Physician Reimbursement Under MACRA: Maximizing the Merit-Based Incentive Payment System

In 2015, Congress voted to enact the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA) of 2015. MACRA authorizes the U.S. Department of Health and Human Services to implement value-based initiatives aimed at improving a clinician’s accountability of care, and the access to care for Medicare and CHIP beneficiaries. Eligible clinicians can choose to attest to either: the Merit-Based Incentive Payment System (MIPS), or Alternative Payment Models (APMs). MIPS incorporates the electronic health record (EHR) incentive program (Meaningful Use), Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VPM) program. Various Accountable Care Organizations and Patient-Centered Medical Homes are the means for qualifying as an APM.(1)

Despite skepticism, MACRA is here to stay. Payment adjustments or penalties under MACRA are expected to increase significantly through 2022. It is essential that clinicians get on board, implement MACRA, and maximize Medicare reimbursement.

MACRA: The MIPS Pathway

MACRA established MIPS, the purpose of which is to streamline three currently independent programs to work as one, easing clinicians’ burdens. MIPS changes the way clinicians get paid by emphasizing quality and value instead of volume. Any clinician, including physician assistant, nurse practitioner, clinical nurse specialist, or certified registered nurse anesthetist, who bills Medicare Part B more than $30,000 in allowed charges a year, and provides care for more than 100 Medicare patients, is eligible to participate in MIPS.(2) Clinicians who participate can receive a payment adjustment up to 4% from CMS in 2019. Clinicians who fail to participate will lose 4% in reimbursement from Medicare. Adjustments and penalties are expected to increase from 5% in 2020 to 9% in 2022.(3)

MIPS uses a scoring system based on points as opposed to the traditional pass/fail system.

To hold clinicians more accountable for quality of care, MIPS uses a scoring system based on points as opposed to the traditional pass/fail system. Using a point system enables CMS and clinicians to compare quality and cost scores among peers. CMS makes payment adjustments based on evidence-based and practice-specific quality data. Clinicians must show they provide high-quality, efficient care supported by technology.

MIPS Performance Categories

The categories that make up MIPS include Quality for Meaningful Use, Advancing Care Information (ACI), Clinical Practice Improvement Activities (CPIAs), and resource use (cost). CMS weighs each performance category separately.(2)

• Quality for Meaningful Use: The category “Quality for Meaningful Use” mimics PQRS and the VPM program. This category was adopted to help clinicians focus on the value of care they provide, which increases the likelihood of patients becoming healthier. To meet requirements for the quality category, MIPS-eligible clinicians are required to report on 6 of the 271 clinical quality measures CMS offers.(4) One of those six measures must be an outcome or high-priority measure. Outcome measures focus on how healthcare services influence patients’ health. High-priority measures focus on patient experience, efficiency, and care coordination.

• Advancing Care Information: ACI replaces and simplifies the Meaningful Use program. ACI aims to make data submission mechanisms less burdensome. Clinicians must provide proof that their EHR system protects patient health information. MIPS-eligible clinicians can select ACI measures that best fit their needs. Scoring for ACI is a three-part process that includes base, performance, and bonus scores. To be eligible for the performance and bonus points, the base score must be met.(5) Once the base score is met, CMS offers additional performance points for clinicians with exceptional performance in patient engagement and information exchanges.(5) Bonus points can also be achieved by reporting on more than six ACI measures.

• Clinical Practice Improvement Activities: The goal of CPIAs is to improve clinical practice in areas such as care coordination, beneficiary management, and patient safety. CMS offers 93 CPIAs that are medium- (10 points) or high-weighted (20 points). For example, annual registration in the Prescription Drug Monitoring Program is medium-weighted, whereas providing 24/7 real-time access of a patient’s medical record to eligible clinicians or groups is a high-weighted activity.(6)

• Cost: For 2017, the cost category is worth 0% of the final MIPS score.(2) No additional information is needed, other than Medicare claims. Medicare claims will be analyzed to help evaluate cost performance and provide feedback to clinicians.

Achieving Successful Outcomes

Open communication, coordination, and collaboration are essential to achieving successful outcomes with MACRA and MIPS. Clinicians may choose to designate employees, or hire externally, to take on the role of a MACRA champion. The MACRA champion can ensure everyone becomes educated on MACRA, roles are coordinated, and employees are collaborating to achieve desirable outcomes. Staff meetings should be conducted on a regular basis to review goals, share outcomes, assess progress, and address workflow issues.

Creating an action plan to improve performance in poorly performing areas will ensure successful outcomes.

