I just spent three days in Las Vegas at the annual HIMSS conference, with 43,000 of my closest friends. As the Vice President for Government Affairs at SRS Health, my goal in attending this conference each year is to get a heads-up directly from the leaders of CMS and ONC regarding what the government has in store for physicians. While no secrets are leaked in the sessions or meetings at HIMSS, several government program–related themes clearly emerged this year—topping the list was interoperability and burden reduction.
- Seema Verma, Administrator of CMS, promised a “complete overhaul” of Meaningful Use, and (I assume) by extension, the ACI portion of MACRA. She was purposely short on details, so we don’t know exactly what that means, but subsequent conversations with her team confirmed what it does not mean: MACRA is not going away; MU3 is not disappearing; and the use of 2015 CEHRT is not off the table. I don’t expect that we will see major changes, but we will have to wait for the details to be revealed in the rulemaking that comes later this year.
- Interoperability will be the focus going forward, and providers were warned that measures are being developed to identify and prevent information blocking, as required by the 21st Century Cures Act, going so far as to impose fines for willful actions in this regard. Patient data must be shared freely between providers; and it must be made easily—and electronically—available to, and controllable by, the owners of that data, i.e., the patients themselves, through programs like the newly announced MyHealthEData initiative.
- Promises of regulatory relief and clinical burden reduction were abundant, and were offered within various contexts, including the overhaul of MACRA to reduce the time providers devote to compliance, streamlining documentation for the E&M coding/billing process, and the introduction of the Meaningful Measures initiative to increase the validity and efficiency of quality measurement and reporting. ONC and CMS led several ”listening sessions” in which they sought feedback on burden reduction—I sensed hopeful optimism tempered by healthy skepticism on the part of attendees.
- The opioid crisis is on everyone’s mind. As one Congressional staffer put it, this is the “issue du jour.” It is being addressed at the national level as well as by the states, the majority of which are already mandating PDMP checking before a physician can write a prescription for a controlled substance. One challenge here will be for HIT and EHR vendors to automate this process so that the problem can be tackled without creating a new task that providers will perceive as yet another burden.
It will be interesting to see what progress is made in all of the above areas when HIMSS reconvenes in 2019.
How many times have you heard the expression, “It would take an act of Congress.”? Well, Congress has acted! Had this blog been posted just 2 weeks ago, the message would have been slightly different and a little more ominous in tone. I would have said—and you may have read articles elsewhere where I did—that the MIPS transition period is coming to an end, and providers should begin to prepare in earnest for 2019, when by law, the MIPS threshold would be much higher and the cost category would account for 30% of the MIPS score. These provisions in MACRA were not subject to CMS’ discretion; but apparently, Congress has been persuaded to extend CMS increased flexibility. As part of the Bipartisan Budget Act of 2018, Congress has pushed out the full implementation of MIPS from 2019 to 2022, effectively making 2019, 2020, and 2021 three additional transition years.
This means that:
- There will still be winners and losers since budget neutrality remains a requirement; however, CMS is now not obligated to set the MIPS threshold at the mean (or median) of prior performance until 2022. Instead, the threshold will be gradually increased to that level over the intervening years, the good news being that it will not be as challenging to avoid a downward adjustment for a few more years. The consequence of this, however, is that the amount of money available to winners will continue to be less than the maximum provided for in the law, (i.e., 5% related to the 2018 performance year, 7% for 2019, and 9% from then on.)
- The Cost category does not jump to 30% of the MIPS score in 2019. CMS can hold off on the increase until as late as 2022, with the flexibility to set the rate at between 10% and 30% each year until then and to make it 30% only when the Secretary is confident that the resource use, (i.e., cost), measures are ready for adoption. In addition, the bonus points for year-over-year improvement in this category have been eliminated.
Through these changes, Congress has relieved some of the immediate pressure for providers. However, this does not change the fact that it will become progressively harder to score well as providers gain experience, making MIPS increasingly competitive in the coming years:
- The Quality and Cost categories will remain distinguishing factors among providers.
- It will become progressively harder to score well in the Quality category. Benchmarks will be more aggressive as providers build experience. The 2018 benchmarks have been posted on the QPP website, and you can already see differences from the 2017 deciles for some measures.
- Improving your comparative Cost position is not something you can do overnight; it takes time. So, it’s not too early to address this area more vigorously.
- MIPS performance has implications beyond Medicare payment adjustments. Your reputation could be impacted as CMS makes more and more performance data publicly available on its Physician Compare website. Consider what you want patients, referring physicians, and payers to see about you when they are researching your practice.
So, don’t let down your guard. Take advantage of the additional transition years to secure your future success.
The proposed rule is here, and it’s another long one! So for those who don’t have the patience (or the time) to read through the 1,000+ pages, here are some highlights from what CMS is suggesting for the second year of MIPS. Bear in mind that these are proposals; they must be confirmed in the Final Rule, which will be released by November. (What had already been set in stone within the MACRA legislation itself is the maximum penalty and related incentive: 5% in 2020 based on performance in 2018, up from 4% in 2019 based on performance in 2017.)
