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Michael McCoy, M.D. Shares His Perspectives on the Current Moment in Healthcare IT

March 13, 2018
by Mark Hagland
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Michael McCoy, M.D. shares his perspectives on the policy, industry, and technological cross-currents influencing the shift from volume to value in healthcare right now

Michael McCoy, M.D. is best known as` the Chief Health Information Officer in the Office of the National Coordinator for Health IT, a role in which he served from January 2015 through January 2016. Meanwhile, Dr. McCoy, who spent 25 years in obstetrics and gynecology practice, has played a number of roles in the healthcare IT world, including as a senior executive at the former Eclipsys Corporation, CMIO at DigiChart, and CMIO, between 2010 and 2013, at the Catholic Health East health system, now a part of the Trinity Health system.

Dr. McCoy currently runs his own consulting firm, Physician Technology Services, and is board co-chair of IHE International (Integrating the Healthcare Enterprise), a not-for-profit initiative by healthcare professionals and industry to improve data- and information-sharing processes in healthcare, via the coordinated use of established standards, including DICOM and HL7.

Dr. McCoy, who is based in Lawrenceville, Georgia, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland, following the conclusion of the annual HIMSS Conference, which took place last week at the Sands Convention Center in Las Vegas. Below are excerpts from that interview.

We were both at HIMSS18, and were able to converse at the CMIO Roundtable. Looking back at HIMSS18, as well as considering all the recent conversations you’ve been having with fellow healthcare IT leaders, how does this moment in healthcare and healthcare IT look to you, broadly speaking?

On the political side, the policymakers [in the current administration] are trying to wind back some of the policies and regulations that have been put in place [including via the MIPS/MACRA law—the Merit-based Payment System, and the Medicare Access and CHIP Reauthorization Act of 2015]. The challenge will be in actually making that happen. Many of those things are baked into law, and you can’t just easily wave your hands and make the law go away. Given that there has been widespread support for many of the elements that have gone into recent lawmaking… it’s difficult to imagine that all of the desired actions would take place.

Michael McCoy, M.D.

At the HIMSS Conference, the federal healthcare officials who spoke, talked fairly extensively about deregulation, either explicitly or implicitly. Do you have any thoughts on that?

Yes; some of those comments were specifically related to payment reform—MIPS/MACRA—and also to the issue of physician burden. Considering that many of the requirements embedded in MIPS/MACRA were written into law [as passed by Congress], it would take another law to undo them, unless you go the route of not ticketing people for slightly speeding—that concept—that idea that you can perhaps allow for [the regulatory path to softening certain requirements]. If the goal is to make sure the public gets something for the dollars spent on health IT, both in terms of hospitals and physicians—and healthcare IT spending—it’s difficult to do some hand-waving stuff and make that [the regulatory requirements embedded in laws like MACRA] go away. So there’s a gap between intentions and the ability to actually make those intentions happen. So that’s one of the concerns. There are similar concerns around balance for things like TEFCA [the federal Trusted Exchange Framework].

You’ve seen the comments from various trade groups and professional associations. I think the concept is good; the problem is in the execution, and how much can get done without pointed regulation. So it’s that balance.

I noted in my HIMSS18 reporting that that CMS Administrator Seema Verma, in her speech last Tuesday, called for empowering patients by giving them control over their data. Still, this administration remains at least nominally committed to repealing the Affordable Care Act, which would cause some loss of health insurance coverage. Can sufficient patient empowerment occur in the absence of health insurance coverage, or might that be an uphill proposition?

With regard to that, I’ll just say that there’s a major disconnect between words and actions there; I’ll just leave it like that.

Meanwhile, what about federal healthcare officials’ potential interventionism around EHR and other healthcare IT vendors? Administrator Verma and HHS Secretary Alex Azar both said last week that they want the free market to lead in helping move us forward on interoperability and patient empowerment. To what extent, though, might a more interventionist stance be necessary on their part?

This is my personal viewpoint, of course; as you may know, I am the co-chair of board of IHE International, the standards development organization, endorsed by the European Commission for a number of interoperability elements. There comes a time when you have to be more forceful. As a matter of policy, the U.S. government does not endorse specific standards. But the development of standards can advance things. Thus far, we have some alignment of incentives in the healthcare IT space, but not complete alignment; there’s still not a good reason yet for patients to move freely between and among different hospitals, for example.

And that alignment will require much more of a policy-driven, rather than a free-market-driven, exercise. So I would agree that it’s unlikely to happen, absent explicit policy moves. I was at a meeting in Washington, D.C., where interoperability through procurement contracting was discussed, and David Shulkin was talking about how the VA [Veterans Administration health system] might leverage its power with Cerner and others. So there’s some opportunity to begin helping physicians to have an interoperable solution, as part of the participation requirement. That in turn would mean they would have to go to their local HER vendor and make sure that’s going to happen. …

So we will need some level of interventionism from the federal agencies, to compel interoperability forward, then, correct?

I would agree with that. Relying on the good intentions of hospitals and doctors to move data forward, is somewhat utopian. Without penalties—such as those coming out of ACO contracts—that’s the reality that will make things happen. And that’s not yet there.

You agree that federal agencies will have to tell vendors what to do around interoperability?