Once clinicians and employees familiarize themselves with MACRA, they need to set target performance goals, and establish an action plan to achieve those goals. Previous participation in Meaningful Use and PQRS puts clinicians at an advantage. Clinicians who have previously participated can access their information to assess and analyze past performances. Benchmarks are based on the actual performance data submitted to PQRS in 2015.(7) With this information, a clinician can identify poorly performing measures, and compare performance results among peers. Assessing these results helps clarify the strengths and weaknesses of an organization. Clinicians then can restrategize and turn their organizational weaknesses into strengths. Creating an action plan to improve performance in poorly performing areas will ensure successful outcomes.

All other clinicians should create a list of measures that suit their practice. When an organization becomes familiar with MACRA, everyday tasks can turn into reimbursement incentives. For example, most healthcare practices send out preappointment reminders to patients. Under MIPS, a practice can receive credit by documenting, within their EHR system, when the preappointment reminder was sent. However, if the employee responsible for sending a preappointment reminder is unaware that documentation is needed within the EHR system, no credit will be received. Clinicians may want to seek assistance to ensure employees are familiar with MACRA and MIPS. Clinicians need to make certain that all departments coordinate their efforts to ensure that successful outcomes are achieved.

CMS offers the option to filter measures based on several factors, including measure priority, data submission method, and clinician specialty.

CMS provides clinicians the flexibility to choose the activities and measures most meaningful to their practice. CMS offers the option to filter measures based on several factors, including measure priority, data submission method, and clinician specialty.(3) For instance, of the 271 quality measures available on the CMS website, 20 are specifically tailored to cardiologists, and 7 are high-priority. Clinicians should start by drilling down on the measures specific to their specialty and identify outcome and high-priority measures, because these measures earn bonus points. The flexibility of MIPS gives clinicians an opportunity to choose measures most applicable to their practice, while increasing chances of maximizing reimbursement.

To help achieve a high performance score, clinicians should understand and assess their current performance under Medicare programs. Confidential feedback reports are offered via CMS’s Physician Feedback Program,(8) also known as the Annual Quality and Resource Use Report. This program provides information about the cost and quality of care provided by physicians and group practices.

Clinicians who use end-to-end electronic reporting for MIPS automatically become eligible for bonus points.

Familiarity with the healthcare organization’s EHR system also is a critical component to achieving successful outcomes with MIPS. Most EHR systems offer support, educational resources, and consultants to help healthcare practices achieve success with MIPS. Clinicians who use end-to-end electronic reporting for MIPS automatically become eligible for bonus points.(7) Understanding how EHRs operate will better ensure the efficiency and effectiveness of the system. For example, most EHR systems include CMS benchmarks that allow a practice to compare their performance on MIPS measures. Once performance is critiqued, changes can be made to achieve organizational success. A practice can access pertinent data and information through their EHR system. Most EHR systems are capable of running performance reports for any given range of dates, which further ensures that clinicians are using appropriate ICD-10 diagnosis codes, receiving accurate patient risk scores, and increasing their reimbursement under MIPS. Reviewing the EHR system and workflow practice is essential to ensure the efficient and effective utilization of resources.

Common Barriers

One of the greatest barriers to implementing MIPS and maximizing incentives is understanding the grading system and cost, which is a bit complex. CMS offers the free MIPS Scoring 101 Guide.(7) The MIPS Scoring 101 Guide goes into explicit detail about the point potential of each MIPS performance category, explains how each category gets scored, and provides tips for success.

If used properly, EHR systems are extremely beneficial in achieving MIPS success. They can, however, also become barriers to success. Despite offering a wealth of information on MACRA, getting one EHR system to communicate with another can be time-consuming and burdensome. Some EHR systems are not interoperable with other systems. For example, as part of ACI, a healthcare organization can receive credit for securely transmitting a referral from one clinician to another via their EHR systems.(7) However, even though messages are encrypted and securely sent through a recognized database, some EHR systems flag and prevent these emails from being retrieved. Clinicians should ensure that their EHR systems are able to perform the tasks required to successfully attest to MIPS. If not, clinicians will have a very hard time meeting performance requirements and will not receive proper credit. Also, some EHRs do not support all CMS measures. If the EHR system does not account for all the favorable measures chosen by a practice, a clinician will receive the minimal amount of allowable points, and poor performance scores. Trying to achieve better scores while using an EHR that does not account for all CMS measures will require excessive, time-consuming work. Clinicians should make sure their EHR systems are compatible with MACRA rules, regulations, and requirements.

It takes time and collaboration to implement organizational change. Educating employees and patients and providing incentives can help smooth the implementation process. For example, under MIPS, a clinician will receive credit for patients who access their health information online.(7) However, not all patients will comply. If employees and patients understand why changes are taking place, and receive incentives to receive organizational giveaways (iPads, computers, electronics, weekend getaways, etc.) for participating, they may be more willing to comply.

