When Physicians Practice recently asked readers what they thought the impact of the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) would be on their reimbursement in 2019, 62 percent of survey respondents said they weren’t sure and 28.8 percent said they expect it to be lower.
That level of uncertainty more than a year after the program — both part of the Medicare Quality Payment Program (QPP)—were first introduced could be seen as a troubling sign of the program’s overall complexity. But Michael Munger, MD, a family physician in Overland Park, Kan., and president of the American Academy of Family Physicians, sees the glass as half full. "The fact that we are hearing more physicians saying they are not yet sure how this is going to impact their bottom line is a real positive because it means they are paying attention," he says. "They are becoming invested. They no longer look at you with a blank stare when you say the MACRA Quality Payment Program."
Before the MACRA final rule for 2018 dropped in early November, physicians, practice administrators, and consultants looked both back at the first year of the QPP for lessons learned and ahead at the next few years, with an eye on reducing physician uncertainty and helping practices respond to new elements of the program. For this article we asked them what aspects of the QPP have proven most difficult or confusing in 2017 and what unintended consequences new elements might bring in 2018 and 2019.
Munger says that this past year the AAFP has had success working with member physicians on MIPS by breaking it down into its component parts, which makes it look more familiar. For several years there was the Physician Quality Reporting System (PQRS), which the quality section is based on; Advancing Care Information is the new Meaningful Use, which they have experience with. "In family medicine we have been working on improvement activities for years," he says. "All the practices that are recognized as patient-centered medical homes by one of the certifying bodies are already there."
Understanding how to report to CMS is one thing, but grasping how it will affect their reimbursement is another. Because the program is required to be budget-neutral, MIPS is actually a zero-sum game in which one physician's high performance score impacts another's payment.
In 2019, 4 percent of revenue generated through Medicare fee-for-service payments will be redistributed under MIPS, escalating to 9 percent by 2022. Funding for the positive payment adjustments is going to come from those who get the negative adjustment. It won't be clear how much money there will be for bonuses until the negative adjustments are collected, explains Amy Mullins, MD, AAFP's medical director of quality improvement.
"That is something we won't know year over year, until we know how many people scored above the threshold and how many below. What a score of 50 [gets] you one year may not get you the same amount the next year. No one likes uncertainty when it comes to revenue streams. That is never a comfortable place to be. But we do know that if you score above the threshold you are not going to get a negative adjustment," she says.