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What’s Next in Federal Healthcare Policy? Two Industry Observers Offer Predictions

March 14, 2017
by Mark Hagland
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Two healthcare attorneys following current developments on Capitol Hill share their perspectives on the current moment in healthcare policy

On Monday, March 13, Healthcare Informatics Editor-in-Chief Mark Hagland interviewed two healthcare industry observers regarding current developments in federal healthcare policy. Hagland interviewed Jeremy Miller and Miranda Franco just hours before the news broke of the “scoring” of the American Health Care Act (AHCA), the healthcare legislation introduced by Republican leaders of the House of Representatives on March 6, to replace elements of the health insurance provisions of the Affordable Care Act (ACA), passed by Congress and signed into law in March2010 by President Barack Obama. The Congressional Budget Office (CBO) announced late Monday afternoon that, while it anticipated that the AHCA could reduce the federal budget deficit by $337 billion over 10 years, it would also lead to the loss of health insurance coverage of 24 million Americans over that same period of time.

Miller is managing partner in the Miller Health Law Group, a Los Angeles law firm with eight attorneys, all of whom specialize in healthcare law. Franco is senior public affairs advisor at Holland & Knight, a Washington, D.C.-based law firm heavily involved in advocacy issues in healthcare and other areas. Franco does advocacy work on behalf of the Cooperative of American Physicians, Inc. (CAP), a California-based provider of medical professional liability protection and other services, while Miller is involved with CAP in an educational role.

In separate interviews, Miller and Franco answered questions from Hagland around a number of federal healthcare policy topics—the current activity in the U.S. Congress around the American Health Care Act (ACHA), the Republicans’ plan to replace some of the health insurance aspects of the Affordable Care Act (ACA); potential modifications to regulations under MACRA (the Medicare Access and CHIP Reauthorization Act of 2015), including to the MIPS (Merit-based Incentive Payment Program); and potential federal healthcare policy changes coming out of the Department of Health and Human Services, under the new Secretary of Health and Human Services, Tom Price, a former Republican congressman from Georgia.

Why did the AHCA focus solely on health insurance? “It’s largely political,” Miller says. “This is what the Republican Party and President Trump campaigned on, and also what’s been in the public eye. And the content involved in [internal health system reform], around bundled payments and readmissions work, was pretty much under the radar” for federal legislators. Still, he says, numerous federal healthcare policy changes could take place within the administrative sphere, under Tom Price, the new Secretary of Health and Human Services (HHS), and a former Republican congressman from Georgia. “The fact is, a lot can go on below that radar, at the sub-regulatory level, partly based on the fact that Dr. Price is the new HHS Secretary.”

Going back to potential eventual federal legislative action, Miller says that “If any significant repeal-and-replace legislation is passed, that could affect the Center for Medicare and Medicaid Innovation [CMMI] and other things” related to internal health system reform. “Dr. Price has indicated that he’s not a big fan of mandatory bundled payments; he’s indicated hostility towards Medicare audits of doctors. So there’s a great deal that can take place independent of the ACA legislation.”

Can healthcare IT leaders begin to plan more safely around the retention of the internal health system reform provisions of the ACA, now that the Republican ACA-repeal legislation has been introduced, and it focuses solely on the health insurance aspects of the law? “Yes,” says Franco, but with a few qualifications around budgeting. “This [bill] is pretty much the first step in three steps. The fact that Medicare was untouched was purposeful. This first leg, the AHCA, was intended to pass under budget reconciliation, which means that only provisions that have a tax or revenue component can be included. The purpose under Title I was to address taxes under [the] Ways and Means [Committee], and Medicaid, under [the] Energy and Commerce [Committee]. The Republicans had said that Medicaid was fiscally unstable and had to be addressed. So it’s no surprise that they would address Medicaid issues first.”

Meanwhile, Franco says, “In terms of any internal health system reform around value-based purchasing, that might happen in a second round” of major federal healthcare legislation. The [inception of the] TJR [total joint replacement mandatory bundled payment] program was delayed [until March 21]. The cardiac episode payment program has been delayed also. Dr. Price has been very vocal that he’s opposed to mandatory bundled payments,” Franco says. “With that said, he’s a staunch supporter of MACRA,” she notes, “and is a supporter of physicians moving into the APM [advanced payment model] program under MACRA, but might make administrative tweaks here and there to temper the timeline. I don’t think we’re going to see an overhaul of the Medicare program,” she adds. “I think we’ll see modest reforms in the administrative rulemaking space.”

“The biggest question will be how much money would be in the system” in the wake of any ACA-repeal legislation being passed, Miller says. “We could see significant cuts in Medicare and Medicaid funding, to help pay for the loss of revenue that is eliminated through any repeal bill, that would impact hospitals more broadly through uninsurance. That would probably be the most dramatic impact” for providers, Miller says. “Dr. Price is a former physician and someone with strong views on these issues; he clearly is not in favor of fraud, waste, or abuse, of course. So getting more bang for the buck may be a focus” of Price’s term at HHS. “He’s on record saying that he wants physician independence of thought and decision-making to be preserved and not interfered with; that’s an area he might be interested in. I haven’t heard that ACOs [accountable care organizations] were in his gunsights, though.”

