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At the World Health Care Congress, a Business Leader and a Hospital Leader Talk About Disruption and Data

May 1, 2018
by Mark Hagland
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At the World Health Care Congress, Duke University Hospital’s Tom Owens, M.D. and venture capitalist John Doerr shared perspectives on transformational change in healthcare

Under the title, “Health Care Tech Trends: Addressing the Value Equation,” John Doerr, chairman of Kleiner Perkins Caufield Byers, a venture capital firm based in Menlo Park, Calif., a Silicon Valley suburb of San Francisco, and Tom Owens, M.D., president of Duke University Hospital, and senior vice president of the Duke University Health System (both Durham, N.C.), discussed the dramatic changes taking place in the U.S. healthcare industry right now, and the important role that technology, including information technology, will be playing in the transformation of the healthcare industry in the coming months and years.

Doerr, the author of Measure What Matters: How Google, Bono, and the Gates Foundation Rock the World with OKRs, speaks regularly about the goal-setting system of objectives and key results (OKRs), and broad business strategy.

After initial introductions, Doerr asked Dr. Owens about the pace of change, and the challenges that Owens and his colleagues at Duke Health are facing right now, as they look into the near future in U.S. healthcare.

“People in healthcare work hard,” Owens said, “and their readiness for change depends on how well they’re feeling, how resilient. A lot of providers are feeling burned out right now, and that’s a challenge every day. In addition, we have challenges we’re facing with regard to reimbursement change.” Asked about the pace of healthcare system transformation in North Carolina, he said, “Our state has been slow to change to value. We’re now moving towards managed Medicaid. I think the big change will come from commercial payers, who will drive providers into risk-based contracts into risk faster than expected.”

“And managed Medicaid will be good?” Doerr asked.

“We feel responsible for the care of our community, and that’s what Medicaid represents for us,” Owens said. “I think that managed Medicaid, done well, could be very good for us; done poorly, it would be [challenging]. We’ve launched an ACO [accountable care organization], and have about a quarter-million lives under some form of management. How we can leverage some of the technology, manage the massive amounts of data involved,” will be an important element in success, Owens said. “And the [historically] siloed approach of community, providers, and payers, isn’t going to work.”

Turning the conversation back to Doerr, Owens said, “You’ve such a big part of changing a number of industries. I’m wondering what advice you have for us in healthcare? How we might think about technology, and disruption, in a healthy way?”

“I would say that I’ve had the privilege of working with some of the country’s most amazing entrepreneurs and disruptors, from Jeff Bezos at Amazon, to the folks at Google, or the folks at Uber, to even Twitter, who wanted to change the way we did texting and exchanging information,” Doerr said. “And what I’d say is true about all those innovators is that they possessed vision for a world that no one else imagined.” For example, he said, “Google was the eighteenth search engine to arrive on the scene; but all their predecessors had produced searches that were kind of crummy. Before Google came along, the ads were banner ads, sold by advertising executives on Madison Avenue, over three-cocktail lunches. And Google said, screw that, we’re going to auction ads, in a way that you could create a sustainable, not an overpriced, marketplace. And the challenge for healthcare, writ large, is that we don’t have a functional market. And consumers have a hard time discerning quality.”

Doerr went on to say, “Duke’s a high-quality organization; I’m sure you have a hard time getting that message out there. There’s little price competition. Many of the elements that make capitalism and the economy go, are not present yet in healthcare. But risk adjustment, flexibility in payments, and providers being responsible for care end-to-end—all elements present in Medicare Advantage—those things allow for innovation. And where is Duke in the journey from fee for service to fee for value?” he asked.

“I’d say we’re in the middle of the pack at best,” Owens said, noting that “The larger transformation” of the healthcare system from fee for service to fee for value “may be even more challenging in academic medical centers. We have great talent and depth, and great success in the current academic model. And we have three missions—clinical care, education and research, and in the U.S., clinical care helps subsidize the other two, so when we think about change, we think about the risk to those missions. We realize we need partners. We can’t get there fast enough developing algorithms for risk adjustment and disease prevention. And so we’re thinking about all kinds of relationships” in terms of moving into the world of risk-based contracting. In that regard, he added, “We laid out a five-year plan three years ago, to think about the way we manage risk and manage patients.”

Owens went on to detail some of the challenges facing physicians in the current practice environment, noting that “Most physicians went into healthcare for the right reasons: they want to take care of patients. And they want to invest in the healthcare of the future. And when we engage them, and we create a path to risk, a path to change, that they can buy into, that’s worked really well for us. And when we’ve been able to shine a light on unnecessary care and variation, it’s been really helpful.”

