The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will have an effect on nearly every physician in the U.S. and will have myriad implications for the healthcare industry. The most immediate change that the implementation of MACRA brings is it ended the widely unpopular Medicare Sustainable Growth Rate (SGR).
While many physicians celebrated the end of the SGR, MACRA installed the Quality Payment Program (QPP), the new method of reimbursing physicians for Medicare patients. The QPP includes two tracks: the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM), both of which require physicians to capture and report data on care quality, practice activities, and technology.
With all of the regulation changes from Washington D.C. over the past year, and perhaps fueled by "doc fixes" to avoid the SGR cuts over the years, some persistent misconceptions about MACRA, MIPS and Advanced APM are still lingering despite the release of the final rule in mid-October 2016.
The following are five of the most common myths surrounding the law and its programs, as well as recommendations physicians can use instead to maximize the incentives they can earn in the QPP.
Myth #1: MACRA will end if Trump repeals Obamacare
Fact: MACRA and the Patient Protection and Affordable Care Act (i.e., "Obamacare") are separate laws.
MACRA passed in the Senate with a vote of 92 to 8 and in the House of Representatives by 392 to 37. In addition, there are strong indications that Trump and the new Congress will continue the industry's transition to value-based care. For example, consulting firm Oliver Wyman noted that a bill repeatedly passed over the years in the House of Representatives to repeal Obamacare contains no provisions to eliminate associated Patient-Centered Medical Home or Medicare Shared Savings Program initiatives.
Myth #2: MIPS eliminates PQRS, MU and VBM
Fact: While technically true, MIPS is more of a consolidation and rebranding of the Physician Quality Reporting System (PQRS), Meaningful Use (MU) and the Value-based Modifier (VBM) programs.
MIPS has four categories:
• Advancing Care Information (ACI)
• Clinical Practice Improvement Activities (CPIA)
The Quality component, which comprises 60 percent of the overall MIPS score in 2017, replaces PQRS, but includes many of the same metrics that providers need to capture.
ACI replaces MU, comprises 25 percent of the MIPS score, and borrows measures from its legacy program.
CPIA is a new MIPS component in which physicians will earn 15 percent of their MIPS scores for 2017 for practice efforts that focus on improving care coordination, patient engagement and safety.
The Cost category replaces the VBM program and is based solely on the provider's Medicare claims, but will not be counted in 2017.
Myth #3: Most physicians do not have to participate in MIPS
Fact: In the first few years, the vast majority of physicians and advanced practice providers — such as nurse practitioners and physician assistants — will participate in MIPS, although there are three exemptions:
1. 2017 is the first year of the provider's Medicare participation
2. The provider collects $30,000 or less in Medicare charges or sees fewer than 100 Medicare patients
3. The provider is significantly participating in an Advanced APM program
This Advanced APM program exemption has led many physicians and practice managers to believe Myth #4.
Myth #4: We participate in an Accountable Care Organization (ACO), so our physicians don't need to worry about MIPS
Fact: CMS offers a narrow definition of Advanced APMs and requires that the organization accept financial risk; therefore, not all ACOs will qualify for a MIPS exemption. Risk-bearing ACOs that participate in the Medicare Shared Savings Program, Next Generation Accountable Care Organization Model, and Comprehensive End-Stage Renal Disease Care Model, are a few examples CMS has offered as organizations that may qualify for the exemption.
Even if the ACO does fit the CMS definition of an Advanced APM, the QPP requires members to report quality measures similar to MIPS and utilize a certified EHR. Practices should protect their providers just in case the ACO fails to report as an Advanced APM. For example, capturing all of the necessary quality metrics and other information for a MIPS report would be an excellent safeguard.
Myth #5: I will not need a 2015 Certified EHR for MIPS until 2018
Fact: MIPS does not require practices to use a 2015 Certified Electronic Health Record (EHR) to report data until 2018, but choosing not to prepare in 2017 and waiting until the last minute could create problems. Most practice managers know how much time and energy it takes to implement an EHR system. Going through that process again with a new system while ensuring compliance with MIPS requirements is likely not feasible in the same year.
The clock has started
Although 2017 is the first year of the QPP, CMS is not requiring physicians to report a full year's worth of data for 2017 and 2018. Practices should leverage this leniency by preparing for MIPS or Advanced APM requirements right away. Preparation starts by ensuring that the EMR is certified for all measures for the current year and that the EHR vendor has a planned path to certification for its next edition.
With some planning, providers can certainly maximize financial incentives in 2017 rather than leaving money on the table.
About the author:
Kathy Claytor is a Product Owner and MACRA, Meaningful Use, & PQRS Subject Matter Expert for Nextech.