The pMD Blog
POSTS BY TAG | MIPS


Image: Dr. Thomas Albini

Here's The Latest in Health Care:


•  Three women between the ages of 72 and 88 had lost most to all of their eyesight after participating in an unproven treatment where stem cells were injected into their eyes. The women later told doctors they thought they were participating in government-approved research after finding the study listed on a government website provided by the National Institutes of Health. Unfortunately, clinical trials do not need government approval to be listed the site.  Read More

•  In Trump's proposed health care budget, the Department of Health and Human Services should expect to see its budget slashed by more than $15 billion in 2018. The Department of Veterans Affairs, however, would see a $4.4 billion increase. The reduction takes funding away from the nation's foremost medical research agency as well as support programs for low-income individuals.  Read More

•  With the new 2017 Merit-Based Incentive Payment System (MIPS) performance period underway, providers are left in the dark as to whether or not they must comply with program criteria. Providers that bill $30,000 or less in Medicare charges or give care to 100 or fewer beneficiaries are exempt from MIPS. The Medical Group Management Association is calling for immediate release of 2017 MIPS eligibility information to find out if clinicians are part of the nearly one-third that are eligible for exemption.  Read More

•  Researchers say that over-the-counter birth control pills would be safe for teens and that there is no evidence that adolescents are at greater risk from birth control pills than adult women. In fact, some of the potential negative side effects of oral contraception are less likely in younger adults, according to Krishna Upadhya, assistant professor of pediatrics at Johns Hopkins University School of Medicine.  Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture software.
PQRS vs MIPS, quality program differences

As March 31st looms on the horizon, we've been hard at work shepherding our PQRS Registry participants towards successful quality reporting. That means we spend a lot of time analyzing data, reviewing measure selections, and answering basic questions about the PQRS program. One consistent pattern we’ve seen is confusion between 2016’s PQRS reporting program and 2017’s MIPS Quality reporting program. It’s understandable: in 2017 MIPS Quality will completely replace PQRS. To help alleviate the confusion, I’ve gathered together 8 main differences between PQRS and the MIPS Quality program.

1. Bonus and Penalty Structure:
PQRS is a stand-alone program. In 2016, failure to satisfactorily report PQRS results in an automatic 2% penalty to your 2018 Medicare billings. But, PQRS also overlaps with a variety of other CMS programs like MAV, VM, and MU. Most of these other programs also carry their own penalty or bonus, so figuring out exactly what’s at stake for one reporting period is complicated. For 2017, CMS has attempted to streamline these various programs. The 2017 MIPS Quality program is actually one part of the bigger MIPS program. So, participants in the MIPS Quality program will only have one overall MIPS penalty or bonus, rather than separate bonuses or penalties for each distinct program.

2. Who Is Required to Report Quality Measures:
For PQRS, everyone that had submitted a bill on a patient to Medicare Part B Fee For Service in 2016 needed to report quality measures if they wanted to avoid the automatic 2% penalty. For MIPS Quality reporting, not everyone that bills Medicare Part B Fee For Service will need to report. For example, the low threshold exception exempts participants who have less than $30,000 worth of Medicare Part B Fee For Service bills, or who have less than 100 Medicare Part B Fee For Service patients. Additionally, certain types of Advanced Payment Models are exempted from MIPS Quality reporting. Finally, participation in a certain other types of Advanced Payment Models means that participants can skip MIPS reporting - including MIPS Quality reporting - altogether.

3. Reporting Time Period:
To avoid an automatic penalty in PQRS, the program required that quality measures be reported for the full performance year, January 1st to December 31st. With MIPS - at least for 2017 - participants can avoid an automatic penalty as long as they report on something for some time period. Though, participants should keep in mind that this relaxed time frame for reporting period will change in 2018 and beyond, eventually once again requiring a full year's reporting.

4. Reporting Population:
PQRS requires that participants report on at least 50% of the Medicare Part B Fee For Service patients who qualify for the chosen quality measures. MIPS requires that participants report on at least 50% of all patients who qualify for the chosen quality measures, regardless of payer.

5. Number of Quality Measures Required to Report:
PQRS requires participants to report at least 9 quality measures. MIPS requires participants to report on 6 quality measures.

