Thinking Strategically about MACRA and MIPS: Will It Be Sink or Swim in 2019? (Part 2 of Two) | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Thinking Strategically about MACRA and MIPS: Will It Be Sink or Swim in 2019? (Part 2 of Two)

May 17, 2017
by Heather Landi
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In Part 1 of this two-part article exploring the implications of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) for healthcare providers, healthcare leaders and health IT experts discussed why it’s critical for clinicians to think strategically, rather than tactically, about MACRA compliance. Part 1 was published last week and can be found here.

MACRA, which was passed with bipartisan support in Congress, launched its first reporting period in January 2017 in which eligible Medicare clinicians will be reporting to a Quality Payment Program (QPP) that determines a physician’s reimbursement based on the high quality, efficient care they provide that’s supported by technology. MACRA includes two payment tracks that eligible Medicare clinicians can take part in that will determine their payment adjustments in future years. Early on in the program, most of these clinicians are expected to participate in the less risky Merit-Based Incentive Payment System (MIPS) track as opposed to the Advanced Alternative Payment Models (APMs) track.

Part Two of this article explores the operational and reputational implications of MIPS reporting and the technology investments that will be vital to success.

As reported by Healthcare Informatics Managing Editor Rajiv Leventhal, the Trump administration is currently reviewing potential 2018 updates to MACRA that would especially ease the burden the new legislation puts on small physician practices. In the first performance year, the Centers for Medicare & Medicaid Services (CMS) allows physicians to “pick their pace” of participation. It’s expected that new Health and Human Services (HHS) Secretary Tom Price, M.D. will extend that flexibility, Leventhal reported. The proposed rule from Price is expected to drop in the coming weeks, if not sooner.

However, even if CMS does extend that flexibility, the MIPS score performance threshold will eventually increase, and provider organizations need to be prepared in order to “keep up with a treadmill that is going faster and faster,” according to Tom Lee, Ph.D., founder and CEO of Chicago-based consulting and software firm SA Ignite. “We are seeing physician practices that are concerned about the immediate and annual reimbursement impacts regarding the payment adjustment, but they are even more concerned about the reputational impact. The winners get richer and the losers get poorer, and then you get to a point where you are not going to be able to catch up.”

Operational and Reputational Implications

Healthcare provider organizations’ MIPS scores will be publicly reported to the Physician Compare website, and will also be accessible by other third party rating systems including Yelp, Angie’s List, Health Grades and Google, something that about half of physician practices were not aware of, according to a recent Black Book Research survey, as reported by Healthcare Informatics.

Lee notes that while CMS has made it relatively easy for physicians to avoid a penalty for the 2017 reporting year, many physicians may not be considering the long-term reputational impact of having a lower score than their peers. “If you get 18 out 100 points, you’ll avoid a penalty by more than 15 points as CMS has set an artificially low threshold of 3 points. However, your 15 out of 100 points will be publicly reported through the Physician Compare website hosted by CMS and you run the risk that your 15 out of 100 points may not look so good to a consumer that’s now looking at how you compare to another clinician on this score out of 100 that has the Medicare stamp of approval on it,” he says.

He continues. “That score basically sticks with you for at least two years, and probably forever. If you pick up and leave an organization in 2018, but you’ve already earned the score of 2017, and then you go to a new organization, that new organization in 2019 will inherit the payment adjustment for MIPS that you earned in 2017. So, the MIPS score is basically irrevocably stamped to your resume as a clinician, and that has very broad implications for physician recruiting, contracting, compensation and credentialing. And a lot of physicians don’t realize that.”

Many healthcare IT leaders recommended that physician groups establish a multidisciplinary MIPS steering committee consisting of clinicians, staff, administrators, IT, and finance, if they haven’t done so already. “The MIPS committees that we see being spun up are very cross functional. The people involved in those MIPS discussions, at a leadership level, they come from every single function, so instead of just the CIO, you get the chief experience officer (CXO), the chief quality officer (CQO) and the COO because MIPS broadly impacts almost every function,” Lee says.

The focus of a cross-functional MIPS steering committee and organizational leadership should not be on just complying with MIPS requirements for 2017, but on the strategic implications moving forward, many industry leaders say. Lee points out that as the “pick your own pace” options end at the end of this year, it could be sink or swim for most organizations when it comes to MACRA in 2018.

According to a survey of healthcare providers conducted by Pittsburgh-based healthcare information technology consulting firm Stoltenberg Consulting, a majority (68 percent) of survey respondents said that preparation and compliance with the MACRA Quality Payment Program should be a combined effort across clinical, financial and IT departments.

“Success with MACRA requires a joint effort of IT and departmental resources to successfully combine clinical, financial and operational data,” Joncé Smith, vice president of revenue cycle management at Stoltenberg Consulting, says. “This effort commands not only a deep technical knowledge of how and where to extract and transform the right data, but also a solid understanding of how to integrate it in such a way that the resulting data demonstrates that an organization meets objective criteria for its chosen reporting path.”