Right, that will give them the ‘air cover’ they need to make changes. Because the vendors won’t do things unless their customers demand it. And the customers won’t demand it until it’s mandated. As a forcing function, regulation can help. I can agree with you partly on the CAFÉ standards—GM wouldn’t have done it. But that was also an example of the federal government pacing some of the wrong things. Regulators aren’t the true engineers in car companies and who can figure out what you can get. To get 40 MPH, we’d have to be driving tiny cars with different engines than consumers want. And also, rather than looking at fuel economy per vehicle, how about fuel economy per passenger? If you’re looking at a seven-seating automobile that mostly carries one person, are you really gaining there? So over-regulation can be just as burdensome as under-regulation. So it comes back to the lack of alignment of incentives on the part of hospitals and physicians. I mean, vendors aren’t deliberately withholding capabilities; they would do it if the customers demanded it.

Moving forward on health IT, what have your conversations been like recently with CIOs, CMIOs, and other healthcare IT leaders?

It’s much more now about optimizing the deployment of systems already in place—whether it’s replacing systems or enhancing them. It depends on the size of the organization. Personally, one of my friends who’s a rheumatologist is looking at replacing her EHR, and she’s very challenged by the expense and the difficult of moving from Vendor X to Vendor Y; it’s a nightmare. And for big patient care organizations, it’s a tweaking kind of thing? Do you re-implement, as opposed to tweaking it? There are all kinds of approaches that have to be considered. Many organizations were penny-wise and pound-foolish, and were just looking at getting the MU dollars.

Given everything going on right now, what should CIOs and CMIOs be focusing on right now?

I would say the first focus should be on cybersecurity, because if your situation [the overall IT infrastructure of your organization] ends up bricked up, nothing else matters. So that should be at the top of the list. And that’s a challenging front, because there are so many ways that one can be taken down, unfortunately; but insiders still doing the wrong thing—insider exposure is still the biggest. And there are organizations that are getting daily now; it’s just a fact of life. So if you don’t manage that properly, with the appropriate business continuity, etc., you’re screwed. So that would be number one.

I think looking at productivity, and how you get clinicians to the right level of resumption of activity, is the next thing. Whether that means reimagining the workflows you have, or if the vendors can provide better updates or UIs to allow that, that would be next. And the third priority would be making sure you’ve got a better understanding of where ewe think we’re going, from a payment perspective. I’m not sure whether anyone can fully predict that—whether ACA is killed or not, or reimagined, or whatever. Healthcare spending can’t continue forward as it has; and Congress has indicated they want a cap on HC spending, and to get more value for what’s spent. And whether that involves a free-market solution, or Medicare for all, or whatever it is, is still to be determined. And people are still getting paid under the old system. There’s a challenge for hospitals to stay alive, during this gradual transition from volume to value.

It's what so many have described as the one-foot-on-the-boat, one-foot-on-the-dock problem, correct?

Yes, with the one foot on a banana peel on the dock! And any readmission within 30 days is a problem. And there are challenges because of the mix of incentives facing providers during this long transition to a value-based system. One of the most entertaining moments for me at the HIMSS Conference was in the CMIO Roundtable, where there was some of the usual EHR-bashing coming from some people, but the gentleman from KLAS indicated that not everybody hates EHRs. The reality is that EHRs aren’t the problem; they’re part of what people can vent at.

The level of abilities needed by CIOs and CMIOs—to be true system leaders—is really amazing now. Many industry observers have talked about the need for “CIOs 2.0,” “CMIOs 2.0,” etc.—healthcare IT leaders who are at entirely new levels of professional development—to help lead their organizations right now.

You’ve hit the nail on the head there; CIOs and CMIOs have been promoted up through the trenches. And the c-suite in general does not realize the true leadership requirements they’re facing, for individuals with those titles. And we generally talk about CMIOs and CNIOs, rather than CHIOs. But when you look at the functions and roles of the CMIOs and CNIOs—focused on their specific disciplines—well, the reality is that we need to work as a team, strategically as well as operationally. Some of the organizations that are just getting going, may need someone in the trenches.

But more advanced organizations need more advanced leaders, focused on moving into population health and analytics, and that’s strategic, that’s not just slapping your colleagues on the back, saying, you’re doing a great job of CPOE, or using your screens. It’s things like transforming care delivery and improving outcomes, and that’s a strategic challenge. And frankly, a lot of the clinical leadership isn’t standing up to the executive leadership and saying, this is an important set of challenges we need. It’s interesting, we have the new clinical engagement officer and patient experience officer and this and that, but they haven’t quite figured out yet what it is that people are really doing. And we talk about mobile technology; well, how much of what we do isn’t mobile anymore these days?

So the reality is that when we talk about mobile health, telehealth, all those things, it’s all just health, really. So that’s part of the long-term strategy; as we learn and adapt to new ways of doing things, I think we are going to have to own up to the fact that computers are everywhere, and the Internet of things and the Internet of threats, they’re all changing everything.

After the experience of the HIMSS Conference this year, would you say overall that you’re more optimistic about healthcare IT leaders moving forward to do what needs to be done? Less optimistic? About the same as before?

From an industry perspective, about the same. It takes time for things to advance; I think things will happen. My concerns are more on the policy side and how that impacts everything else. I think it will take a few years to sort out what will happen in the policy area, and how that will affect everything. From the perspective of a large patient care organization, how do you plan for the future when you don’t know exactly what it will be? That is an important question that will be difficult for many to answer right now.




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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.



Related Insights For: Payment


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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