Last week, the Centers for Medicare & Medicaid Services (CMS) released a Proposed Rule in the Federal Register. This massive, 962-page document describes the government’s approach to future Medicare reimbursement, as required by the Medicare Access and CHIP Reauthorization Act (MACRA), which was signed into law in April of 2015. The new program is the Merit-based Incentive Payment System (MIPS), with the government’s stated goal to transition to a new payment model based on an assimilation of the programs requested of physicians today. Instead of the Electronic Health Record (EHR) Incentive Program, the Physician Quality Reporting System (PQRS) and the Value-based Payment Modifier (VBPM), the government is fusing them together into a single payment platform.
The new payment model is based on a MIPS Composite Performance Score (CPS), calculated on a 0 to 100-point scale. The score, designed based on CMS’ conversions of measures and activities to points, determines your Medicare payment adjustment – up or down. Geared to commence in 2019 as required by MACRA, CMS is using the coming year – calendar year 2017 – to base the initial reimbursement. Unlike past programs, this isn’t a voluntary process. All physicians (except for new ones or those with only a trickle of Medicare business) are enlisted, as well as a vastly expanded list of health care professionals.
Let’s break down the proposed categories of the MIPS CPS for the 2017 reporting year:
Quality: This category, which replaces the multitude of quality indicators being requested by the various government programs today, counts for 50% of the first year payment program. While PQRS required nine criteria, MIPS drops the count to six measures, offering new specialty measure sets as well as individual standards. From a reporting perspective, there are a multitude of methods by which to report, including most of those available by PQRS today.
Resource Use: Accounting for only 10% of the score, CMS also dubs this category as “costs”; designed to parlay the cost component of the VBPM program, the score is calculated based on a behind-the-scenes assessment of your Medicare claims, with no required reporting of data per se.
Clinical Practice Improvement Activities: A totally new category, this is probably the one that will bring the biggest surprise. Eligible health care professionals will report a minimum of one activity out of 90 proposed for a score to which 15% is attributed, with additional credit for more actions. The activities include care coordination and after-hours care, with most of the list of 90 falling under practice operations. Of note, if you are a patient-centered medical home, you automatically get the full credit for this category.
Advancing Care Information (ACI, the government’s proposed new term for meaningful use [MU]): Replacing MU, this category, which accounts for 25% of the score, features the measures related to the use of an EHR system. Think of it like MU Phase 2, although fundamental changes are in store. These include participating as a group practice, dropping the “all or nothing” aspect of the program, and eliminating the measures related to computerized provider order entry (CPOE) and clinical decision support (CDS). Given the fact that physician assistants (with few exceptions) and nurse practitioners were not eligible to participate in MU in the first place, CMS is exempting these advanced practice providers from the ACI category. The tally for this category is centered on a base score, a performance assessment and even a bonus point. Just like MU today, you’ll report a numerator, denominator or yes/no for the criteria. While there’s a new name, the standards required for reporting are familiar, to include protecting health information, electronic prescribing and patient electronic access.
You may have heard that you can get out of the new MIPS program – and even qualify for a boost in reimbursement – by being a member of an “alternative payment model” (APM). That’s correct, but CMS reveals – not surprisingly – that the model must be a specific so-called advanced APM. To be a qualifying APM participant, you are obligated to have a certain percentage of your patients or payments through an advanced APM during the reporting year (2017 for the 2019 payment adjustment, for example). These advanced APMs, which include CMS Innovation Models and Medicare Sharing Savings Program Tracks 2 and 3, must require participants to use an EHR system (more than 50%, for the first year, climbing to 75% by year two), base payment on quality (including at least one outcome measure) and take financial risk. The final criterion is really the deal breaker, with explicit financial risk standards.
In essence, if you want to get out of MIPS and achieve an additional, automatic, lump sum bonus of 5% of your Medicare reimbursement, CMS is making sure that dodging the new payment structure puts you in an entity that mirrors the principles of MIPS.
CMS is accepting comments on the Proposed Rule now, so it will likely be the end of the year before we fully understand the new payment model. This leaves little time to prepare for the initial reporting period for MIPS, which commences January 1, 2017, with adjustments in 2019. According to CMS, you’ll get your first feedback report in July 2017. Four percent is at risk, but more “losers” will drive the eligible bonus for high performers to 12% to ensure the required budget neutrality for the program. Plus, an additional 10% is available for “exceptional” performance. The potential upside is very compelling, but there are clearly a set of hoops to jump through to get there.
CMS is no longer dabbling in payment adjustments – either you’re in, or you’re out. Increase your knowledge base in the coming months, in order to ensure success in 2017.
For more information, click this link for CMS’ summary of the proposal.