4 Strategies for Merit-Based Incentive Payment System Success

By Jacqueline LaPointe

October 23, 2017 - Medicare providers who qualify to participate in MACRA’s Merit-Based Incentive Payment System (MIPS) face up to a 4 percent incentive payment or penalty based on their performance in 2017.

Despite MIPS putting revenue at risk, many providers have yet to prepare, or even understand, the value-based reimbursement program, which launched in January 2017.

Only about one-half of providers said that they were somewhat knowledgeable of the value-based reimbursement tracks in MACRA, a recent American Medical Association and KMPG survey revealed.

Another 41 percent stated that they had heard of the program, but would not consider themselves knowledgeable. Just 8 percent identified themselves as deeply knowledgeable.

Hospital and health system executives were just as in the dark about MIPS. A recent Nuance Communications survey revealed that 61 percent of finance executives were confident that they understood MIPS and the program’s requirements.

However, over three-quarters of the respondents who expressed confidence in their understanding did not correctly identify the greatest potential penalty eligible clinicians could receive under MIPS in 2017.

Another one-half of confident leaders also either underestimated or did not know the number of days required for full MIPS data submission.

As the first MIPS performance year draws to a close by December 2017, eligible clinicians should be investing time and resources into understanding and reporting to MIPS. Otherwise, they could see their Medicare revenue fall by 4 percent if they fail to meet reporting requirements or performance dips below the MIPS performance threshold.

How can eligible clinicians maximize revenue under MIPS and where can clinicians find MIPS reporting support? RevCycleIntelligence.com explores key considerations from industry experts on preventing value-based penalties under MIPS and succeeding during the program’s first performance year.

Select MIPS measures that you already performed well on

When designing MIPS, CMS aimed to grant eligible clinicians as many quality reporting flexibilities as possible. As part of this plan, the federal agency allows clinicians to report on quality measures of their choosing for several of the MIPS performance categories.

For example, eligible clinicians can earn maximum points under the Quality category by reporting on just six out of 271 measures. They must also choose four Improvement Activities to report on out of 93 approved activities.

Clinicians should leverage the MIPS reporting flexibilities to maximize their composite performance scores and avoid penalties, explained Michael Abrams, MA, Managing Partner at the healthcare consulting firm Numerof & Associates.

“You don’t always get the option of choosing exactly what metrics on which you’re going to be held accountable,” he said. “In that sense, there’s tremendous amount of flexibility here that also gives providers the opportunity to choose those metrics that they believe represent strengths for them.”

To select suitable measures, clinicians should evaluate and understand their organization’s strengths and weaknesses with quality reporting, he advised.

Clinicians may want to revisit performance reports from legacy value-based reimbursement programs, such as the Hospital Value-Based Purchasing and Value Modifier models. Program results should indicate which measures organizations performed well on and which still need improvement.

Once an organization’s strengths are identified, clinicians should find similar MIPS measures and report on those to maximize performance.

While clinicians may not want to report on weak measures, identifying quality reporting challenges should also help clinicians improve their performance, Abrams stated.

“Any performance measure also provides the opportunity to understand your own performance better,” he said. “To the extent that thinking about their performance as measured in this way gives them insight into where they could or should improve, then focusing on those areas is an obvious next step for them to improve their scores.”

Partner with EHR, health IT vendors for MIPS reporting support

Eligible clinicians are turning to health IT solutions to help them avoid MIPS penalties in 2017. Over three-quarters (77 percent) of practices with three or more clinicians sought MIPS compliance technology, a recent Black Book Market Research survey uncovered.

Of the practices seeking MIPS technology, 89 percent primarily wanted a solution to help identify potential incentive payments or penalties.

While implementing a MIPS-specific solution would help, practice leaders experienced trouble finding vendor solutions. About 92 percent of respondents reported that they did not know of any branded MIPS compliance technologies from vendors outside of their EHR companies.

With limited branded options, providers should call on their existing health IT and EHR vendors for help.

Brad J. Abrams, DO, FAAD, a dermatologist and Mohs surgeon at Premier Dermatology recently explained to RevCycleIntelligence.com that his EHR vendor provided comprehensive MIPS support. The company implemented MIPS performance score reports into the EHR system so clinicians could regularly view their overall score and make improvements.

The EHR system also incorporated MIPS reporting requirements into clinician workflows.

“When my medical assistants go into the room, they go into the MIPS program and there’s a bunch of questions that they answer,” he said. “Has the patient been vaccinated for the flu? Any history of melanoma? Was it reported? They just check off all the boxes.”

The system also remembers if clinicians have already covered MIPS reporting requirements for each patient. For example, if a patient already received a flu vaccination and the clinicians documented that, the system would not prompt the provider to ask that question at the next appointment.

