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How Physicians are Getting Ready for MIPS/MACRA

CMS has formalized its plan to implement the Quality Payment Program requirements under the MACRA. CMS says it is focused on improving the way physicians and clinicians are paid to incentivize quality and value of care over quantity of services. Addressing the AHA annual meeting, CMS Acting Administrator Andy Slavitt said implementation of the MACRA is the “next transformative step in health care.” He explained that the MACRA rules are intended to “create on-ramps and off-ramps” that will allow physicians to more easily enter and exit payment reform programs.

As part of payment reform, the MACRA ends the Sustainable Growth Rate (SGR) formula that has been in place since 1997. Under SGR, CMS is allowed to cut physician payments if overall costs are greater than targeted Medicare expenditures. Each year, Congress has passed temporary “doc fixes” to avert cuts. For example, if no fix had been passed in 2015, physicians and other providers who bill Medicare would have seen a 21% cut in Medicare payments.

The MACRA aims to help Medicare achieve its goal of paying for value and better care through two new programs:

• Merit-based Incentive Payment System (MIPS)

• Alternative Payment Models (APMs)

Most Medicare clinicians will initially participate in the Quality Payment Program through MIPS, which will include components of the existing Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier, and the Medicare Electronic Health Record Incentive Program. CMS has also proposed to establish incentives for Medicare providers to participate in APMs, which would exempt these clinicians from MIPS reporting and would qualify them for financial bonuses. CMS has set 2017 as the performance period for the first MIPS payment adjustment in 2019. MIPS payment adjustments will be based on providers’ performance on measures and activities in four performance categories—quality, advancing care information, clinical practice improvement activities, and cost.

The Potential Reward is High, but so is the Risk

In 2019, year one of the program, MIPS clinicians stand to receive a positive, negative, or neutral payment adjustment of up to 4%. That percentage increases to 9% in 2022. The positive adjustments will be scaled up or down to achieve budget neutrality, meaning that the maximum positive adjustment could be lower or higher than 4%. In the first five years of the program, CMS has also allocated $500 million in an additional performance bonus that is exempt from budget neutrality to reward exceptional performance.

This bonus will provide high performers a gradually increasing adjustment based on their MIPS score that can add up to an additional 10%. In addition, CMS has allocated $20 million per year to small practices to provide technical assistance on MIPS performance criteria or assistance transitioning to an APM.

CAHPS for MIPS Survey

So, where does that leave the annual CAHPS for PQRS Survey? In 2019, that survey will be renamed “CAHPS for MIPS.” While CMS says that they anticipate that the MIPS survey will closely align with the PQRS survey, they say that they may explore the possibility of adding questions and possibly expanding the survey to specialists. In addition, they have proposed a scoring incentive for reporting the CAHPS for MIPS survey. “Because we believe patients’ experiences as they interact with the health care system are important, our proposed scoring methodology would give bonus points for reporting CAHPS data (or other patient experience measures).” In future years of the MIPS program, CMS has said they may consider expanding the measure to all payers, so that Medicare and non-Medicare patients can be included in the survey sample. CMS also promises to evaluate the use of “innovative technology” (e.g., smartphones) for the administration of CAHPS surveys, including electronic short-form patient experience surveys, which could ultimately pave the way for measurement of the patient experience at the individual physician level.

This article is an excerpt from the 3Q 2016 PX Advisor.

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