6. Structure of Required Quality Measures:
PQRS requires that the quality measures participants choose to report span across 3 domains, which are like categories of effective healthcare. MIPS only requires quality measures to be reported, they do not have to be chosen from any specific categories.

7. Cross-Cutting Measures vs. Outcomes Measures:
PQRS requires that the quality measures reported by participants include one cross-cutting measure, unless a special exception applies. MIPS does not require cross-cutting measures, but rather requests that the quality measures reported by participants include one outcomes measure.

8. Measure Groups:
PQRS allowed participants to utilize measure groups reporting as an alternative way to satisfactorily report quality measures; MIPS does not allow for measure groups reporting.

And, finally, one bonus difference plus similarity...

Still a Four Letter Word, Just a Different One:
PQRS means the “Physician Quality Reporting System” and MIPS is the “Merit-Based Incentive Payment System.” Thus far, despite efforts by CMS to ease the burden of quality reporting, both programs have caused frustration, anxiety and struggle for many of those involved.
As I've worked with several health systems on how they have been handling PQRS reporting and how they intend to report MIPS quality data to CMS, I've seen some things that I can't unsee: the thick binder overflowing with handwritten pages describing various quality measures; the room full of data entry personnel busily reading patient charts; the EHR screens packed with data fields for a physician group that turned on every single outpatient quality measure.

"We'll capture them all up front, then we'll figure out which ones to submit to CMS later," they said. But it turned out that they were having a hard time convincing physicians to go into that EHR screen at all because it was so heinous. Hence the room full of data entry folks.

MIPS is complicated to begin with; and for complicated health systems, it can get REALLY complicated. They have physicians reporting under multiple Tax ID Numbers (TINs), and often many completely different specialties that ended up sharing a single TIN. Assuming they're reporting as a group (GPRO), that means they often pick "lowest common denominator" measures centered around primary care. This burdens their already-overworked Primary Care Providers with additional data entry, and it effectively excludes many hospitalists, surgeons, and other specialists from quality reporting - certainly from any quality metrics that matter to them.

But with ever-increasing risk from mandatory bundled payments, Accountable Care Organizations and other advanced payment models, and the upcoming cost component of MIPS, I'm hearing from more and more of these enterprises that they can no longer afford to make quality something that only the Primary Care Providers and care coordinators worry about. It's something that involves the specialists too - for example, if a hospitalist fails to talk with a patient about their advance care planning, that patient could end up receiving a very costly and unpleasant intervention that perhaps they didn't want. Getting buy-in from the specialists, and giving them a way to measure their success on these metrics, is vital.

Thinking back to the room full of data entry specialists reading charts, I'm struck by the gap between the ostensible intention of these quality programs (improve the quality of care by rewarding physicians who follow evidence-based care) versus their result (the physicians are not engaged, and the hospital suffers additional costs to hire a room full of people to read their charts and enter data into a registry). There is a better way to engage specialists in quality programs and to actually improve outcomes in the process, but it has to meet them where they are - which is not necessarily sitting in front of a computer - and it has to offer them targeted measures that are relevant to their specialty, not just smoking cessation.

At pMD, we say: bring it on! We love working with specialists of all kinds, and we've developed some innovative tools that help with measure selection and targeted mobile data capture during hospital rounds and immediately after surgeries. There is no one-size-fits-all solution for MIPS, but the future is bright for organizations that embrace their own complexity and find a nuanced solution that will work for them and their physicians.
To run a health care practice, it’s crucial to have the right information to navigate through the many government changes. So I’ve put together a MIPS For Dummies, of sorts. My goal is to give you some insight into the quickly approaching government changes to the reimbursement process. The Centers for Medicare & Medicaid Services (CMS) has released some preliminary information and here is what we know.

Let’s start with the basics. What does MIPS stand for?
Monkey-Identified Petite Scoliosis. Just kidding! MIPS is the Merit-Based Incentive Payment System and it is a new value-based payment model. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is the statute that created this new advancement of the value-based payment model.

What is MIPS?
MIPS is a new payment system outlining financial incentives (and penalties) based on the data submitted by practices, which judges the quality, outcomes, and efficiency of patient treatment. Imagine that the Value-Based Modifier Program, Physician Quality Reporting System (PQRS), and the Medicare Electronic Health Record (EHR) all met and joined forces under one larger, combined program.

