Climbing Up the Risk Ladder: How National ACO Has Built a Winning Value-Based Care Infrastructure | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Climbing Up the Risk Ladder: How National ACO Has Built a Winning Value-Based Care Infrastructure

September 27, 2018
by Rajiv Leventhal, Managing Editor
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The organization’s president and chief medical officer discusses the ACO’s journey into risk while offering comment on a recent controversial policy proposal

A physician-owned and operated accountable care organization (ACO) that got up-and-running in 2013, National ACO—headquartered in Beverly Hills, Calif., but with providers in multiple states—has progressed through the federal ACO ranks in a way that potentially could set the path for others as they prepare for their risk-based journeys.

In January 2013, National ACO, with provider networks in multiple states, including California, Nevada, Tennessee and Pennsylvania, started on its Medicare ACO expedition by entering the MSSP (Medicare Shared Savings Program) Track 1 model. At that time, it was also approved for what was called an advanced payment model, becoming one of just 35 ACOs in the nation that received this opportunity. The 35 ACOs each received up-front funds from the government as a loan to the ACO, so they could begin to operate, and provide an infrastructure and foundation to move forward.  

“Our model is to help community-based physicians, providers and suppliers not only survive, but thrive, as U.S. healthcare [continues] to change,” says Alex Foxman, M.D., National ACO president and chief medical officer. “We are not localized to one area; we look for aligned performing providers all over the nation, and we see if we can move them from volume to value,” he adds.

In 2013, National ACO started with a small number of providers, having just 21 Tax ID numbers and 5,600 attributed lives, but by 2016, that grew to approximately 130 participating providers and about 11,000 attributed lives. In that span, says Foxman, the organization achieved savings for Medicare in three separate years, and in two of those years, it achieved shared savings of more than 4 percent, which equals approximately $3 million each year back to National ACO.

In 2017, National ACO moved into the Next Generation ACO model, which involves two-sided risk. Foxman, which notes that there are only a few community-based physician-owned and operated ACOs in the Next Gen program, says that when National ACO first began in this model, it had 21,000 attributed lives, and now has approximately 31,000.

“We were attracted to the Next Gen model because we clearly saw there were flaws at that time in the MSSP,” he says. Explaining further, Foxman believes that one flaw in the MSSP was that attribution was provided on a quarterly basis, so if the ACO had a panel of beneficiaries that it was managing aggressively, suddenly in the next quarter these beneficiaries could leave with new ones coming in. “It became challenging for us to manage a population in the MSSP. That turnover [rate] was as high as 10 percent every quarter,” he says.

Alex Foxman, M.D.

What’s more, Foxman continues, when the ACO did achieve savings, per the MSSP rules, it had to perform against itself in the following year to beat that those savings—rather than perform against other ACOs. “So we were constantly fighting against ourselves when we were being successful,” he says.

And yet another challenge with the MSSP was the benchmarking methodology was not on a regional level, but on a much broader level. Foxman notes that “The cost of healthcare and healthcare are really different in different regions, and our goal was to expand our organization nationally, so that became a real challenge as well.”

All put together, National ACO leaders were attracted to the innovation in the Next Gen model since they saw that this was the next iteration and the next step to take risk. “All of healthcare is moving to risk-based programs, similar to Medicare Advantage programs. The enhancements provided within the Next Gen program, including reimbursable telehealth waivers, three-day skilled nursing facility (SNF) waivers, and additional services for mobile visits, became attractive to us,” he says.

Building a Successful ACO

Foxman says that different programs were built into the ACO to help its providers manage the patients as well to try to help prevent unnecessary hospitalizations, nursing home utilization, and ER visits. One example of this is via a mobile medical practice called Mobile Physician Associates, which Foxman helped create, and helps serve the needs of the home bound, frail elderly and disabled populations of Southern California. Another offering is an app that Foxman developed called PriveMD, which he says is analogous to an Uber for doctors, in that it works to deploy providers to a patient’s home or community setting quickly to decrease the chances he or she goes to a hospital or nursing home.

What’s more, National ACO is also implementing programs to help manage its high-risk patients, and is embracing analytics by utilizing the power of all the claims data it is receiving from CMS (the Centers for Medicare & Medicaid Services). It’s now able to integrate with ADT (admission, discharge, transfer) feeds, as well as with all of the various EHRs (electronic health records) in its physician population. “We are able to get the most information we can to identify an understand our population, and to hyper-manage those patients who make up the bulk of our costs and have the highest risk,” Foxman says.