Of course, developments are moving rapidly in certain areas. For example, on Monday, Seema Verma was confirmed by Congress as CMS administrator. Certainly, Verma’s policy priorities will carry great weight within CMS, and it remains to see what those priorities are, and how Verma’s priorities might align with those of HSS Secretary Price.

Tort reform in the offing?

What might the chances be now of what is often referred to as “tort reform”—changes in medical-legal laws that Republicans in Congress and in the state legislatures have long advocated, such as changes in medical malpractice laws? “A tort reform bill has been proposed,” Miller says, referring to H.R. 1215, the “Protecting Access Care Act of 2017,” introduced on Feb. 24 into the Judiciary Committee in the House of Representatives by Rep. Steve King (R-Iowa). Among other things, that bill calls for the limiting of noneconomic damages in healthcare lawsuits to $250,000; a three-year statute of limitations for the filing of a healthcare lawsuit; and strong restrictions on plaintiffs’ attorneys’ ability to recover contingency fees in medical malpractice cases.

Could some version of H.R. 1215 pass Congress? “It’s hard to say,” Miller says. “There certainly have been a lot of efforts in this regard over the years. A lot of these things are modeled after California’s tort reform, which is more than 30 years on now. The medical associations are always in favor of it, and the trial lawyers are always opposed. It’s hard to say who’s in the ascendancy or not,” he adds. “But I would say that it’s more possible now than when the Democrats were in control of the White House and Congress.”

More broadly, what should healthcare and healthcare IT leaders be thinking about, when it comes to trends in healthcare policy and payment in the next couple of years? “The laws of economics and math can’t be repealed,” Miller says. “And there’s an increasing Medicare population as the Baby Boomers edge into it; and even though the economy’s been recovering, it’s unlikely that happy days will be here again for providers, given budgetary constraints that can be expected at all levels of government. So I’d say it’s going to continue to be challenging going forward in terms of federal healthcare payment, he says. “But I remember having a discussion with an audience of mostly hospital executives, during the time that the ACA was in the Supreme Court for a decision, and I asked for a show of hands. How many might have put aside their performance improvement work, if the ACA were to be repealed? I asked. And no one raised their hands; and I don’t see that that will change.”

More narrowly, Miller says, he does see the Independent Payment Advisory Board, or IPAB, as being in danger in the relatively near future. “I think that IPAB is very much in the gunsights” of federal legislature, he says, “and there’s a fair amount of bipartisan support for that. And even though the IPAB has not specifically been targeted for extinction, it’s still at serious risk of being extinguished in this legislation or in future legislation.”

One potential target: the CMMI

One department within the Centers for Medicare and Medicaid Services (CMS) that has been a target of criticism on the part of some congressional Republicans—including Tom Price, when he was still a congressman from Georgia—for a long time, has been the Centers for Medicare & Medicaid Innovation (CMMI).  “There’s been a lot of talk for some time among Republicans about scaling back CMMI,” Franco says, “but you have to consider that it’s one avenue for creating reforms administratively. I think they might start looking outside accountable care organizations and bundled payments, and perhaps they might look at bringing in private payers into the discussion,” she says, adding that, in any case, “I don’t envision them totally repealing funding for CMMI, because it’s so connected to MACRA, and MACRA was so much a bipartisan legislation, that physicians are already beginning to comply with. I would not want to say definitively, though.”

What about the future of core elements of the internal health system reforms within the ACA?  “We’ve seen the readmissions program—there’s been success in terms of improving outcomes because of that program—the conditions targeted by that program have gone down,” Franco notes. “And that’s reducing costs. So these are areas in which we might see little tweaks, but I don’t see a huge overhaul” of any of the value-based payment-related provisions of the ACA, she says.

Does that include the mandatory bundled payment programs in the total joint replacement and cardiac care areas that came into existence under the Obama administration? As has been well-known, Tom Price, as a Republican congressman, expressed strong disapproval of mandatory bundled payments. Asked whether Price could totally eliminate the two bundled payment programs himself, Franco says, “Yes ,he does have that authority, because they weren’t established by statute, but by regulation. MACRA advanced alternative payment models, but gave the Secretary the authority. Now, there’s a difference between ending those problems and making them voluntary. So I think that the Secretary might just switch those to voluntary. CJR [the Comprehensive Care for Joint Replacement mandatory bundled payment program] has already been in effect, and the hospitals have already been participating in CJR, so that could continue.” As for the cardiac mandatory bundled payment program, she says that “That program technically is scheduled to launch in March now, with the bundles beginning in July.” And that one, she says is far more likely to be simply eliminated.

Finally, asked how she sees federal healthcare policy evolving forward in the next few years, Franco says that “So much of it depends on what happens here,” referring to the current battle in Congress over the AHCA legislation that is focused on repealing parts of the ACA. “In six or seven years, we’ve seen a complete sea-change,” she notes, speaking of the reversal of the legislation now being debated in Congress. “But whatever version makes its way through passage, the pull of the previous administration will carry through to the new administration that that transition from volume to value,” she says. “That [the ongoing shift away from volume and towards value] won’t change. There might be changes around how much risk we engage on, but value is a shared goal. And I don’t see fundamental change around that. I think there’s a lot of commitment to that.”



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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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