Who is at the mercy of MIPS?
Perhaps you, if you’re reading this blog post. But really, MIPS reporting will be required for any clinician billing for professional services under Medicare Part B. This includes all physicians, dentists, chiropractors, physician assistants, physical or speech therapists, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and hospital-based eligible providers. Providers who are in their first year of Medicare or are below the low-volume threshold may not be required to participate in MIPS.

When is MIPS currently scheduled to roll out?
January 1, 2017! This time I’m not kidding…

Finally, here are some fun facts about MIPS:
1. Centers for Medicare & Medicaid Services (CMS) is no longer accepting comments on the proposed rule - The cut off date was June 27, 2016. However, the final rule with comment period was issued on 11/4/16, and you can comment on that for only a few more days! Cut off for the comment period for this version of the rule is 12/19/16.

2. Qualifying Advanced Alternative Payment Model (APM) Participants are eligible clinicians who are exempt from the MIPS model. This includes Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models.

3. CMS released a fancy new (and surprisingly helpful!) website that guides practices through how to participate in each category of MIPS.

4. To participate in the ACI portion of MIPS you will need a 2014 or 2015 Edition Certified EHR before or on January 1, 2017.

5. If you're eligible for MIPS but decide not to participate in the program, you will receive an automatic negative 4% payment adjustment on your 2018 Medicare reimbursements. (This one is a not-so-fun fact).

Now, last but not least, pMD’s web portal can produce reports reflecting valuable quality data that can be leveraged for MIPS reporting, PQRS solutions and other government changes.

#MIPTASTIC #MIPSYALL #MIPSYEAH
One of pMD’s mottos is to work like a beautifully engineered German car: fast, fun, and efficient. As pMD’s in-house attorney, I’m often pulled in the polar opposite direction as I wade through dry, convoluted, acronym-heavy health care regulations. It takes no stretch of the imagination to realize that government health care regulations are not fast, fun, nor efficient. So, one of my favorite challenges is to take this complicated regulatory jargon and break it down to easy to understand language. This week’s challenge: MACRA, QPP, MIPS, and APMs.

What is MACRA?

MACRA is the acronym for a federal law that is officially titled the “Medicare Access and CHIP Reauthorization Act of 2015.” MACRA was touted as the largest health care bill to pass since the Affordable Care Act was signed into law in 2010, and had impressive bipartisan support. MACRA made several changes to existing health care laws, including restructuring Medicare payments. Thus, the law is the newest solution to the ongoing challenge of shifting Medicare payments from fee-for-service to value based. MACRA created the newest evolution of the value based payment model.

This newest evolution, as proposed by CMS last week, is called the Quality Payment Program, or QPP. The Quality Payment Program officially ends and replaces the controversial Sustainable Growth Rate (SGR) payment formula and combines existing value based payment formulas to create a new framework. The QPP offers two distinct paths to payment:

1. Merit Based Incentive Payment System (MIPS); and
2. Alternative Payment Models (APMs).



What is MIPS?
MIPS consolidates three of CMS’s current value based payment programs. Those three programs are:

1. Physician Quality Reporting System (PQRS);
2. Meaningful Use; and
3. Value Based Modifiers.

CMS aims to fully dissolve these programs and replace them with MIPS by 2019. The MIPS framework will use these programs as a reference point to award composite scores to each provider. There are four factors influencing the composite score:

1. Quality;
2. Advancing Care Information (formerly Meaningful Use);
3. Clinical Practice Improvement Activities; and
4. Cost or Resource Use.

Each category is weighted differently, with quality as the most influential factor. Small practices can combine to report as a “virtual group” and be scored together on combined performance.

The current timeline is to begin measuring MIPS in calendar year 2017, which will influence payments in calendar year 2019. Potential bonuses for high scoring practices range from 4% in 2019 to 9% in 2022. Additionally, $500M has been set aside to potentially be awarded as “exceptional performance” bonuses. Low scoring practices will see equivalent percentage based fee reductions. Standard fee schedule updates will remain flat from 2019 to 2025, when a yearly 0.25% increase will begin for MIPS participants.