To this end, National ACO has also partnered with The Garage, an Orlando-based population health management technology company, utilizing its SaaS-based population health management platform, Bridge, to streamline data collection and reporting across physician practice locations in the different states.

Foxman, who attests that “data is king or queen in our program,” admits that this is the fourth analytics platform the organization has used. In 2013, when National ACO first started out, the value-based platforms that were available did not fit the ACO’s needs, as they were more for capitated and HMO-type environments, he explains. After that didn’t work out, the ACO’s executives linked up with a third party to build its own analytics platform. “That worked out OK for the MSSP, but as we moved into models where we had to integrate data from labs, from HIEs (health information exchanges), from ADT feeds, and from electronic health companies, having everything available in one platform—including patient health records, referral managers, secure messaging, and telehealth—was critical. So we then went out and performed an RFP in 2017, narrowed it down, and chose The Garage.”

Indeed, the platform arms National ACO with comprehensive population health management solutions, including tools and resources for care coordination and connectivity, member engagement, care management, and more. The cloud-based platform also leverages innovative technology, such as artificial intelligence, telemedicine and predictive modeling, officials noted.

For others that are in a physician-owned and operated community-based model, Foxman stresses the need to look carefully at one’s provider population—particularly that the people being brought in are aligned and they will comply with the program. In these types of programs, he explains, once providers are in, and their attributed beneficiaries are in, they are in for the whole year. “You have to make sure that it’s something you vet ahead of time,” Foxman advises.

At the same time, there is no reason to start “big,” he says, noting that CMS has programs where even individual doctors will be able to take the plunge into risk, including its Direct Provider Contracting model that is currently being considered, in which physicians can be in risk-based agreements with CMS for their patient population.

Thoughts on Controversial ACO Policy

Across the ACO landscape these days exists much controversy around a recent CMS proposed rule that shortens the time ACOs can spend in one-sided risk models while limiting their shared savings. The idea, per the proposal, is to push ACOs into two-sided risk models as the government believes upside-only risk programs cost Medicare money and are not effective.

While different stakeholders have varying viewpoints on this proposal, Foxman has a strong take on the matter, and believes that “accountability is very important in the healthcare system.” He says, “If you are running a program where there is no downside risk and little responsibility for reigning in the costs, it won’t be a very successful program across the board. By bringing in that ‘skin in the game’ concept into healthcare, we will help greatly and quickly accelerate the alignment we need for all of us to succeed. Until a provider takes out his or her wallet and has to virtually pay for the services that are being provided either inside or outside the office, he or she will not feel that concern financially that will help us reign in costs.”

What’s more, regarding the likelihood that some ACOs that will certainly leave the MSSP program if this rule gets finalized, Foxman notes that “There will always be bail threats, but the reality is Medicare is the largest health insurer in the world, and providers will only have certain options moving forward.” He adds, “We know that volume-based care doesn’t work because there is no alignment among the different components of healthcare for us to manage the patient in a population-based environment.”

Foxman attests that if hospitals continue to fill the beds, if nursing homes continue to keep their bed days high, if home health agencies continue to recertify patients, and if physicians continue to see more and more patients in their offices despite reimbursement going down, “we are circling the drain in failure moving forward.”

He adds that “significant and powerful action” is needed to preserve the healthcare system moving forward. And the industry has seen that in other risk-based environments—such as Medicare Advantage, IPAs (independent practice associations) and HMOs that are taking on risk—this works. “The initial fear of taking on risk is a very visceral response and that’s understandable; it will take some time for everyone to move forward and be successful,” he says. “But if CMS provides us with support, that sting may not be as strong as it is now when you’re taking on risk.”

 

 


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Healthcare Industry Could Save $12.4B With Full Adoption of Electronic Transactions

January 17, 2019
by Heather Landi, Associate Editor
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The healthcare industry continues to make progress automating business processes, but significant gaps remain, representing an opportunity for $12.4 billion in savings through further automation, according to new data from the 2018 CAQH Index.