- CMS would allow clinicians to use either 2014- or 2015-Certified EHR technology to report for 2018. Acknowledging the slower-than-anticipated pace at which EHRs are achieving the next required certification, this accommodation will facilitate more successful, non-rushed upgrades and provide sufficient time for training on the new capabilities and associated requirements. To encourage the move to 2015 CEHRT, 10 ACI bonus points would be awarded for its exclusive use. (Finalized as proposed)
- The Quality reporting period returns to full year, but ACI (Advancing Care Information) and Improvement Activities remain at a minimum of 90 days. Cost is still unscored, but performance in this category will be evaluated by CMS and feedback will be provided to clinicians to prepare them for 2019 when, by law, the cost category must account for 30% of the MIPS score. (Finalized as proposed)
- The proposed performance threshold separating “the winners” from “the losers”, (i.e., recipients of positive vs. negative payment adjustments), would increase from 3 points out of 100 in 2017 to 15 MIPS points in 2018—still an eminently achievable bar. (Finalized as proposed)
- CMS would implement increased protection for small groups (≤15 eligible clinicians)—these are the practices that had been predicted to be the most vulnerable to penalties. (Finalized as proposed)
- Many more clinicians would be exempt from MIPS altogether because the eligibility threshold would increase from $30,000 to $90,000 in annual Medicare revenue and from at least 100 to at least 200 Medicare patients.
- Small groups that do participate in MIPS would receive 5 bonus points toward their score, in an attempt to level the playing field.
- And my favorite proposal (Unfortunately, not finalized as proposed) is one that specialists, in particular, will appreciate: the elimination of the restriction that all 6 quality measures had to be reported by the same submission method. In 2018, clinicians would be able to mix and match submission methods within a category. Specialists, who have typically been faced with an insufficient number of relevant eCQMs, would be able to continue reporting those measures which are available by EHR submission, but could supplement them with registry or claims measures that are also specialty specific. The result would be more meaningful reporting and more equitable scoring. This is a request that SRS has included in its comments to each of the previous proposed and final MACRA rules, so we were very happy to see this change.
MIPS is only one of the two MACRA participation options, and CMS has also proposed some changes designed to accelerate the shift from MIPS to Alternate Payment Models. More on that topic in a future post.
It’s been all over the press for the past week—CMS paid a lot of money in the form of EHR incentives (Meaningful Use) to providers who did not truly earn them. These inappropriate payments were revealed in a report by the OIG (Office of the Inspector General) that reviewed CMS’s compliance with Federal requirements in the Medicare EHR Incentive Program for eligible professionals from 2011-2014. Although the subject of the OIG’s audit was CMS—in contrast to the audits of providers (pre- and post-payment) that have been conducted by Figliozzi and Company—there are some important implications for providers.
Here are two of the OIG’s major conclusions:
- 14 EPs (Eligible Professionals), out of a sample of 100 who attested to having met MU one or more times did not actually meet the MU requirements. They either could not support their attestation with sufficient evidence or had errors in their attestation. Affected payments to these providers totaled $291,222. Extrapolating on this data, the auditors estimated that CMS inappropriately paid over $729 million.
- In addition, 471 payments to EPs who switched between the Medicare and Medicaid incentive programs were incorrectly calculated, accounting for another $2.3 million.
The report recommended that CMS:
- recover the $291,222 from the EPs who had the unfortunate luck to have been sampled [editorial comment is mine, not the OIGs!] and found to be non-compliant;
- recover the $2.3 million in overpayments to EPs who switched programs; and
- try to recover some of the estimated inappropriate payments made to other providers.
It’s likely that CMS will pursue the first two recommendations, but yet to be determined what—if anything—they will do about the third. That said, however, one thing is certain: CMS will intensify its oversight going forward. (This was another of the OIG’s recommendations.) Does this mean you should abandon your plans to participate in MIPS and/or MU (Medicaid program)? Absolutely not! It does, however, imply that it will now be more important than ever to keep full documentation to support everything you submit. And, make sure to keep it somewhere that will survive any future changes in software, hardware, and/or practice staff.
Clinicians have two options for MACRA participation—an Advanced Alternate Payment Model (AAPM) or the Merit-Based Incentive Payment System (MIPS).
CMS has structured MACRA to encourage AAPM participation, offering clinicians a 5% lump-sum bonus on top of a share in the savings achieved by the organization. The following questions will help you determine whether you qualify for the AAPM option:
- Do you participate in an APM? (An ACO or other risk-based healthcare delivery program?)
- Is your APM an AAPM? The APMs identified in the image above qualify as AAPMs by virtue of the fact that:
- the hospital and the clinicians use certified EHR technology,
- the organization bears both upside and downside financial risk, and
- the providers report quality measures.
