Navigating the Shifting Sand under MACRA/MIPS

Regardless of what changes are ultimately made to MACRA, the overall market is staunchly marching towards value-based payment models.

Towards the end of the first reporting year for the Merit Based Incentive Payment System (MIPS), many physician practices were still solidifying their strategy to gain incentives and avoid penalties when a new wrinkle appeared. At its October meeting, the Medicare Payment Advisory Commission (MedPAC) unexpectedly proposed scrapping MIPS in favor of an alternative program that would penalize clinicians unless they tied their payment to “population-based outcome measures,” patient experience, and cost.  At its January meeting, MedPAC voted 14-2 in favor of replacing MIPS with their proposed alternative.

The possibility that MACRA/MIPS could be jettisoned entirely, less than a month after CMS delivered its final rule, is unsettling. To calm any frayed nerves, CMS Administrator Seema Verma followed the initial MEDPAC announcement with the release of a new “Meaningful Measures” initiative and a commitment to providing more flexibility with new payment models. The new information was likely reassuring to provider groups who had felt paralyzed by the lack of insight into the future of MACRA/MIPS. 

Forging a path forward

Regardless of what changes are ultimately made to MACRA, the overall market is staunchly marching towards value-based payment models.  Both the MIPS and MedPAC’s alternative model, the Voluntary Value Program (VPP), ultimately incentivize participation in Advanced Alternative Payment Models (APMs).  Physician practices therefore need to adopt strategies that are not married to a specific set of guidelines, but support value. ACOs and primary-care providers should seek to address the underlying challenges in healthcare delivery that drive both excessive cost and reduce quality of care.

There are many fee-for-service (FFS) CMS programs that are designed to help facilitate a transformation to value-based payment models, many of which have been highly underutilized.  Annual Wellness Visits (AWV), Transitional Care Management (TCM), Behavioral Health Integration Services (BHI), and Chronic Care Management (CCM) can help healthcare organizations move forward amid the uncertainty. 

CCM, in particular, is a great starting point, because it helps to better manage costs by keeping in close contact with chronically ill patients between visits. This allows doctors to quickly intervene when symptoms worsen, medication adherence slips, or there are other indicators the patient could be heading towards an acute episode. 

One of the new behavioral health integration codes, called General BHI, is very similar to CCM, but is for beneficiaries with just one behavioral health or substance abuse condition.  Since the scope of service is essentially the same as CCM, the two programs can easily be rolled out together.  For primary-care physicians that prescribe mood medications or antidepressants, using validated rating scales to assess patient status monthly via the

General BHI program provides an excellent means to measure clinical progress.

The following challenges can all be addressed by adding CCM and General BHI to the services primary-care practices provide, all of which impact both cost and quality of care:

Managing Super-Utilizers

It’s often been said that 80 percent of healthcare costs are driven by 20 percent of patients and that 50 percent of costs are incurred by just 5 percent of patients, aka Super-Utilizers. Among Medicare fee-for-service (FFS) beneficiaries, people with multiple chronic conditions account for 93 percent of Medicare spending.  Additionally, 26 percent of FFS Medicare beneficiaries (more than 13 million Americans) suffer from at least one behavioral health condition, and they are also at greater suicide risk than the general population.   CCM and General BHI provide a FFS mechanism to manage the super-utilizers, as well as those at greater than average risk of escalation.

Avoiding the avoidable

Avoidable hospital readmissions and adverse events due to drug interaction or medication non-adherence are two key areas of risk for physician practices under value-based payment modelsNever-events, like hospital-acquired infections and surgical errors, are no longer covered by CMS. But avoiding the avoidable is a game of Russian roulette if the only contact physicians have with patients is a couple of appointments each year. Physician groups must find ways to connect with patients between appointments and be alerted to any worsening symptoms, side effects, financial concerns, or other issues that might lead patients to discontinue their regimens. Identifying the patients most in need of regular support, and offering non-face-to-face touchpoints between appointments, will enable physician groups to reduce never-events, aiding them in performing well in any value based payment model.

Engaging patients

No longer a “nice-to-have,” patient engagement is a necessary pre-requisite in value-based care. While value-based care initiatives often focus on keeping patients out of the doctor’s office, it’s challenging to develop the intimacy needed to engage patients, if they are only seen a couple of times a year. The monthly touchpoints of CCM and General BHI serve to deepen that relationship, especially if they are designed with patient value in mind and place an emphasis on a meaningful, bidirectional dialog.  These regular discussions with a care manager who really “knows” their conditions and concerns helps to establish trust and engagement that will deliver ongoing benefits in terms of both patient satisfaction and physician insights.

Becoming a “learning health system”

The Agency for Healthcare Quality defines a “learning health system” this way: “In a learning health system, internal data and experience are systematically integrated with external evidence and that knowledge is put into practice. As a result, patients get higher quality, safer, more efficient care, and health care delivery organizations become better places to work.”

Under MACRA, physician practices must embrace becoming a learning health system in order to meet increasingly challenging benchmarks in future reporting years. For instance, the assumptions discussed in the 2018 Final Rule for MACRA seem to indicate that CMS is expecting 75 percent of clinicians to have a MIPS score of greater than 70 this year, which is this year’s benchmark for achieving the exceptional performance bonus. But next year, practices will have to maintain scores above the average to avoid penalties and potentially win incentives, meaning that total scores in the 70 range may not be high enough to avoid penalties in 2021.

As the percentage of the MIPS score tied to cost rises from 10 percent in 2017 to 30 percent in 2018, finding practice-wide solutions to impact cost will take on urgency. Programs like CCM and General BHI can help make the difference.

Alex Tse, MD, is a primary-care provider with over 40 years of primary care practice. He is the chief medical information officer of SmartlinkHealth.