Electronic adoption and transaction volume increased in 2018, with several common transactions reaching 80 percent electronic adoption across the sector, according to the latest CAQH Index. This progress resulted in a narrowing of the cost savings opportunity for the first time in CAQH Index history.

CAQH is a Washington, D.C.-based non-profit alliance of health plans and trade associations. The findings from the 2018 CAQH Index are based on voluntary nationwide surveys of providers, as well as commercial medical and dental health plans. Participating medical health plans represent over 160 million covered lives—nearly 49 percent of the commercially insured U.S. population—and 7.8 billion transactions conducted in 2018.

The sixth annual CAQH Index is an annual report tracking the adoption of HIPAA-mandated and other electronic administrative transactions between healthcare providers and health plans in the medical and dental industries. These transactions include verifying a patient’s insurance coverage, obtaining authorization for care, submitting a claim and supplemental medical information and sending and receiving payments. The CAQH Index also estimates the annual volume of these transactions, their cost and the time needed to complete them.

By benchmarking progress, industry and government can more easily identify barriers that may be preventing stakeholders from realizing the full benefit of electronic administrative transactions. These insights can prompt new initiatives to address and reduce barriers. For the report, data was submitted by medical and dental plans that cover roughly half of the insured population in the United States and providers representing a range of specialties.

After reporting modest progress over the past few years, the 2018 CAQH Index findings suggest more positive change is occurring in the industry overall. Healthcare industry stakeholders made progress on many fronts this year—in adoption of electronic transactions, reductions in the volume of manual transactions and reductions in the remaining savings opportunity.

“The results highlighted in the 2018 Index are encouraging,” Kristine Burnaska, director of research and measurement at CAQH, said in a statement. “Both providers and health plans are saving time and reducing administrative costs, but more effort is needed to significantly reduce the volume of expensive, time consuming manual processing.”

While the overall volume of transactions in the medical industry increased by 18 percent in the past year, the volume of manual transactions declined, falling 6 percent for health plans and 1 percent for providers, according to the CAQH Index.

Medical industry adoption of electronic eligibility and benefit verification increased six percentage points to 85 percent in 2018; adoption of electronic coordination of benefits rose to 80 percent in 2018, up from 75 percent in 2017. Adoption of electronic claim submission stands at 96 percent and 71 percent of healthcare organizations have adopted electronic claim status inquiries.

However, the healthcare industry made little progress in the adoption of other electronic administrative transactions—only 12 percent of organizations have adopted electronic prior authorization, although that is up from 8 percent the year before. Adoption of electronic claim payment stands at 63 percent and less than half of healthcare organizations (48 percent) have adopted electronic remittance advice processes.

However, continued efforts are needed to significantly reduce the volume of expensive, time-consuming manual transactions and adapt to the changing administrative needs of the healthcare system, according to the CAQH Index. The Index estimates that the medical and dental industries could save an additional $12.4 billion annually with full adoption of electronic administrative transactions, particularly through greater automation by providers, which could save an additional $8.5 billion.

During a period of rising transaction volume, the medical industry shaved $1.3 billion from its savings opportunity, bringing it to $9.8 billion.

The Index also highlights a substantial rise in overall transaction volume, growing in parallel with industry complexity. As these trends persist, the Index finds that the industry would benefit from updated standards, operating rules, infrastructure and functionality that can accommodate the increase in volume and growing complexity associated with the need to connect administrative and clinical data elements in value-based payment models.

“The industry is making progress,” April Todd, senior vice president, CORE and Explorations at CAQH, said in a statement. “But, we are at an inflection point where processes and technology must adapt to a healthcare system that is transitioning to value-based payment and becoming increasingly complex.”

The CAQH Index notes that industry complexity is growing in parallel with transaction volume. “As these trends persist, the industry will benefit from standards, operating rules, infrastructure and functionality that can accommodate both the increase in volume and the growing complexity associated with varying plan and payment models designed to increase the value and quality of healthcare for consumers. There is a need for all stakeholders to support initiatives that lay the groundwork for the future,” the report authors wrote.

The CAQH Index also issued a number calls to action for the healthcare industry, including focusing efforts to address cost savings opportunities. Several transactions offer the greatest potential for savings and should be the subject of attention—transactions include eligibility and benefit verification, claim status, remittance advice and prior authorization. The medical industry could save an additional $4 billion on eligibility and benefit verifications and $2.6 billion on claim status transactions by fully adopting electronic transactions, according to the CAQH Index.