NOTE: The CMS CJR (Comprehensive Care for Joint Replacement) program is now considered an AAPM. (According to the CMS Fact Sheet, this program was recently added to the list of 2017 AAPMs.)
- Do you meet the participation volume thresholds, i.e., do you derive 25% of your Medicare revenue or see 20% of your Medicare patients through one of these channels?
If the answer to all the questions above is “Yes,” you may be a QP (qualified participant) in an AAPM. Talk to the organization’s sponsor (typically a hospital) about your participation in MACRA.
If the answer is “No,” to all, or some, of these questions, your route to MACRA success will be via MIPS, or a MIPS APM, respectively.
For more information about MIPS and MIPS APMs, see the CMS QPP website or contact me at SRS Health. I also invite you to watch (or watch again) my webinar titled, “MACRA/MIPS: The Future Starts Now.”
You’ve come out of your eggnog-induced holiday fog and realize that you did not organize your practice for full-year MIPS reporting. With January 1 now in the rear-view mirror, you regretfully—but erroneously—conclude that you have missed out on the opportunity to earn the maximum positive payment adjustment in 2019. This is a common misconception that has been perpetuated in many MIPS-related webinars, blogs, and other communications. (That confusion exists is not surprising, given the spate of changes to MACRA in the last few months and the inherent complexity of the program itself.)
The fact is: Full-year reporting is NOT required to earn the maximum positive MIPS incentive in 2019. Rather, it is performance that counts, i.e. the number of MIPS points you earn and the level of quality you demonstrate, not the length of your reporting period or the amount of data you submit. If you look at the most recent CMS presentations, you will see images and text that clarify this point.
It could be argued—and representatives of CMS have done so—that it might be easier to achieve a high MIPS score with a longer reporting period, particularly on certain quality measures. Perhaps so… but this does not preclude clinicians from achieving an equally high score in a shorter period.
Of course, there is no such thing as a free lunch; and there are consequences—possibly unintended—of CMS’ largess in offering the Pick Your Pace options for 2017. Regardless of how many MIPS points an eligible clinician earns in 2017, his/her 2019 payment adjustment will, of necessity, fall short of the originally planned 4% due to the legislative mandate for budget neutrality. In the Final Rule, CMS estimated that the upward adjustment potential will now be less than 1% for the base performance and under 2.4% when the additional money for exceptional performance is included. (For an explanation and graphic that explains the required “scaling process”, see pages 77340 – 77342 of the Final Rule.)
That said, however, the good news remains: You have not missed the boat! But it is time to get to work to allow yourself the time and flexibility to maximize your performance, identify the optimal reporting period, and earn the greatest reward.
CMS has given providers an early holiday present with the Final MACRA Rule, affording everyone the opportunity to easily avoid a penalty in 2019. This is surely reassuring news and has been widely received with a huge sigh of relief—but before you let your guard down, it is important to acknowledge that the program will build back up to an only slightly modified version of its originally proposed self, with many of the complexities and challenges intact. CMS is calling 2017—and to a lesser extent 2018—“transition years.” Treating them as such offers an opportunity to prepare for the future, while treating them as a free pass only delays the inevitable.
In 2017, eligible clinicians who participate in MIPS can protect their 2019 Medicare fee schedule by merely reporting any ONE of the following:
- 1 quality measure, or
- 1 Improvement Activity (formerly called Clinical Practice Improvement Activities), or
- The 4 required Advancing Care Information (formerly Meaningful Use) measures.
Anyone who has participated in Meaningful Use and/or PQRS has already far exceeded these requirements, and will find this an extremely low bar. So why not aim for one of the more advanced “pick your pace” participation options and potentially benefit from an upward adjustment to your fee schedule? All it takes is reporting anything more than the above for a period of at least 90 days, and you could earn a “small” adjustment in 2019. Participate more fully—for anywhere from 90 days to a full year—and you could be eligible for the maximum, albeit “modest,” payment adjustment. (Note that it is performance that drives the payment adjustment, not the length of the reporting period.)
The downside of this new flexibility is that these “small” and “modest” adjustments for successful MIPS participants will now be very small or modest in 2019—far short of the originally planned 4%. Congress mandated that MACRA be budget neutral, so with dramatically fewer losers in 2017 to fund the gains of the winners, bonuses will be scaled down. Near-term financial rewards are unlikely to be a strong motivator of compliance this year.
However, by 2020, the difference between the most and least successful providers will exceed 18% (i.e., 2022 payment adjustments will range from -9% to +9% with potential additional bonuses available for the highest performers). So while it might be tempting to sit back and relax next year, consider using 2017 instead as it was intended—as a transition from MU and PQRS to MACRA. If you have been successful in the past, now is a good time to experiment with new workflows, new technologies, and/or alternate measures or reporting methods that might improve your performance. If you’ve never participated in these programs before, you can start now and get off the penalty track.
You can view the 2017 Final Rule as a free pass or as an opportunity—the choice is yours.