Recommendations

• Quality for Meaningful Use: Clinicians can avoid the 4% penalty imposed by CMS by reporting for at least one patient, on one quality measure, one improvement activity, or the required ACI measures.(7) Clinicians wanting to attain an upward payment adjustment should submit more than the minimum. CMS takes the top six scoring quality measures of a practice to determine a performance score.(7) If a practice submits only six quality measures, the performance score is limited to those six quality measures. Submitting more than six quality measures can increase a clinician’s chances of maximizing reimbursement. Clinicians also get bonus points in the quality performance category by submitting more high-priority measures.(7 )Of the 20 quality measures available to cardiologists, for example, CMS recognizes seven as high-priority. Only two high-priority quality measures are needed to attest to MIPS. A clinician can earn bonus points and incentives by choosing to attest to more than the minimum. The more high-priority measures clinicians report on, the more likely it is that their reimbursement incentives will increase under MIPS. CMS also offers bonus points to clinicians who submit MIPS information via CERT or end-to-end reporting.(7)

• Advancing Care Information: Bonus points are available for clinicians who exemplify superior performance under ACI. Clinicians must meet a mandated base score. Then they can qualify for additional performance points, based on exceptional performance in patient engagement and information exchanges.(7) Bonus points also can be earned by clinicians who report on more than the six required ACI measures. One bonus point is received for every additional report made on behalf of a clinician to the public health registries.(7) Clinicians can maximize reimbursement by reporting on additional ACI measures.

• Clinical Practice Improvement Activities: It is essential for clinicians to understand how CPIAs are weighed and which group they fall under. Group practices with more than 15 MIPS participants must choose two high-weighted activities, four medium-weighted activities, or one high-weighted and two medium-weighted activities. Additionally, CMS gives more points to practices with fewer than 15 participants, non–patient-facing clinicians, and clinicians located in a rural or health professional shortage area. These smaller healthcare organizations must attest to a minimum of two medium-weighted or one high-weighted CPIA.(7 )Clinicians must identify how they will be submitting data (individually or as a group) and which CPIAs are already in place within their practice. For instance, a clinician may already participate in a prescription drug monitoring program, or provide 24/7 access of patient’s medical records to other eligible clinicians. Regardless, clinicians need to thoroughly review all CPIAs, submit to those CPIAs that meet the needs of their patients, and improve the efficiency of their practice.

• Cost: The cost category does not weigh on a clinician’s final results. However, CMS will use a clinician’s Medicare claims data to assess their cost performance with hopes of providing feedback to clinicians by July of the following year.(7) The feedback CMS provides can be very beneficial and should be used to assess their costs versus the costs of their peers. Once improvement areas are identified, clinicians can implement the changes necessary to provide more cost-effective care.

Conclusion

MACRA is a competitive program that offers significant financial incentives for high-performing clinicians who participate. Clinicians will be ranked among their peers with scores made publicly available by CMS. Clinicians who failed to participate will have low performance scores shared, whereas clinicians who did participate will have higher performance scores and higher payment adjustments. Making clinicians more aware of the variables that affect their overall performance scores is critical for MIPS success. Regardless of the approach, clinicians must act now to ensure MACRA gets implemented within their practice. To excel within each category, processes must be put into place, goals must be defined, and a strategy must be established. Only then can a clinician create a pathway to MIPS success and maximize reimbursement.

References

1. The American Medical Association. 2018 Quality Payment Program Final Rule Highlights: pages 1-3. November 2017. www.ama-assn.org/sites/default/files/media-browser/member/arc/qpp-final-rule-highlights.pdf . Accessed February 15, 2018.

2. The American Medical Association. AMA Summary: Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program Final Rule. October 19, 2016. www.ama-assn.org/sites/default/files/media-browser/public/physicians/macra/macra-qpp-summary.pdf . Accessed February 15, 2018.

3. The Centers for Medicare and Medicaid. The Merit-Based Incentive Payment System: MIPS Scoring Methodology Overview. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf. Accessed February 15, 2018.

4. The Centers for Medicare and Medicaid Services. Merit-based Incentive Payment System (MIPS): Quality Measures. qpp.cms.gov/mips/quality-measures . Accessed February 15, 2018.

5. The Centers for Medicare and Medicaid Services. Merit-based Incentive Payment System (MIPS): Advancing Care Information. https://qpp.cms.gov/mips/advancing-care-information. Accessed February 15, 2018.

6. The Centers for Medicare and Medicaid Services. Merit-based Incentive Payment System (MIPS): Improvement Activities. https://qpp.cms.gov/mips/improvement-activities . Accessed March 21, 2018.

7. The Centers for Medicare and Medicaid Services. Merit-based Incentive Payment System (MIPS): Scoring 101 Guide for the 2017 Performance Period. www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/MIPS-Scoring-101-Guide.pdf. Accessed March 22, 2018.

8. The Centers for Medicare and Medicaid Services. 2016 Quality and Resource Use Reports (QRUR) and 2018 Value Modifier. January 12, 2018. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2016-QRUR.html .