B R O U G H T T O Y O U B Y:

WHITEPAPER

BY KEN TERRY

ewer than half of

physicians are
aware of the
Medicare Access &
CHIP Reauthorization Act (MACRA), and
most of those who do know about
it probably wish it would go away.
Nevertheless, this law will determine how Medicare reimburses
doctors, starting in 2019.
Although the Centers for
Medicare & Medicaid Services
(CMS) wont release its final
MACRA rule until later this fall,
CMS recently changed the timeline for measuring the performance of physicians on quality,
cost and other parameters. This
1

modification will make things

considerably easier for doctors,
but they should still start getting
ready for MACRA immediately,
experts say.
Under CMS original proposal, physicians would have had
to report on their performance
for a full calendar year, starting
January 1, 2017. The fee for
service Medicare income of most
physicians would be adjusted up
or down 4% in 2019, depending on their scores. The at-risk
portion of their Medicare reimbursement would rise to plus or
minus 9% by 2022.
The new CMS policy gives
physicians more flexibility to

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adjust to this new reimbursement

approach. In the first option,
physicians who submit at least
some data to CMS new Quality
Payment Program in 2017 will
not be financially penalized in
2019. In option two, doctors can
start submitting the full range of
data required by CMS anytime
in 2017 and qualify for a partial
bonus if they do well. In option
three, practices can submit data
for the full calendar year and
qualify for full bonuses, again
assuming that they do better than
average on the measures.
These three options are
designed for physicians who
elect to go into the Merit-Based

Incentive System (MIPS), one of

two tracks in the Quality Payment Program. The fourth option is to apply for recognition
as one of MACRAs Alternative
Payment Models (APMs), which
include certain accountable care
organizations (ACOs) and the
5,000 practices that will participate in CMS new Comprehen-

Physicians who dont participate in the Quality Payment

Program will automatically get
the full downward adjustments
in their reimbursement rate
in 2019. Nevertheless, some
doctors might be inclined to
take the hit on their Medicare
income, at least temporarily,
rather than invest in new elec-

ALTHOUGH PRACTICES MAY NOT SEE AN

IMMEDIATE ROI, THE PERCENTAGE OF INCOME
A PRACTICE COULD GAIN IS SIGNIFICANT
AND THE AMOUNT THEY COULD LOSE
COULD BE EVEN MORE PROBLEMATIC.

sive Primary Care Plus demonstration. No more than 10%

of physicians are expected to
participate in APMs, which must
take on a significant amount of
financial risk for care delivery.
Doctors in APMs will automatically receive 5% annual bonuses
for five years, starting in 2019.

tronic health records (EHRs) or

upgrades or hire additional staff
to meet the MIPS criteria. They
might also not want to invest in
MIPS-mandated clinical practice
improvement activities, such as
engaging in population health
management.
David Wofford, a San Diego-

MIPS Guarantee from

athenahealths network-enabled services help practices thrive
through change. athenahealth incorporates quality measures directly into a practices workflow to help clients meet
requirements without additional work.
To support clients in preparing for MIPS, athenahealth
guarantees that new clients using its services will avoid any
MIPS payment penalties in 2019 based on 2017 performance.
If a practice receives a downward payment adjustment, the
company promises to credit the client the amount of the penalty for the 2017 reporting period. athenahealth partners with
practices of all sizes to help ensure MIPS success.

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based consultant with ECG

Management Consultants,
acknowledges that practices are
unlikely to see an immediate
return on such investments with
only 4% of Medicare revenue at
risk in MIPS. But the percentage
of income that a practice could
gain or lose will quickly grow,
he notes, and the program might
evolve into something more
problematic for those who dont
participate now.
I see MIPS as just training
wheels, he stated. Theyre preparing us for something else
some kind of expanded risk.
Heres how to navigate these
challenges both now and in the
future.
WHAT YOU NEED TO DO NOW

Practices should immediately

consult with their EHR vendors
to find out when their products
will be ready for MIPS. CMS
will allow practices to use their
current certified EHRs until
2018, when they must switch
over to EHRs that meet different
certification standards. The latter
EHRs are not yet available. But
the current EHRs were not programmed to work with the MIPS
quality measures, which wont be
described in detail until the final
rule is issued. So EHR vendors
will have to tweak their products
to calculate those measures.
With the greater flexibility
that CMS recently introduced to
the rules, however, the vendors
wont have to sprint to meet
the January 1 deadline. If a
practices EHR is upgraded
by January 1, the practice can
report with minimal difficulty if
it chooses the full-year reporting
option. Otherwise, the practice might want to wait until
it receives the upgrade before
beginning to report.
While awaiting the EHR
updates, practices should carefully evaluate their systems to see
how they can be used to support

MIPS. For example, they might

decide that their current EHR
will not provide them with the
capabilities they will need for
MIPS going forward. If they
decided to switch EHRs, under
the new MIPS rules theyd have a
large part of next year to choose
another system and implement it.

There are ways to obtain

comparative data that is more
usable than what QRURs offer.
Some cloud-based EHR vendors
offer benchmarking services
based on their customers data.
Groups can also report their
quality data to CMS through
qualified clinical data registries

SINCE QUALITY MEASURES COMPRISE HALF

OF THE SCORE, EXPERTS EMPHASIZE THE
IMPORTANCE OF EXCELLING IN THAT AREA,
AND THEY REGARD THE SELECTION OF THE RIGHT
QUALITY MEASURES AS THE KEY TO SUCCESS.