CAQH also recommends accelerating standards and operating rule development and encouraging timely vendor adoption of standards and operating rules.

 

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Has CMS Just Tipped the Scales Towards Provider Alienation, in its ACO Final Rule?

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CMS’s release of its final rule on MSSP ACO participation has pushed the healthcare industry into a very fraught moment in the ongoing evolution of the ACO experiment

As Healthcare Informatics Associate Editor Heather Landi reported on Dec. 21, that morning, “The Centers for Medicare & Medicaid Services (CMS) on Friday morning published a final rule that makes sweeping changes to the Medicare Shared Savings (MSSP) Accountable Care Organization (ACO) program, with the goal to push Medicare ACOs more quickly into two-sided risk models.”

Indeed, as Landi noted in her report, “Referred to as ‘Pathways to Success,’ the Trump Administration’s overhaul of Medicare’s ACO program will redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase in higher levels of risk; and the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.”

And, Landi noted, “Currently, the MSSP model includes three tracks and is structured to allow ACOs to gain experience with the program before transitioning to performance-based risk. The vast majority of Shared Savings Program ACOs have chosen to enter and maximize the allowed time under Track 1, which is an ‘upside-only’ risk model. MSSP Tracks 2 and 3 involve downside risk, but participation in these tracks has been limited thus far.”

One of the biggest points of contention in recent months as centered on how aggressive a push on the part of CMS to compel providers forward into two-sided risk would be desirable, or even wise. Some in the industry tried to put a positive spin on the “low-income” element of the program, with that term referring to smaller physician groups choosing to participate in the MSSP. On Friday morning, in response to the final rule, Travis Broome, vice president of policy at Aledade, a Bethesda, Md.-based company focused on physician-led ACO development, tweeted, “One more change to Basic. Low-revenue ACOs will be able to stay in 1-sided risk for 3 years. Difference [between] 2 & 3 years is big. The decision to take risk is made summer before the year starts. So 2 years of 1-sided risk meant making the risk decision before year 1 results even came in.”

But in a statement from the National Association of ACOs (NAACOS), an association comprised of more than 360 ACOs, Clif Gaus, Sc.D., NAACOS’s president and CEO expressed concern that CMS retained the two-year limit for other ACOs. “Becoming a well-functioning ACO takes time and requires building of IT infrastructure, hiring care coordinators, changing the culture of providers, among other tasks. Under CMS’s proposed rule, many ACOs would have just a single year of performance data available to them before evaluating the required move to risk in their third year of the program,” Gaus stated.

Gaus did include a conciliatory note in his statement, saying that "We appreciate CMS' effort in the final rule to provide greater stability to the Medicare Shared Savings Program with five-year agreement periods and more flexibility through waivers for telehealth and skilled nursing facility stays. We look forward to working with CMS to ensure that the Medicare Shared Savings Program, which has a track record of saving taxpayer hundreds of millions of dollars while demonstrably improving care for patients, continues to attract new participants and reap savings." NAACOS has been among the most vocal of healthcare professional associations this year, as CMS Administrator Seema Verma has intensified her call for providers to move forward quickly into more advanced forms of alternative payment models.

But, choosing not to sound any notes of conciliation on Friday, was the Chicago-based American Hospital Association, the largest U.S. hospital association, representing nearly 5,000 hospitals nationwide. A statement attributed to Tom Nickels, AHA vice president, on Dec. 21, said, “Today’s final rule will not be helpful in the move toward value-based care. None of the actions taken today will better empower ACOs to maximize their contribution to patient care and are not pathways for improving the value of the program for patients. We remain opposed to CMS drastically shortening the length of time in which ACOs can participate in an upside-only model. Hospitals and health systems have asked for a more gradual pathway because building a successful ACO that is able to take on financial risk requires significant investments in time, effort and finances.”

Further, the AHA statement said, “While CMS made some improvements to its shared savings rate policies from the proposed rule, they still are not sufficient to appropriately reward ACOs for improving quality and reducing costs. We are particularly concerned about the impact of these and other policies on high-revenue ACOs. We do appreciate that CMS took certain steps to expand participants’ ability to provide care to beneficiaries – for example, via telehealth and longer agreement periods.”