CMS believes that most providers will begin their QPP participation on the MIPS pathway, and then gradually transition towards the APM pathway. Indeed, CMS has created certain incentives to encourage providers to move towards substantial involvement in an APM.

What is an APM?

The second path to payment offered by QPP is participating in an alternate payment model, or APM. Providers participating in the APM pathway can avoid the reporting mechanisms required by MIPS, and still be eligible for financial bonuses. CMS hopes that eventually a majority of providers will participate in APMs, and thus has further incentivized this pathway within the QPP. However, exactly which organizations qualify as APMs is still unknown. Familiar organizations such as Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are currently considered to be included. But, MACRA charged CMS with creating an APM certification process so that innovative health care solutions can become certified APMs under the QPP.

CMS’s goal is to begin payout of a flat 5% fee increase in calendar year 2019 for all APM participants. As with MIPS, standard fee schedule updates will remain flat from 2019 to 2025, but unlike MIPS, a yearly 0.75% increase will begin for APM participants in 2026.

What does this all mean?

Ultimately, it means that Medicare payment models are changing… again. But, the exact requirements necessary to earn these payments is still open for debate. So, the ultimate outcome of the legislation and how much closer on the path to value it will bring our health care system remains to be seen.

All this brings me to the plainest, simplest summary of MACRA, QPP, MIPS, and APMs I can muster:

MACRA is a law. The QPP is the newest evolution of a value based payment model, which offers two distinct payment programs: MIPS and APMs. The QPP was created by MACRA.

The exact implementation plans for MACRA and the QPP takes us back to the world of dry, convoluted, acronym-heavy health care regulations. But, that’s another blog post. At the end of the day, Medicare payment changes once again hover on the horizon. And while pMD can’t advise our charge capture customers on complying with these regulatory payment issues, we can – and do – create fast, fun, and efficient tools to help them propel medical practices through the ever-changing regulatory landscape to success.

One thing that we can predict with certainty in the health care industry is new acronyms. And new acronyms can mean changes to CMS payment programs. It was approximately one year ago that my colleague Elise wrote a great article on the Physician Quality Reporting System (PQRS). PQRS was originally an incentive based program which, in 2006, included a 1.5% incentive payment based on total allowable charges to providers who reported quality information to CMS. In 2008, the Medicare Improvement for Patients and Providers Act (MIPPA) extended PQRS and increased the incentive to 2%.

This incentive continued until 2010 when the Affordable Care Act (ACA) introduced penalties for providers who did not submit PQRS data. The introduction of penalties forced providers to rethink how they were submitting PQRS data in order to ensure they wouldn't see their levels of reimbursement decline. Participating providers were forced to adopt additional software solutions, employ additional specialists, or join PQRS registries (like us!) in order to not be penalized.

Fast forward to 2016, and after 13 years and over $150 billion spent, the Sustainable Growth Rate (SGR) formula is being eliminated! The Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law by the President on April 16, 2015 and completely revamps how CMS pays providers.

According to MACRA, we are now in a transition period whereby:

• Physicians will receive annual growth fee schedule rate increases of 0.5% starting on July 1st, 2015 through the end of 2018.
• There will be a 2% penalty for failure to report PQRS measures.
• There will be a 3% penalty for failure to meet meaningful use requirements.
• The rates in 2019 will be effective through 2025 and providers will have the opportunity to receive additional payments through the 'Merit-Based Incentive Payment System' (MIPS).

Compare the MIPS incentive payments to the SGR formula of a 21% cut in reimbursement, and you can see why the American College of Physicians is in complete support of MACRA and MIPS.

The most surprising provision in MACRA, however, is the fact that CMS is now required to replace not only the SGR, but also PQRS, the Electronic Medical Record Incentive Program (Meaningful Use), and the Value Based Modifier program by 2019 with MIPS.

The AMA and the ACP both agree that the MIPS program is a positive development for physicians as it allows them to effectively determine their eligibility for incentive payments beginning in 2019.

pMD is getting set to help our providers proactively set their performance goals and get credit where credit is due! Check back for part two on MIPS where I describe how pMD helps our providers in the four MIPS assessment categories which will be crucial to receiving positive MIPS adjustments in 2019.