To improve performance on
quality measures, Wofford says,
physicians need both historical
data on their patient populations
and near-real-time data on the
services theyre providingor not
providingto their patients. Much
of that data will come from EHRs,
but there are other information
sources that can be valuable.
For instance, doctors need
benchmarking data to see how
they stack up with their peers
in MIPS. Practices that have
submitted data to the Physician Quality Reporting System
(PQRS) can access Quality and
Resource Use Reports (QRURs)
on CMS web portal. These
reports are annual, so the data
in them is not timely. Nevertheless, QRURs can help physicians
see where they stand on quality measures compared to their
colleagues, says Krista Teske, a
consultant with The Advisory
Board Company, a Washington,
D.C., consulting firm.
3

(QCDRs) that are provided by

specialty societies, certification
boards, and regional healthcare
collaboratives. If practices do
that, says Erin Mastagni, also of
ECG Management Consultants,
physicians should be able to see
how their performance compares whenever they want.
CHOOSING MEASURES

A physicians MIPS score represents his or her comparative

performance in four categories:
quality (50%), meaningful use
of EHRs (25%), clinical quality

improvement activities (15%),

and cost (10%). Since quality
measures comprise half of the
score, experts emphasize the
importance of excelling in that
area, and they regard the selection of the right quality measures as the key to success. They
suggest choosing metrics that the
practice has done well on in the
PQRS program, especially those
on which their performance exceeds that of their peers. Groups
should also choose some measures that cut across specialties,
which will increase the completeness of their data, Teske
notes. Some EHR suppliers help
practices select the measures that
theyre best suited for.
To improve quality scores,
practices should use the patient
registries built into their EHRs.
Besides sending alerts and reminders to providers at the point
of care, these registries can also
be used to run reports on which
subsets of patients have not
received certain types of preventive and chronic care. Practices
can then alert doctors that they
need to provide those services
when these patients visit. They
can also send out automated
phone or email reminders to
let patients know that they are
overdue for recommended care.
CMS will allow practices to
report quality data using any of
the methods they have employed
to report to PQRS. These include
the use of special procedure
codes, direct EHR reporting,

A PHYSICIANS MIPS SCORE REPRESENTS

HIS OR HER COMPARATIVE PERFORMANCE
IN FOUR CATEGORIES:

50% 25% 15% 10%

QUALITY

MEANINGFUL
USE OF EHRs

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CLINICAL QUALITY
COST
IMPROVEMENT ACTIVITIES

qualified registries, and QCDRs.

Groups of 25 or more eligible
clinicians may also use a CMS
web interface for reporting.
While claims-based reporting
is still the most common method,
Teske points out that it may become more difficult to do it this
way in MIPS. That is because the
percentage of Medicare patients
on which practices must report
for a particular measure will rise
from 50% to 80%. Groups
should be evaluating other EHRbased and QCDR mechanisms

have already met the stage 2

requirements. In 2018, they will
have more stringent requirements based on stage 3 metrics.
The clinical practice improvement activities (CPIA) section
requires changes in practice
operations. Practices can choose
among 90 activities as diverse as
expanding access to the practice,
improving communications with
patients, and delivering test results in a timely manner. For example, expanded practice access
might include increased evening

AS THEY CHOOSE A PARTNER,

THE PRACTICE SHOULD MAKE SURE
THIS COMPANY IS FOCUSED ON HELPING
IT GENERATE HIGH MIPS SCORES
WITHOUT TOO MUCH EXERTION.
and migrating toward those
because of the data completeness
component, she says.
MEANINGFUL USE SUCCESSOR

The successor to Meaningful

Use, called Advancing Care Information (ACI), will include 11
measures of EHR use that have
been modified from the Meaningful Use Stage 2 criteria. ACIs
objectives encompass data security, patient electronic access,
coordination of care, and health
information exchange. Graduated scoring will replace the pass/
fail Meaningful Use approach,
and doctors will get 50% of the
points just for reporting.
To do well on ACI, practices
will have to exceed the average
ranking. But it shouldnt be a
big challenge in 2017 if they

and weekend hours, urgent care

access, use of telehealth services,
collection of patient experience
data and a plan for improvement, or the hiring of an onsite
diabetes educator.
Some of these CPIAs will
require a substantial investment,
while others may be things a
practice is already doing. In
some cases, a practice can use
its quality measurement efforts
to meet CPIA requirements,
Wofford notes. The American
Academy of Family Physicians
(AAFP) suggests that physicians consider using Medicares
Chronic Care Management
Program, which pays $40 per
patient per month for enhanced
care management, to cover the
costs of practice transformations

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that will help them with CPIAs

and other MIPS criteria.
The resource use section
doesnt require reporting,
because CMS will use Medicare
claims data to measure utilization. Right now, resource use
comprises only 10% of the
MIPS score, but that percentage is expected to rise. Teske
recommends that independent
practices focus on reducing
hospitalizations to improve their
utilization scores. They could
also be careful not to over-order
diagnostic tests.
CONCLUSION

Even small practices can tackle

MIPS successfully if they prepare
and have the right technology
partners. As they choose a partner, the practice should make
sure this company is focused
on helping it generate high
MIPS scores without too much
exertion. For example, an EHR
supplier should be able to ease
the burden of data collection,
reporting and feedback.
In the near term, practices
should stay in touch with their
EHR vendor, observe what
comes out of the final rule, and
select the right quality measures.
In the long run, they should
keep trying to improve and
should work at it all year round,
not just when its time to report,
says Teske.
Practices that want to succeed in a value-based environment should not just look at
the short-term ROI from MIPS,
notes David Zetter, a healthcare
consultant in Mechanicsburg,
Pennsylvania. They should be
trying to transform themselves
so they can raise their performance scores, he says. Ultimately, there will be winners
and losers under MACRA, and
the proactive practices are more
likely to be winners.