Clinician productivity, as well as MIPS performance scores, benefit from the EHR support, Abrams stated.

In addition to EHR system supports, Abram’s EHR vendors also paired his practice with an industry expert. The expert monitored his practice’s MIPS performance scores and alerted practice leaders of significant changes.

Abrams also relied on the MIPS coach for information on MACRA implementation and interpretations of CMS regulations.

With the support, he anticipates earning a positive MIPS payment adjustment based on his 2017 performance.

Identify physicians to champion MIPS education, performance improvements

Engaging health IT and EHR vendors is key to implementing data analytics and quality reporting tools needed for MIPS success. But healthcare organizations may also need to engage their physicians to prevent penalties, stated Rebecca Altman, Managing Director at Berkeley Research Group.

“It is hard to get physicians to take time out of seeing their patients, especially because we are progressively moving away from sheer volume and fee-for-service base to more of that value-based purchasing process,” she said. “But making sure that you have some good physicians who are wanting to lead that charge is one critically important strategy.”

Using physicians to educate their peers on MIPS and its financial implications may be the answer to MACRA implementation challenges. Physician skepticism and negative views on MACRA has troubled provider organizations.

A recent MGMA survey found that MIPS topped the list of most burdensome regulations for healthcare providers. Approximately 82 percent of leaders viewed MACRA and MIPS as “very” or “extremely” burdensome.

About 73 percent of provider leaders stated that MIPS was a “government program that does not support their practice’s clinical quality priorities.”

Another 63 percent of providers in a Kareo survey also expressed skepticism about provider profitability under MIPS. They said that they were uncertain whether the value-based reimbursement model would decrease their reimbursement revenue.

Provider views on MIPS have hindered MACRA implementation. Motivating staff across the organization to work as a team to achieve MIPS goals was a top MACRA implementation challenge, according to a recent analysis from Stoltenberg Consulting.

About 68 percent of healthcare professionals stated that MACRA implementation should be a team effort and employees from clinical, financial, and IT departments are critical parts of that process.

Using a physician champion can overcome these challenges. Providers can communicate MIPS and its financial impact using the same language as clinicians. They can also draw on their experiences to design clinician workflows that incorporate MIPS requirements without detracting from patient care time and other clinical responsibilities.

Altman suggested that healthcare organizations select one to two physicians to become MACRA implementation experts. These physicians should have experience with value-based reimbursement models.

Improve clinical documentation to maximize MIPS points

Eligible clinicians can maximum MIPS performance by ensuring coding and clinical documentation meets the program’s data completeness requirements.

The majority of MIPS measures have data completeness requirements so CMS can evaluate a clinician’s performance against a benchmark and ensure sufficient case volume. At least 50 percent of possible data must be submitted on a measure to meet data completeness requirements.

Failing to submit the required information will result in zero points on a MIPS measure, whereas submitting sufficient data will automatically earn the clinicians 3 points in 2017. Submitting over one-half of the possible data could generate even more points.

Data completeness may not be a major MIPS challenge at larger organizations because providers tend to have access to certified EHR technology and other health IT systems to support data collection, Altman stated.

However, small and rural organizations may not have access to automated coding and clinical documentation solutions and human capital to improve the processes.

“That takes a lot of not just work, but it takes the resources to be able to do that,” she said. “Because a physician can’t see patients and then also try to implement, collect, and monitor the data and things like that. You really do need resources.”

“For the smaller rural practices that are wanting to, or at least embarking on this, they will need additional resources,” she added. “That’s probably an expense they can’t necessarily afford.”

Small, rural practice leaders should allocate resources and human capital to clinical documentation improvement (CDI) efforts, Altman suggested. CDI initiatives should help clinicians ensure data completeness.

Coding and clinical documentation advancements could also increase MIPS performance scores under bonus categories available in later performance years. CMS proposed to award clinicians extra MIPS points for treating chronically ill and medically complex patients starting in 2018.

“It is critically important that they really leverage that because a lot of these rural and even midsize to large facilities take care of complex chronic patients,” Altman explained. “They really need to be pragmatic in their coding practices and making sure that they are collecting that specific data to ensure that they are getting those credits for taking care of those patients because that is the bulk of the work, ensuring those patients are cared for properly out in the community and preventing readmission.”

Ensuring that clinicians are prepared for MIPS in 2017 is critical to preventing penalties in 2019, the first MIPS payment year. But educating staff and implementing workflows that support MIPS will be a journey for provider organizations as the value-based reimbursement program matures.

Provider organizations can help their clinicians avoid penalties, and even generate positive payment adjustments, by engaging them in the MACRA implementation process and giving them access to MIPS supports, such as score reports and CDI tools.

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