With major changes coming to Medicare this year, doctors must decide now how to tackle payment reform
Since 2015, when Congress passed significant Medicare payment reform legislation, primary care physicians have treated the measure as something to deal with sometime in the future.
That future arrived January 1.
The beginning of 2017 marked the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), which puts real weight behind the federal insurance program’s push to increase the quality and accountability of care.
Though they may not all be aware of it, many practices are now operating under MACRA rules. For an estimated 600,000 practices, that means their Medicare Part B payments are now determined by a new value-based program called MIPS, short for Merit-based Incentive Payment System.
For many primary care physicians, success under the new program will require significant changes in how they deliver care and the ways they track and report the outcomes. MIPS includes new initiatives with new benchmarks, different reporting measures and escalating financial incentives and penalties.
MACRA is designed to strengthen primary care and position it at the controls of a coordinated network of care providers. And if it works as intended, PCPs will see earnings increase along with responsibilities. But to achieve that, doctors have to learn and then integrate the new program into their practices.
“You can go outside for advice, but you can’t get someone else to do it. It needs to be central to your practice,” says consultant Jeanne Chamberlin, MA, FACMPE, of MSOC Health in Chapel Hill, North Carolina.
Because the Centers for Medicare & Medicaid Services (CMS) regards 2017 as a transition year for MACRA, practices can choose their pace of participation. CMS hopes MIPS-eligible practices will participate as fully as possible so as to be ready for future years.
Before making that decision, however, practices have to know what’s required, where they stand and how they can improve-knowledge many lack, according to David Zetter, CHBC, CHCC, principal of Zetter Healthcare, a practice management consulting firm in Mechanicsburg, Pennsylvania.
For many practices, success under MIPS, at least initially, will depend on the extent of their previous participation in value-based programs and reporting. MIPS will be easier for those with experience collecting and reporting data for programs such as the Physician Quality Reporting System (PQRS) and Meaningful Use (MU). Those who have yet to participate in value-based programs face a steeper implementation curve.
Practices must decide if they’re up to the task of implementing MIPS, says James M. Daniel, JD, MBA, a healthcare attorney and consultant in Richmond, Virginia. He advises his clients to study the MIPS reporting and performance requirements and compare them to what the practice already is tracking for MU or PQRS. That can help practices decide the extent to which they should participate in MIPS for 2017.
Next: A closer look at what PCPs should be doing now
Some practices will seek safety in numbers. MIPS allows PCPs to be rated as individuals or as a group (defined by a tax ID). “Virtual group” reporting will be allowed beginning in 2018. These are groups of no more than 10 clinicians who can report jointly without actually merging their practices.
Further reading: How physicians can overcome payment obstacles in 2017
While many practices are coming to grips with the new reporting requirements, practice management consultant Chamberlin worries that the MIPS requirements for this year are so lax that practices will opt out or participate only minimally. To avoid a payment penalty, PCPs have only to report one measure in either the new Quality Performance or Clinical Improvement Activities categories.
“They reduced the requirements so much that to avoid the penalty you have to do almost nothing,” Chamberlin says. “It’s hard to make a case to a family physician that you should do a whole lot of stuff to get 1% of $100,000.”
But the possible benefits and penalties grow in coming years and practices should do as much as they can this year to be better prepared for 2018’s stiffer requirements, she says.
Because practices will not know if they’ve made errors in collecting and reporting this year’s data until they receive their 2019 payments-when it’s too late to fix any mistakes-it’s essential that they follow procedures correctly this year, Chamberlin adds.
The uncertainty over what their Medicare reimbursements will be come 2019 also complicates financial planning for many practices. Experts recommend not counting on an increase and building in a margin in case reimbursements are penalized or expected bonuses aren’t forthcoming.
Here’s a closer look at what PCPs should be doing now in MIPS’ four reporting categories.
This category replaces PQRS and accounts for 60% of category weight for reporting in 2017. To fully participate in MIPS, practices must report on at least six quality measures, including at least one outcome measure for a minimum of 90 continuous days in the calendar year. Groups using the web interface must report 15 quality measures for a full year.
The MIPS quality measures are largely the same as those in the PQRS and Value-Based Payment Modifier (VBM) programs, and include such activities as:
In addition, MIPS calculates one population measure for groups with 16 or more clinicians and a minimum of 200 cases. Practices can earn bonuses can be earned for activities such as reporting outcomes, appropriate use and electronic health record (EHR) reporting.
Though it is tempting to do only the minimum required this year to avoid a penalty, Chamberlin advises practices to participate as fully as possible to prepare for more stringent reporting requirements in coming years. She adds that practices should pick a mix of easy and challenging goals based on a well-thought-out plan.
Next: CPI activities
This category accounts for 15% of 2017 category weight. MIPS designates 92 CPI activities and groups them by high- and medium-weight. To fully participate in MIPS, practices must engage in four medium-weighted or two high-weighted activities. Small practices, rural practices or those in medically underserved areas can do one high-weighted or two medium-weighted activities. The minimum requirement to avoid a penalty is one activity.
The activities are a mix of clinical and procedural. High-weight activities include those such as providing 24/7 access to eligible clinicians or groups with real-time
access to patient medical records, glycemic management services and engagement of new Medicaid patients.
Among the medium-weight activities are annual registration in the Prescription Drug Monitoring program, depression screening, diabetes screening and engaging patients, family and caregivers in developing a plan of care. A complete list is available at
The key is knowing your practice and patients and what’s achievable with them, says Melissa White, practice administrator for Newton Family Physicians, in Newton, North Carolina. The five-doctor, four-nurse practitioner practice views performing well under MIPS as a necessity to remain independent, she says.
“We have not approached any of these processes by checking the boxes or thinking what we can do that’s easy,” White says.
To prepare, the practice examined its patient data and volume for the appropriate conditions on which to report, ran trial reports, and eventually chose to report on two conditions for adults and two for children, measures for which it knew it could meet the reporting requirements. “We’re trying not to reinvent the wheel,” White says.
This replaces MU and accounts for 25% of 2017 category weight. To fully participate, practices are required to report on five measures: security risk analysis, e-prescribing, patient electronic access, and requesting/accepting a summary of care document.
Next: "The practice needs to make this work"
PCPs can earn additional points for such activities as secure messaging and immunization registry reporting. As with the other categories, it’s important that PCPs examine the data they already collect, as well as how they collect it, to identify both shortcomings and measures at which the practice excels.
EHRs are required for MIPS reporting, and practices that don’t have one should add an EHR as quickly as possible, says Leigh Burchell, vice president of government affairs at Allscripts, an EHR vendor.
Those that do have EHRs should make sure their systems are up to the task of collecting and reporting the necessary data. Burchell cautions against relying solely on EHRs to reach compliance, however.
“We’ll do everything we can, but the practice needs to make this work,” she says.
Before the reporting period starts, practices should run trials to make sure they can capture and deliver the necessary data, Burchell says. Practices still using 2014-certified EHRs should upgrade to 2015 certification because it’s far more capable, adds Chamberlin, although 2015 certification won’t be required until 2018.
This replaces the Value-based Modifier program. CMS has delayed the requirement to report on costs until 2018, when it will count for 10%. No data submission will be required; it will be calculated from adjudicated claims. While it might be tempting to ignore the category this year, practices should start collecting data to determine how they will fare in the coming years.