthcare organization, regardless of the size, MIPS could be a real strategic benefit for you,” he says.