In the not-too-distant future, doctors will have to make an important decision each year-one that will affect their pay.
Beginning in 2019, doctors will be required to participate in the Merit-Based Incentive Payment System (MIPS) or an alternative payment model (APM). Bob Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians, explains what physicians need to know about the programs.
Although there is some time before this value-based transition occurs, it’s not too early for practices to start deciding where they are headed in the future. “The question is, which path is best for you? There’s no one-size-fits all. Be prepared, don’t be caught in a less advantageous position,” Doherty says.
Starting in 2019, physicians and their practices will have to choose between two options-MIPS or APM- for Medicare reimbursement. “Although they will need to be enrolled in one of these two options starting in 2019, they will need to make the decision considerably before then, and ensure that their practices are ready,” Doherty says.
They can chose to participate in the new quality reporting program MIPS, which will adjust their Medicare physician fee schedule payments up or down based on performance measures on four weighted categories: quality, resource use, meaningful use of electronic health records, and clinical improvement. They will get a score from 1 to 100, based on how well they do.
The total score will be based on their performance compared to their peers, as well as their own year-to-year improvements. The maximum positive and negative performance-based adjustments will grow each year: plus/minus 4% in 2019; plus/minus 5% in 2020; plus/minus 7% in 2021; and plus/minus 9% starting in 2022. Top performers who score in the top quartile of all physicians can get additional annual incentive payments of up to 10% each year.
To qualify for reimbursement as an APM-such as an accountable care organization (ACO), patient-centered medical home (PCMH), or by using condition-specific bundled payments-the law requires that the practice accept financial risk for the quality and effectiveness of care provided, with one exception: PCMHs are required to accept financial risk, but would have to demonstrate to Medicare that they can improve quality without increasing costs, or lower costs without harming quality. The practice would have to demonstrate that a substantial portion of their total payments comes from the APM.
Physicians who are in an APM practice would get annual baseline updates of 5% each year from 2019 through 2024 on all services paid under Medicare’s physician fee schedule, with the opportunity to earn more if they meet savings targets. On the other hand, APMs that take on direct financial risk may have to re-pay Medicare if they don’t meet their savings targets.
Start thinking about it
It is too early for practices to decide now which option is best for them starting in 2019, because the Medicare program has yet to work out how to sign up for MIPS, be accepted as an APM, or related issues.
Physicians and practices that are already successfully participating in the current Medicare reporting programs-Physician Quality Reporting System (PQRS), meaningful use, and the Medicare value-modifier index-will have a leg up on practices that are not participating in, or have not been successful in reporting under those existing programs. That’s because the current programs will be folded into MIPS in 2019.
Similarly, physicians in practices that are currently participating in Medicare’s ACOs, bundled payments, or Medicare’s Comprehensive Primary Care Initiative (medical homes) will have an advantage over practices that are not part of these alternative models, whether they decide to choose the APM or the MIPS option beginning in 2019.
There is no “one-size-fits-all” framework for deciding which path, MIPS or APMs, is best for an individual physician, their practice, and their patients. The decision should be based on what the practitioners and their administrators, determine works best for them for that year.
Certified PCMHs automatically qualify for the highest possible score for the practice improvement component of the MIPS program (15% of their total score), and as noted above, PCMHs also can qualify as an APM without having to take direct financial risk.
Doherty says Medicare still has to work out the details on what a practice must do to be certified-and who will do the certifying-as a Medicare PCMH. “Still, it stands to reason that physicians and practices that have embraced the PCMH model will be way ahead of those that have not,” he says.