Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Value-Based Care News

Key Ways to Succeed Under MACRA’s Quality Payment Program

Clinicians can succeed during the Quality Payment Program’s transitional year by submitting quality data early and on the most appropriate measures.

By Jacqueline LaPointe

- Do not feel overwhelmed by the upcoming Quality Payment Program, a healthcare expert at CAPG, a non-profit trade association for accountable physician organizations, advised the projected 592,000 to 642,000 eligible clinicians participating in the Merit-Based Incentive Payment System (MIPS) in 2017 and another 70,000 to 120,000 estimated to identify as qualifying alternative payment model participants.

Clinicians can maximize revenue and implement APMs by understanding quality reporting under the Quality Payment Program

“It’s only MACRA, don’t panic,” Amy Nguyen Howell, MD, MBA, FAAFP, CAPG’s Chief Medical Officer, recently told “It’s not that bad.”

Keeping with CAPG’s new slogan, “Keep Calm, It’s Only MACRA,” Nguyen Howell suggested four key ways that eligible clinicians can succeed under MIPS during the 2017 transition year and move towards the Advanced Alternative Payment Model (APM) track, which contains higher value-based incentive payments.

The first year of the Quality Payment Program will be a lot easier with the new transition year track, Nguyen Howell stated, but providers should still ease into MIPS, identify common quality measures across payers, report on quality measures they already score well on, and start population health management programs.

Nguyen Howell recommended that eligible clinicians start by easing themselves into the Quality Payment Program by using a flexible MACRA attestation track.

READ MORE: Oncologists Need Data Reporting, Time for MACRA Implementation

“First of all, with the final rule, we do have to applaud CMS for listening to all of the clinicians and providers from across the country,” said Nguyen Howell. “The transitional year is going to be really easy for providers because it lessens their reporting requirements from their current PQRS [Physician Quality Reporting System], Value-Based Modifier, Meaningful Use requirements to basically one quality requirement. The ease into the Quality Payment Program is great.”

Under the final MACRA implementation rule, eligible clinicians can avoid a negative four percent Medicare payment adjustment in 2019 by submitting data on at least one MIPS measure by Mar. 31, 2018. CMS stipulated that eligible clinicians in this flexible MACRA attestation track must submit data to Medicare on either a quality performance, improvement activity, or Advancing Care Information measure.

Eligible clinicians, however, will need to choose from 271 quality, 15 advancing care information, and 93 improvement activities measures, according to the Quality Payment Program’s official website.

To help providers narrow down the quality measure list, Nguyen Howell recommended that eligible clinicians start by pinpointing common quality measures among their payer mix and reporting on those that are also included in MIPS.

“Look at the quality measures across all of your business lines in which you participate, Medicare Advantage, Stars, HEDIS, commercial, Medicaid, and Medicare fee-for-service, because for the first year 60 percent of the composite score will be based on quality measures,” asserted Nguyen Howell. “Look at all of these measures and see which ones are common to each other, which ones align with one another, and then, pick those because those will qualify for MIPS.”

READ MORE: MIPS Reporting Success Depends on Choosing Suitable Measures

For CAPG members, Nguyen Howell created a crosswalk for all business lines and found six MIPS measures that align with the different payer programs. By reporting on these six measures, providers could fulfill both MIPS and other payer requirements while potentially earning maximum value-based incentive payments for quality reporting.

“I’m not telling people how to deliver care, but I’m saying look at these,” Nguyen Howell said. “If I were to bill it down for you, look at these six quality measures that will fulfill your quality component, that you could potentially get 100 percent on, get the extra bonus money on, and see how well do you rank right now. Is it worth it to report on these?”

In addition, eligible clinicians should report on quality measures during the Quality Payment Program’s transition year that they tend to score well on, Nguyen Howell advised.

“My third recommendation is report on the quality measures that you do best on, not those that you do poorly on and could improve on because it’s a budget neutral program,” she stated. “There are going to be winners and losers and the losers will pay for the winners. You want to start right off the bat doing well and not having to play catch up,” she continued. “It’s really important to know what you’re doing well at and to continue to do well in those measures.”

When clinicians understand MIPS measures and their quality performance, then they can start to transition to the Advanced APM track by monitoring their patient populations and developing population health management programs, Nguyen Howell added.

READ MORE: AAFP: Drop MIPS APM Pathway to Simplify MACRA Implementation

“My fourth recommendation is once you start learning the measures and your true performance, you’ll get a better idea about your population,” Nguyen Howell suggested. “How well are you treating this population based on your quality measures? How well you are performing on population health management? That’s your introduction into APMs.”

While understanding population health management is crucial to overall APM success, especially with accountable care organization (ACO) models, Nguyen Howell stated, providers need to know both their patient and provider populations to implement APMs, especially condition-, episode-, and population-specific models.