And, the AHA said, “As a whole, the policies in the rule will likely result in a significant decrease in program participation. That would be unfortunate, as we seek to transform care to better serve our patients and communities.”

While the Centers for Medicare & Medicaid Services (CMS) finalized some improvements to the Medicare Shared Savings Program (MSSP), the Premier healthcare alliance is extremely concerned that these are overshadowed by unrealistic expectations of the speed at which providers can transition to risk-based tracks, the un-level playing field created for hospital-led vs. physician-led ACOs and the imbalance of risk vs. reward.

Meanwhile, leaders at the Charlotte-based Premier Inc. were equally critical. In a statement released on Friday, Blair Childs, Premier’s senior vice president of public affairs said that while “Premier appreciates that CMS finalized the extension of waivers and the longer agreement period and heard our concerns about the reduction in shared savings,” “We are extremely disappointed, however, that CMS has moved forward in creating an unlevel playing field that disadvantages high-revenue ACOs—primarily hospital-led ACOs. Premier and other stakeholders, including MedPAC, oppose this policy,” the statement read. “Hospital-led ACOs in Premier’s Population Health Management Collaborative performed twice as well as all the other ACOs nationally. CMS should be taking steps to enhance, not limit, the inclusion of all innovative providers that are seeking to move to value-based care. For an Administration that has been outspoken in advocating for market solutions and level playing fields among competitors, it’s an enormous mistake to finalize a policy that pits providers against each other rather than focusing on collaboration, as the model intends.”

So, where does this leave the industry? Quite possibly, at an important inflection point, now that what was a proposed rule is now a final rule. One could argue this situation from a number of standpoints, but the bottom line is simple: in her desire to push providers forward quickly and decisively into two-sided risk—and even with the carrot-like incentives for smaller physician groups that have been added—Administrator Verma is now strongly risking a massive wave of defections from the MSSP.

As NAACOS’ Gaus noted in his statement, “Under CMS's proposed rule, many ACOs would have just a single year of performance data available to them before evaluating the required move to risk in their third year of the program.” Perhaps similarly importantly, he noted, "Although we are pleased that CMS finalized a new, limited exception to its high-low policy, we remain concerned that the high-low revenue ACO distinction could deter providers who want to embark on the path of value-based care and could unintentionally harm physician-led ACOs. We urged CMS in the rulemaking process to provide an equal playing field for all ACOs and will continue to advocate for changes to this policy. A NAACOS analysis of how ACOs would be classified under CMS's proposed definitions found almost 20 percent of physician-led ACOs would be considered high revenue ACOs. Furthermore, federally qualified health centers and rural health clinics would also have a fair proportion of high revenue ACOs.”

So, here we come to a very tricky set of issues. First, the entire point of adding in the “low-income ACO” distinction was to encourage more physician groups to join the MSSP; and that would be very important for the survival and thriving of the program, since the participation of hospital-based organizations has been slow to date, and one key way to encourage participation by all types of patient care organizations would be to be able to boast about rapidly increasing participation. But if, as Gaus has noted, NAACOS’ analysis finds that nearly 20 percent of physician-led ACOs would actually end up being “high-revenue ACOs,” that could indeed complicate CMS’s attempts to quickly gain new participants.

Further, the short period of time between initial participation and having to decide whether to stay in the voluntary program and take on mandated two-sided risk, poses one of the most serious barriers to increased participation; and therein lies the real rub for CMS, because if this final rule ends up causing mass defections in the next two years, the agency’s signature and largest federal ACO program could begin to fall apart, precisely at the time that Administrator Verma, Health and Human Services Secretary Alex Azar, and all their fellow senior federal healthcare policy officials, would be hoping to accelerate the shift from volume to value in U.S. healthcare, and prove that the broad ACO experiment is working.

On the other hand, it’s also true that if CMS allows the forward evolution of the MSSP program to progress too slowly, that could cause members of Congress and their staffs to determine that voluntary programs simply aren’t cutting it, and move towards massive Medicare cuts instead, in an attempt to get better control of overall U.S. healthcare inflation, at a time when all discretionary spending in the federal budget is increasingly becoming politically fraught.

