If you've been following the news since the Medicare Access and CHIP Reauthorization Act (MACRA) proposed rule was released, you've likely seen a plethora of articles that are, in a word, scary. For ACO's, medical groups, and small practices slow to adapt to this change, there are good reasons to be concerned. The proposed first reporting period begins Jan. 1, 2017 for the Merit-based Incentive Payment System (MIPS), which currently applies to more than 90 percent of eligible clinicians. However, for those already moving in the right direction or proactively beginning to adopt the right strategies now, there is tremendous opportunity. In addition to the positive payment adjustment, the top performing quartile will receive a 10 percent bonus and there is potential for up to an 18 percent additional bonus. The spread in potential payment adjustments could therefore be as much as 26 percent in 2019, and 46 percent in 2022 and beyond.
Many clinicians breathed a sigh of relief when CMS announced recently that they will allow physicians to pick their pace of participation for the first performance year. In reality, those that avail themselves of the slower pace option now available will continue to fall further behind their peers, increasing the probability of maximum penalties in later years. Risk is now unavoidable and the race to demonstrate improvements in the cost and quality of care is already underway.
Gaining a Competitive Edge
Under MIPS, eligible clinicians are now in a race against their peers. Those that get off the starting block first and are able to maintain momentum will outperform those who wait. The winning strategy is to increase focus on categories of the MIPS score that will differentiate high and low performers. Based on the scoring criteria for Clinical Practice Improvement and Advancing Care Information, both are unlikely to be areas of strong differentiation compared to Quality and Cost/resource utilization.
At 50 percent of the MIPS score in year one, it is reasonable to expect some initial differentiation in Quality, but scores will quickly become similar among top performers. Cost is by far the most difficult to control and also the area that clinicians have the least experience with. While MIPS, Alternative Payment Models (APMs), and Advanced APMs won't receive a cost score, their cost performance will directly drive their shared savings and at-risk revenue. Clinicians that are able to get ahead of their peers in the cost category are likely to stay ahead, and will therefore become the strongest performers under MIPS. They also will be the best prepared to succeed under APM models.
Top Five Priorities for Success
In order to optimize payments under Advanced APMs, MIPS, and APMs, eligible clinicians should focus their efforts on these five areas immediately:
1. Join a group or APM team and fully participate
Controlling cost and quality is a team sport with multiple providers collaborating. Together, clinicians can pool resources to implement improved processes/technology and reporting, pool risk, and co-manage attributed patients. Additionally, MIPS scores will be reported publically, either individually or as a group. If you "go it alone" and don't score well, it may be more difficult to join an APM later.
2. Take control of downstream spend by coordinating referred care with high value referral partners
The average primary-care physician makes 1,000 referrals every year, thereby influencing ten million dollars in downstream healthcare spend, according to research in JAMA. That means that a group of 100 primary care physicians influences one billion dollars of healthcare spend every year, and may have over 16,000 patients in the process of receiving care elsewhere at any given time. On average, up to half of this spending may be on Medicare patients. All of this begs the question — how can you successfully manage cost if you don't know where your patients are?