And when Doerr asked him how he saw the future role of hospitals, Owens said, “That’s right, focusing on health means focusing on the earliest stage of disease, on health and wellness and prevention, and that’s not the hospital. We’re still in a growing market that allows us to make some changes,” he added. “This morning, I had 71 patients I didn’t have beds for at university hospital. But we do need to lower utilization. We also need to recognize that the next generation of patients has very different ideas about health and healthcare. When I talk to millennials or to my own teenagers, they have very different ideas of how to interact with caregivers.”

“What’s your view of the Aetna/CVS merger?” Doerr asked. “It certainly offers tremendous alignment around the pharmacy benefit management piece,” Owens said. “CVS obviously has a tremendous handle on that. And the CVS provider network is still focused on convenient care, so it’s not yet a big threat to providers, but it certainly is an interesting play—it certainly gives us thoughts about how we might react to such disruptors” entering the operational area historically dominated by hospitals and traditional physician practices.

And, Owens in turn asked Doerr, “What’s your perspective on the Amazon/Berkshire Hathaway/JP Morgan Chase announcement?”

“I’m a long-term friend of Jeff Bezos,” Doerr said. Meanwhile, he said, “I think larger employers are very frustrated” by the rising costs, lack of transparency, and lack of documented quality of healthcare services in the U.S. In that regard, he said, the Amazon/Berkshire Hathaway/JP Morgan Chase announcement was “largely driven by the benefits groups in those companies. One challenge” for employer-purchasers, when it comes to flexing clout with providers at the local and regional levels, “is getting enough geographic density in individual markets. The other is getting 40 of anything to agree on anything. I’d love for them to be successful,” he said, “because we all agree with Warren Buffett that having a third of a $3 trillion annual spending bill to be wasteful or duplicative, is not sustainable. Warren Buffett said recently, ‘You people focused on taxes are on the wrong island.’” Instead, Doerr opined, “The fact that healthcare is going to reach 20 percent of GDP” in the United States, “is a huge tapeworm” eating at the country’s business vitality over time. Given the size of all three corporations’ employee bases, he said, “I’d expect them to innovate on every front: the PBM front, the pharmacy front, and in terms of the consumer experience. I do think they’ll work with providers in the current marketplace, and I can’t wait to see how that turns out.”

A bit later in the conversation, Doerr asked Owens about the subject of providers becoming payers, and vice versa. “We tried being a payer, 18 years ago, and that experiment didn’t work well for Duke,” Owens said. “We had challenges with adverse risk, etc. What happened was that a lot of sick patients chose the Duke brand, but that’s not a good thing if you don’t get the actuarial model right. So the brightest future would be if we integrated the best capabilities of payers and providers, and could find some integration.. and find a path we can align on and engage with, and do that in three to five years. And the good news about being in market that hasn’t yet changed, is that we’re in a market that hasn’t changed. The bad news is that when it changes, it’ll change fast. And there will be winners and losers. And we’re committed to being one of the winners.”

Later in the discussion, Owens told Doerr, “I’m impressed by what you’ve taught about measuring what matters. How does that look in healthcare?

“Healthcare is hard, and for me, it’s humbling,” Doerr told him. “It’s complicated for others of us. I’m excited about what’s going on in the field. My theory of change for healthcare is, if we liberate the data, which we’ve all heard is siloed, I like to say it’s been incarcerated—and if we have flexible payment models—my favorite is Medicare Advantage, which gives the provider a great deal of discretion—if you liberate the data, the innovators will take care of the rest. Amazon and Google didn’t have those challenges. Not only did they have to liberate the data, they could crawl the web. And either the services were free, or you could charge the consumer before you sent the product. Amazon had about a 70-day float, and that fueled a lot of growth. I think this is a time when change is crashing onto the system that we didn’t anticipate. I like to say this is the year of the data quake in healthcare. A week ago, Verma said that in addition to the Medicare FFS data was being made available publicly, the Medicare Advantage data would be made available, and later, all the Medicaid data.”

And, he added, referring to the harnessing of data and information to improve healthcare delivery and operations, “I think things were overhyped earlier, but now, Google has about a thousand researchers researching AI in healthcare. You’ll see it applied in areas like radiology interpretation, but also in process improvement. Behind the scenes, we’ll see AI really improve the quality and efficiency of so many tasks. I think actually the potential of AI in healthcare has been under-hyped and under-appreciated. My advice? Run, do not walk to the web. Break open the jails, liberate this data in a respectful, privacy way, and keep an eye out for flexible payment models.”

 

 

 


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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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