For the time being, there is no simple answer to any of this. It’s as though the levers of power and influence must be used in an exquisitely calibrated way. There seems to be no “Goldilocks pace” of change here that will both maximize new participation, and ongoing participation, in the MSSP program, on the part of wary providers, and yet also fulfill all the demands and desires of senior federal healthcare policy officials. Only time will tell, but this moment feels more fraught than ever, in the ongoing evolution of the ACO experiment. There’s no doubt that 2019 could be a determinative year for MSSP.

 

 

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CMS: 93% of Clinicians Get Positive Payment Adjustments for MIPS Year 1

November 8, 2018
by Rajiv Leventhal, Managing Editor
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Ninety-three percent of MIPS (Merit-based Incentive Payment System)-eligible clinicians received a positive payment adjustment for their performance in 2017, and 95 percent overall avoided a negative payment adjustment, according to a CMS (Centers for Medicare & Medicaid Services) announcement today.

The first year of MIPS under MACRA’s Quality Payment Program (QPP) was dubbed by CMS as a “pick your pace year,” which essentially enabled clinicians to avoid payment penalties as long as they submitted at least the minimum amount of quality data. As such, in its announcement, CMS did admit that the overall performance threshold for MIPS was established at a relatively low level of three points, and the availability of “pick your pace” provided participation flexibility through three reporting options for clinicians: “test”, partial year, or full-year reporting.

CMS said that 93 percent of MIPS-eligible clinicians received a positive payment adjustment for their performance in 2017, and 95 percent overall avoided a negative payment adjustment. CMS specifically calculated that approximately 1.06 million MIPS-eligible clinicians in total will receive a MIPS payment adjustment, either positive, neutral, or negative. The payment adjustments for the 2017 program year get reflected in 2019.

Breaking down the 93 percent of participants that received a positive payment adjustment last year, 71 percent earned a positive payment adjustment and an adjustment for exceptional performance, while 22 percent earned a positive payment adjustment only. Meanwhile, just 5 percent of MIPS-eligible clinicians received a negative payment adjustment, and 2 percent received a neutral adjustment (no increase or decrease).

Of the total population, just over one million MIPS-eligible clinicians reported data as either an individual, as a part of a group, or through an Alternative Payment Model (APM), and received a neutral payment adjustment or better. Additionally, under the Advanced APM track, just more than 99,000 eligible clinicians earned Qualifying APM Participant (QP) status, according to the CMS data.

CMS Administrator Seema Verma noted on the first pick-your-pace year of the QPP, “This measured approach allowed more clinicians to successfully participate, which led to many clinicians exceeding the performance threshold and a wider distribution of positive payment adjustments. We expect that the gradual increases in the performance thresholds in future program years will create an evolving distribution of payment adjustments for high performing clinicians who continue to invest in improving quality and outcomes for beneficiaries.”

For 2018, the second year of the QPP, CMS raised the stakes for those participating clinicians. And in the third year of the program, set to start in January 2019, a final rule was just published with year three requirements. Undoubtedly, as time passes, eligible clinicians will be asked for greater participation at higher levels. At the same time, CMS continues to exempt certain clinicians who don’t meet a low-volume Medicare threshold.

Earlier this year, CMS said that 91 percent of all MIPS-eligible clinicians participated in the first year of the QPP, exceeding the agency’s internal goal.

What’s more, from a scoring perspective in 2017, the overall national mean score for MIPS-eligible clinicians was 74.01 points, and the national median was 88.97 points, on a 0 to 100 scale. Further breaking down the mean and median:

  • Clinicians participating in MIPS as individuals or groups (and not through an APM) received a mean score of 65.71 points and a median score of 83.04 points
  • Clinicians participating in MIPS through an APM received a mean score of 87.64 points and a median score of 91.67 points

Additionally, clinicians in small and rural practices who were not in APMs and who chose to participate in MIPS also performed well, CMS noted. On average, MIPS eligible clinicians in rural practices earned a mean score of 63.08 points, while clinicians in small practices received a mean score of 43.46 points.

Said Verma, “While we understand that challenges remain for clinicians in small practices, these results suggest that these clinicians and those in rural practices can successfully participate in the program. With these mean scores, clinicians in small and rural practices would still receive a neutral or positive payment adjustment for the 2017, 2018, and 2019 performance years due to the relatively modest performance thresholds that we have established. We will also continue to directly support these clinicians now and in future years of the program.”

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