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.