JANUARY 7, 2019

Welcome to the MACRA MIPS/APM Update eNewsletter
Editor: Philip L. Ronning
This issue sponsored by the
National Pay for Performance (PfP) Summit, the National Population Health Colloquium,
and the Combined National ACO, Bundled Payment, and MACRA Summit.

MIPS Rewards Are Too Small, and That's Okay
The pay-for-performance program for clinicians who treat Medicare patients has a problem: the incentives it offers to promote better and cheaper care are too small to accomplish that goal, a situation that will likely persist over time for many practices. Ironically, this challenge to the program's effectiveness actually points to ways to make it stronger by encouraging the Centers for Medicare & Medicaid Services (CMS), the agency that runs the program, to focus on continually simplifying the program and measuring what truly matters. The Merit-based Incentive Payment System (MIPS), as the incentive program is known, is a newer nationwide pay-for-performance program that grades clinicians enrolled in Medicare on quality, cost, engagement in practice improvement activities, and the effective use of electronic health record (EHR) technology. Clinicians who perform very well can earn potentially large incentives. The challenge is that MIPS must be budget-neutral by law. This means that, despite the potentially large rewards available to clinicians, actual rewards to clinicians who perform well cannot exceed penalties collected from those who perform poorly. CMS has adopted many policies to help clinicians succeed under MIPS, but if most succeed and only a few are penalized, actual rewards will be small. As an exception to the budget neutrality requirement, $500 million is available annually from 2019 through 2024 to fund additional rewards for exceptional performance, but these additional incentives have been similarly attenuated by the high number of clinicians qualifying for them (more than 70 percent of clinicians subject to MIPS in the program's first year). (Mathematica, December 14, 2018)

Check Now: Your 2018 MIPS Eligibility Status May Have Changed
CMS is asking physicians to take a few minutes to review, via the Quality Payment Program (QPP) Participation Status Tool,(qpp.cms.gov) their eligibility for the 2018 Merit-based Incentive Payment System (MIPS). In an email to physicians, the agency noted that physicians' initial 2018 MIPS status may have changed, and some physicians may, in fact, no longer be eligible to participate. CMS conducted an initial review of Medicare Part B claims dated Sept. 1, 2016, to Aug. 31, 2017, and updated physicians' status based on a second review from Sept. 1, 2017, to Aug. 31, 2018. Several factors, detailed below, may affect an individual's eligibility status. If a physician joined a new practice after Aug. 31, 2018, he or she would not be eligible to participate in MIPS as an individual but could receive a MIPS payment adjustment based on the practice group's participation in MIPS. Furthermore, a physician's eligibility status could be affected by changes made to the MIPS low-volume threshold in 2018. Specifically, clinicians and groups are now excluded from MIPS if they:

  • billed $90,000 or less in Medicare Part B allowed charges for covered professional services during either of the two determination periods (Sept. 1, 2016, to Aug. 31, 2017, or Sept. 1, 2017, to Aug. 31, 2018); or
  • provided covered professional services to 200 or fewer Medicare Part B-enrolled patients during either of these periods.

CMS reiterated that an eligible clinician or group must exceed both of the criteria listed above to achieve MIPS eligibility. (AAFP, December 5, 2018)

MACRA MIPS 2019 Highlights: What You Need to Know!

(AdvancedMD, December 11, 2018)

As End of Summer Nears, Clinicians Should Prepare for 'Junior Year' of MACRA
On July 12, 2018, the U.S. Centers for Medicare and Medicaid Services (CMS) released proposed changes for the third year of the Quality Payment Program (QPP) under MACRA, and proposed updates for the Medicare physician fee schedule. I find it interesting that CMS decided to combine the Medicare physician fee schedule with proposed MACRA changes. This is like receiving an extensive summer reading assignment before the start of a challenging school year. Recognizing that MACRA is a significant and disruptive change, Congress gave hospitals and clinicians time to ease into the new payment models. In 2017, it wasn't difficult for clinicians to report at least one measure and avoid the negative payment adjustments. But this is changing as CMS is proposing to increase the performance thresholds under the Merit-based Incentive Payment System (MIPS). What this means is for clinicians whose payments are under MIPS, the plusses and minuses are going to be larger. They are going to see bigger swings and MACRA will start to look more like the law that Congress intended. The agency uses a MIPS final score -- between 0 and 100 points -- to determine which clinicians will receive a negative, neutral, or positive adjustment to their Medicare Part B payments. For the 2017 and 2018 performance years, CMS set the performance threshold at 3 points and 15 points, respectively (see table, below). The low threshold early on was an effort to limit the application of negative payment adjustments while MACRA's QPP is implemented. Under the proposal, the performance thresholds -- the point at which a qualified practitioner receives either a neutral or positive payment adjustment or a negative payment adjustment -- would increase from 15 points in 2018 to 30 points in 2019. The proposed payment range also increases. The program is budget-neutral, which means the positive payment adjustments must be offset by negative adjustments.

The table below summarized MIPS performance thresholds for performance the first three performance years.

In a sense, MACRA has been grading on a curve since 2017, but that curve is going to get wider in 2019. The top performers will reap the biggest rewards, and the lower-performers will see deeper cuts. For 2018, clinicians will see favorable adjustments as high as +5, and negative adjustments as low as -5. (The Wall Street Journal, August 2018)

4 Ways to Prepare for MACRA in 2019
The new year is fast approaching, and practices must keep pace with evolving Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) policies. With the new final reporting rule, it is often difficult to balance optimizing the revenue cycle while monitoring impacts on performance scores and operational workflows. To combat these challenges, practices can apply the following four tips to enhance cash flow while being mindful of MACRA's Merit-based Incentive Payment System (MIPS) reporting requirements:

  1. Prepare for major changes for MIPS Year 3.
  2. Strategize MIPS performance category submissions.
  3. Ensure more conscientious registration processes.
  4. Encourage patient portal participation.

Fully comprehending the evolving MACRA changes can be extremely difficult for already strained practice staff. By following these four recommendations, practices can improve their collections and documentation workflows, maximize reimbursement opportunities, and improve practice operations significantly. (Physicians Practice, December 18, 2018)

Vast Majority of Doctors Will Get a Pay Bump Under MIPS -- But It Won't Be Much
Most doctors and other clinicians did OK in the first year of the Merit-based Incentive Payment System (MIPS). More than 90% of the doctors and clinicians who participated in MIPS will receive a pay bump based on their performance in 2017, said CMS administrator Seema Verma in a blog post about the program implemented under MACRA in which clinicians receive either a positive, negative or neutral payment adjustment based on their performance. However, it won't be much. Even those with the highest performance scores only earned a 1.88% positive adjustment. That left many physicians disheartened. At last month's Medical Group Management annual conference, one official commented that those low MIPS payments left many physicians "feeling like it was just for nothing." (FierceHealthcare, November 8, 2018)

What Doctors Need to Know About MACRA's New Patient Relationship Codes
Doctors may have heard plenty about MACRA. But they may be far less familiar when it comes to new patient relationship categories and codes. But, according to a perspective piece in the New England Journal of Medicine, they are one of the "more important provisions" of the Medicare Access and CHIP Reauthorization Act (MACRA). And they may ultimately be tied to physicians' payments under the Merit-Based Incentive Payment System (MIPS). he billing-code modifiers, which allow clinicians to report their relationship to a patient at a given point in time and for a particular service rendered, kicked on January 1, 2018 on a voluntary basis. They help Medicare determine the extent to which a provider is responsible for elements of a patient's care. (FierceHealthcare, December 13, 2018)

Telemedicine: The Promise and the Performance

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