And, Smith adds that a cross-disciplinary committee should also be a flexible working group that “understands that you can’t rest on your laurels within this program, what you choose for year one may change for year two, may change for year three, and again all of that has to go into the makings of the data repository in your BI tool. You’re going to have to re-engineer this group—their goals, their agenda and the points in the program that they are moving forward to.”

Investing in Health IT Tools and Other Resources

Drilling down, MACRA participants will need their IT infrastructure to be ready for these regulatory changes. In the aforementioned Black Book Research survey, 83 percent of users of the top eight electronic health record (EHR) systems are upgrading or optimizing their systems for MIPS compliance. EHRs can be a practice’s strongest asset in collecting and submitting data, some healthcare IT leaders say.

Mark Miller, M.D., an independent family medicine physician who practices in Fayetteville, Arkansas, says he plans to participate in the MIPS track, although his plan is to eventually move over into the APM track. Physician practices need to evaluate their EHR systems’ functionalities for collecting and reporting MIPS measures, he says.

Mark Miller, M.D.

“Having an EHR that is makes quality reporting very easy to do is very important and it needs to be user-friendly for the physician to be able to document the things that need to be followed on a longitudinal basis to report quality metrics. The EHR plays a vital role in this MACRA effort going forward,” he says. Miller uses a cloud-based technology platfrom developed by Kareo, which includes an EHR system. In addition, Miller says he has hired a medical assistant to oversee the additional quality reporting requirements under MACRA. “For me, that investment I’m making in that position is going to make great dividends down the road. I think that position will pay for itself five or ten times over just due to the ability to reimburse better over time.”

Collecting, monitoring, and reporting MIPS measures may require IT capabilities beyond the typical EHR. “Because you are combining clinical data, financial data, and operational data, you’re going to need a really strong reporting tool and resources to run that tool to ensure that the information is being maintained and being extracted and transformed and loaded into your business intelligence tool,” Smith says.

In its survey, Stoltenberg Consulting found that one-third of respondents reported that revising data management and reporting mechanisms to meet new reporting requirements was a top MACRA obstacle. “With MACRA, you are having to select particular patient populations to report your measures on, so a facility has to really understand the population health of their patient population, they have to be up to speed and very cognitive about their EHRs reporting capabilities and they have to be able to interpret these rules to understand which measures to select that would best suit their reporting abilities,” Smith says. “You’ve got a lot of different dynamics that are happening to physician groups. And many physician groups of smaller size, by that I mean 100 physicians or less, are just not robust enough to do a lot of this reporting, so I think some of them are going to have to purchase tools in order to do this. So now we’re talking a capital expenditure in a group that probably thought that was another couple of years off.”

Smith continues, “Provider organizations have to first look within their own EHRs to get some of this data out of that. I think there is a need to assess their current toolkit and if they find that there are gaps between what they own and what they need to do, they are certainly going to have to pursue purchasing something.”

Smith adds that many business intelligence data analytics tools in the market now are capable of helping provider organizations with this type of data reporting. “But many organizations are still going to lack the skill sets to ensure that the precise measurements are found within that data that’s been collected within that tools’ database to report off of it. So there’s going to be a learning curve associated with that and they are going to have to look to external resources,” she says.

Smith asserts that unlike previous physician reimbursement incentive models, success under the MACRA QPP program will take far more than just passive submission of claims data. “Proactive measurement, planning and forecasting and a three-to-five year strategic roadway is absolutely critical with this program because once you reach out to year 2022, which will be based on reporting in 2020, year adjustments can range up to the 9 percent range, and that is large. That’s a lot of money within any physician group,” she says.

“One of the nice things about MACRA is that you’re going to be getting feedback, not just at the end of the reporting period, but during the reporting period,” Smith adds. “There’s nothing better than to have a visual roadmap, a dashboard if you will, for your physicians to see, ‘Okay I’m within two or three points of obtaining the threshold that my peers are at, so I’m not far off.’ It’s very easy then to instill within them, ‘Okay, these are the steps to raise us to that threshold or even exceed it.’ All of this is within the BI tools that the market now has.”

Looking ahead, CMS has proposed the concept of Virtual Groups as a participation option in MIPS in 2018. Virtual Groups would be a new participation option for solo practitioners and small practices to join together to report on MIPS requirements as a collective entity.

“It will allow practices that are up to 10 clinicians each to band together, pull their resources and pull their EHRs and then report to MIPS and be assessed as a group, and so [practices] can gain some efficiencies,” Lee says, noting that Virtual Groups could be a strategic option for small practices to consider as an alternative to going the strategic acquisition route. There have been numerous surveys indicating that many independent practices are considering selling their practices to hospitals or group practices to eliminate the administrative burden of complying with MACRA.

 


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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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