“What’s most prudent at the physician organization-level is to know your patients, number one, meaning that you should know what your patient population is like and what are the specific disease conditions with which your patients struggle,” she said. “Is it cardiac? Is it pulmonary? Is it orthopedic? Is it infectious disease? Based on your risk adjustment, your claims, and your encounters, what does that make up look like?”

Using information from predictive modeling tools, episode treatment groups, or claims data, providers need to identify their patient populations and understand them from risk severity illness- and cost-based standpoints, Nguyen Howell added.

Provider organizations should also understand who their physicians are and if the care they provide matches the value that the organization is paying them. Organizations should know if their providers are treating the high-cost, high-need populations that will greatly affect reimbursement.

“Secondly, know your providers, know your provider network, know which providers are actually providing high-quality care for the value that they are distributing to the patients,” Nguyen Howell said. “For the value you pay them, are they delivering high-quality care? That’s where that value-based payment comes in.”

In addition, understanding providers and their networks helps organizations to match the appropriate physician to patients. With patient satisfaction scores increasingly impacting value-based reimbursement, organizations may maximize revenue by ensuring that patients get the right care from the most appropriate provider at the first encounter.

“That’s where you can succeed in these alternative payment models that are currently out there,” Nguyen Howell added. “Having the right match of patient and provider and making sure the attribution model supports that match is key.”

However, not all APMs are created equal under the Quality Payment Program. CMS mandates that Advanced APMs require participating clinicians to bear financial risk for monetary losses of more than a nominal amount under the model. Participants must also demonstrate certified EHR use and be reimbursed based on quality measures comparable to those in MIPS.

Therefore, only risk-bearing providers in specific APMs will qualify for a five percent value-based incentive payment in 2019 based on their 2017 performance.

Despite the financial incentive, taking on more risk may be challenging for many providers because risk-based revenue is not common. Only one-third of healthcare organizations received more than half of their revenue from a risk-based reimbursement model, according to a June study in the American Journal of Managed Care.

For providers who are not familiar with financial risk models or feel as if they are being pushed into these APMs, Nguyen Howell suggested that they go back to the basics of how to perform risk-based care coordination.

“The hard answer is they have to learn the true elements, the true fundamentals of how to perform risk-based coordinated care,” she advised. “That means how do you negotiate a risk-based payment and a risk-based contract? How do you negotiate the two-sided risk, both the upside and the downside? How do you negotiate the division of financial responsibility? Who gets paid for what?”

Clinicians should then ask their organizations if they have the infrastructure to support risk-based APMs, Nguyen Howell continued.

She suggested that organizations ask themselves, “How do you build your infrastructure? Your care management infrastructure? Your utilization management infrastructure? What’s your acuity ratio? What’s your nurse-to-patient ratio? What are the qualities you need and who is on the care team? How many hospitals do you need to employ?”

Nguyen Howell pointed out that clinicians can get answers to many of these questions by joining healthcare associations, like CAPG. Through associations, providers gain access not only to best practices of risk-based APM implementation, but lessons learned from failed attempts.

“Imagine being able to tap into that knowledge and being able to tap into the networking opportunities among, I won’t say elite, but among such a knowledgeable army of combats,” Nguyen Howell stated. “Even though they are competitors of one another, they learn from each other in such a collegial way.”

Associations, like CAPG, also offer providers resources on how to successfully implement and participate in APMs. For example, CAPG developed complimentary risk readiness checklists that walk providers through important areas of MACRA, including patient safety, effective clinical care, provider communication, and care coordination.

“We are a small, but mighty team,” Nguyen Howell remarked. “We have truly helped our members grow and prosper in risk-based payment models. If folks are looking at this for the first time, they have no idea, but they kind of have an interest in risk-based or they feel like they are getting pushed into it, there are viable resources that can help.”

While participating in approved risk-based APMs may yield the highest value-based incentive payment, Nguyen Howell asserted that all eligible clinicians can increase their chances of earning positive Medicare payment adjustments by submitting data to the Quality Payment Program as soon as possible in 2017.

Under the final MACRA implementation rule, CMS expressed their commitment to providing more data to eligible clinicians early in 2017, whereas the proposed rule stipulated that clinicians would not hear about Quality Payment Program data, including if one qualified to participated in the Advanced APM track, until later in the year.

CAPG voiced concerns in June that delayed feedback could impede clinician success in the Quality Payment Program because it would leave little to no time for clinicians to report to MIPS if they were denied Advanced APM participation.

Nguyen Howell commended CMS for its commitment to putting data in provider hands sooner rather than later and advised clinicians to take advantage of faster feedback.

“Our members will definitely start reporting Jan. 1, 2017, so they can really get that feedback and that data ASAP,” Nguyen Howell stated. “That is the key if you’re going to write the story, for folks to get in their reporting as soon as possible, so that they can get back the data as soon as possible.”

Dig Deeper:

What We Know About Value-Based Care Under MACRA, MIPS, APMs

CMS Timelines for Stage 3 Meaningful Use, MACRA Implementation


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