CMS Unveils More MACRAnomics Detail for Physicians

Thursday, May 5, 2016 | Larry Sobal

 

Last week, the Department of Health and Human Services released the long-awaited proposed rule to implement the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposed rule would implement these key provisions of MACRA through the unified framework, called the “Quality Payment Program.” In addition, the announcement clarified that the statutorily-mandated “low-volume threshold” exclusion for physicians will apply to those with fewer than 100 Medicare Part B-eligible patients—and less than $10,000 billed charges for Medicare.

I cannot emphasize enough that physicians and health systems need to be spending time right now becoming intimately familiar with the various MACRA programs—to begin to prepare for the changes that are looming in the near future.

Note that when it says “proposed rule,” that’s exactly what it is. CMS will accept public comments on the 962-page regulation over the next two months, with final rules expected to be issued by the end of the year. It’s hard to say how much CMS will consider public comments before implementing the final rules. Historically, there have been some examples where CMS has taken suggestions into account and made changes—and others where it has not. My opinion is that you shouldn’t expect substantive changes to occur to what has already been widely publicized.

What does this mean for physicians? I cannot emphasize enough that physicians and health systems need to be spending time right now becoming intimately familiar with the various MACRA programs—to begin to prepare for the changes that are looming in the near future.

The most important thing to know is that services provided by physicians—and your performance—beginning January 1, 2017 (8 short months from now) will directly impact your CMS reimbursement beginning in 2019 (the first year in which the MIPS and APMs take effect).

Second, be aware that instead of separate programs for Meaningful Use (MU), Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VBM), CMS is combining them into MIPS.

Imagine a 9 percent reduction to your overall CMS reimbursement. That would be painful.

MIPS is much more than a confusing exercise in acronyms. Participants in MIPS will be eligible to receive a positive payment adjustment, but are also at risk of negative adjustments. While the maximum adjustment is 4 percent for 2019, it will eventually reach 9 percent. Imagine a 9 percent reduction to your overall CMS reimbursement. That would be painful.

How your bonus or penalty will be determined by MIPS is that providers will each earn up to 100 MIPS performance points annually, across four performance categories: Meaningful Use (max 25 points), PQRS/VBM quality (30 points), VBM cost or resource use (30 points), and clinical practice improvement (15 points). Hence, 85 percent of MIPS is determined by success, according to MU, PQRS, and VBM program rules.

Every MIPS point translates into positive or negative dollars of reimbursement. Each year, CMS will define an overall performance threshold—say 50 points—such that a provider earning 50 points will receive zero percent payment adjustments. A score of 51 will earn a slight incentive, 49 will incur a slight penalty, and the incentive or penalty increases the further the points earned are away from 50. It’s not anticipated to be proportional, therefore a score of 70 might earn an incentive of six percent and a score of 40 could incur a penalty of three percent. It’s important to note that CMS sets the performance threshold so that those receiving incentives take money from those receiving penalties, as the entire program is designed to be budget neutral. 

You don’t have to wait until 2019 to find out your fate—whether or not you are likely to receive a positive or negative adjustment. For one thing, CMS predicts that the likelihood of receiving an upward performance adjustment goes up significantly as practice size expands. Among practices with two to nine eligible MIPS clinicians, only 29.8 percent are currently predicted to receive a positive adjustment. This estimate increases to 81.3 percent for practices with 100 or more. Solo practitioners are predicted to be hit hardest by MIPS, with 87 percent estimated to incur a negative reimbursement adjustment.

If you aren’t comfortable with those odds—or waiting until 2019—I suggest three things: 

1. Review your Quality Resource and Use Reports to understand how you and/or your practice is fairing under the VPM.
2. If you have not already attested for Meaningful Use, begin doing so in 2016.
3. If you have not already reported data under PQRS, begin doing so in 2016.

Finally, be aware that MACRA allows physicians participating in APMs to avoid the MIPS process altogether, so you might also look to be a participant in one of the CMS APM programs.

The bottom line is, you must take time now to learn about MACRA. MedAxiom is a great resource for you. Take the MACRA Readiness Assessment.

Also, don’t forget to register for 2016 CVSL Symposium, where MedAxiom experts will share the most up-to-date information. You can also refer to my March 31 blog, Physicians, Are You Passing MACRAnomics 101? to learn more.

---

 

Larry Sobal is Executive Vice President of Business Development at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and insurance. As part of his current role, Larry consults, writes and presents on topics relevant to transforming physician practices and health systems.

 

---