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What does MACRA mean for you? Key takeaways


CMS’ Quality Payment Program (QPP) introduced in the Medicare Access and CHIP Reauthorization Act (MACRA) has created a seismic effect across provider organizations.

CMS’ Quality Payment Program (QPP) introduced in the Medicare Access and CHIP Reauthorization Act (MACRA) has created a seismic effect across provider organizations.

Within the QPP are two paths providers can follow: the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (APM). The significant impact providers are feeling is due to the fact that MIPS and APM are combining three deeply entrenched CMS programs: meaningful use (MU) of electronic health records (EHRs), the Physician Quality Reporting System (PQRS) and the Value-based Modifier (VM).

In the MACRA proposed rule, the new initiatives combine elements of the existing programs, but the scoring, payment incentives and penalties are quite different. For example, under MIPS, by 2022, a provider’s negative adjustment can be 9% and positive adjustment can be up to 27%.

In addition, while the existing programs have been merged under MIPS and APM, the data capture, analysis and reporting required for compliance will be no less challenging if most of the proposed rule’s provisions are accepted when the final rule hits this fall.

Healthcare organizations that want to maximize incentive payments under the MACRA programs will need to enable the free flow of data across their enterprise so metrics can be continually analyzed to monitor and improve performance.

Quality is the emphasis

The MACRA program that most eligible clinicians will likely participate in is MIPS. MIPS evaluates performance across four categories:

  • Quality

  • Resource use

  • Clinical practice improvement activities (CPIA)

  • Advancing care information (ACI)

These categories, however, are not weighted equally. The quality category represents 50% of the MIPS Composite Performance Score (CPS) in first year. Performance category weightage varies in subsequent years. Providers with strong PQRS historic performance should excel under the MIPS quality category, which is a slightly streamlined version of the expiring program. For example, MIPS quality is comprised of six measures, down from the nine measures required under PQRS, with no domain requirement, unlike PQRS. There is also at least one cross-cutting measure and an outcome measure or high-priority measure, which puts greater emphasis on outcome data capture for providers.

Additionally, bonus points will be offered for reporting higher-priority measures and using an EHR for reporting. The scores in the quality category will be assigned based on a national level percentile for the reporting clinician. This offers a radically different focus from PQRS, which emphasizes only the number of Medicare Part B patients, rather than the actual provider performance.

Under the proposed rule, quality measures will be selected annually, and the final list will be published in the Federal Register by November 1 of each year. Provider organizations can be confident that familiar Clinical Quality Measures from PQRS and VM will appear in this category.

Next: ACI is meaningful use (MU) rebranded


ACI is meaningful use (MU) rebranded

The expiration of MU may be a welcome change for some provider organizations, but MIPS and APM do not quite remove the program altogether. Under MIPS, the EHR performance category, named ACI, contains elements from the MU Stage 3 final rule and comprises 25% of the overall MIPS CPS. The good news is ACI does not appear to be as demanding as MU Stage 3.

For instance, providers can automatically earn 50 points out of a possible 130 (the maximum achievable score will be capped at 100), by just reporting measures on six ACI objectives, including electronic prescribing, patient electronic data access and immunization registry reporting. One of these objectives, however, protecting electronic protected health information (ePHI) can result in a zero score across the entire ACI category, if not achieved.

CPIA and resource use

The other MIPS categories, CPIA and resource use comprise 15% and 10% of providers’ CPS respectively.

Since CPIA is a new category, and there are more than 90 activities providers can choose from such as care coordination, shared decision-making and safety check lists, organizations should compare eligible CPIA activities against their internal programs to determine which may qualify.

Resource use is based solely on Medicare claims data and requires no provider reporting, but accurately monitoring and controlling costs is foundational to any value-based care program. Similar to the quality category, Resource use will also score clinicians based on a national level percentile.

Next: APM offers advantages, risks



APM offers advantages, risks

Fewer provider organizations will qualify for the APM, but forming or joining an APM may appeal to a physician or an organization if they feel their earning potential is higher than MIPS. Providers who qualify for an APM include the following:

  • Those participating in Center for Medicare and Medicaid Innovation programs or Medicare Shared Savings Program accountable care organizations.

  • Providers participating in the Health Care Quality Demonstration Program.

  • Providers participating in other CMS demonstration programs.

Based on the proposed rule criteria, six current APMs will be Advanced APMs in 2017.

Regardless, all APMs need to use certified EHRs and meet their own set of stringent performance and reporting demands. APM participants need to meet certain threshold criteria to be exempted from MIPS and be eligible for APM incentives.

The essential element in complying with either path’s requirements will be having access to tools to make data integration, aggregation and analysis efficient so providers can monitor performance. With timely benchmarking and easy-to-interpret reports, organizations can adjust work flows and provider behaviors to improve the quality metrics that will drive MIPS scores and APM performance up while improving outcomes and patient satisfaction.

Change is never easy, but if organizations start preparing now and leverage the right available technology as well as knowledge gained from the expiring programs, providers can greatly accelerate progress and enable long-term success.

Manan Shah and Akash Jha are healthcare consultants at CitiusTech.





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