- The healthcare industry is moving beyond a “sick care” system and shifting to chronic disease prevention to lower costs and improve quality. However, the healthcare payment system is just catching up to the preventative care trend.
Fee-for-service perpetuates a sick care model in which providers get paid for treating an illness and delivering services. With payment depending on services delivered, chronic disease prevention is not a top priority for providers looking to boost their bottom line.
Value-based reimbursement programs like MACRA’s Merit-Based Incentive Payment System (MIPS) aim to pay providers for delivering preventative care services. By tying payments to provider performance and patient outcomes, MIPS incentivizes providers to get ahead of expensive, adverse healthcare events like diabetes and heart disease.
Diabetes and heart disease are two of the most expensive and prevalent chronic diseases.
According to data from the CDC, an adult dies from a cardiovascular-related health condition such as a heart attack every 40 seconds. The costs of cardiovascular diseases total $317 billion per year and heart disease treatment accounts for one of every $6 spent on healthcare in the country.
The CDC also reports that 29 million Americans are known to be living with diabetes and another 86 million are on the verge of developing the disease that is the seventh-leading cause of death. In 2016 alone, diabetes cost the industry $245 billion.
Preventing chronic diseases is a top priority for providers looking to improve care quality and lower costs. But preventing the conditions can also maximize provider reimbursement under MIPS, the American Medical Association (AMA) recently explained.
In two new resources, the industry group detailed how chronic disease prevention efforts targeting prediabetes and hypertension can improve the health of patients while checking off MIPS boxes along the way.
Preventing diabetes through MIPS
In its “Disease focus: Prediabetes” report, the AMA explains how clinicians eligible to participate in MIPS can maximize their performance score and prevent the spread of diabetes among their patients.
For example, if an eligible clinician is focusing on prediabetes and uses a 2015 Edition EHR system, then he can report on the patient-generated health data measure (PI_CCTPE_3) in the MIPS Promoting Interoperability performance category.
Formerly known as Advancing Care Information, the Promoting Interoperability performance category is centered on patient engagement and electronic exchange of health data using certified EHR technology.
To get credit for prediabetes work in the Promoting Interoperability category, the AMA suggests that eligible clinicians incorporate patient-generated health data into its EHR for at least one patient. Clinicians can also incorporate data from a non-clinical setting to earn points.
The industry group advises clinicians to create a prediabetes risk test to score points for diabetes prevention efforts under Promoting Interoperability. The questionnaire should offer “patients the opportunity to learn about their risk for prediabetes while helping care teams identify patients at great risk.”
“This can be done using the online risk test screener or through patient portal messaging,” the AMA writes.
Eligible clinicians can also maximize their MIPS scores while preventing diabetes through the Improvement Activities performance category. The new performance category gauges a clinician’s participation in activities that improve clinical practice.
Chronic care and preventative care management for empaneled patients (IA_PM_13) is a key Improvement Activity for eligible clinicians focusing on prediabetes, the AMA states. The MIPS measure requires clinicians to proactively manage chronic and preventative care for empaneled patients using one of more of the following:
- Providing patients each year with the opportunity for development and/or adjustment of a personalized care plan
- Employing condition-specific pathways for chronic disease management with evidence-based protocols in place to guide treatment to target, such as CDC-approved diabetes prevention program
- Using pre-visit planning to improve preventative care and team management
- Having panel support tools ready to identify services needed
- Using predictive analytics models to predict risk, onset, and progression of chronic disease
- Implementing reminders and outreach to alert and educate patients about services needed and/or routine medication reconciliation
Other MIPS Improvement Activities related to prediabetes treatment include:
- Glycemic screening services (IA_PM_19)
- Glycemic referring services (IA_PM_20)
- Practice improvements that engage community resources to support patient health goals (IA_CC_14)
- Participation in Maintenance of Certification (MOC) Part IV (IA_PSPA_2)
- Completion of the AMA STEPS Forward program (IA_PSPA_9)
- Implementation of condition-specific chronic disease self-management support programs (IA_BE_20)
The prediabetes identification and management protocol is key to earning points for Improvement Activities related to prediabetes treatment, the AMA states. The protocol is an algorithm that helps practices identify and manage patients with prediabetes, and providers can access the protocol through the AMA.
Creating a sample patient referral form that helps providers engage with patients and prepare them for diabetes prevention programs is also a vital step to maximizing MIPS Improvement Activities scores, the industry group advises.
The AMA noted that MIPS does not have relevant prediabetes measures in its Quality performance category.
Using hypertension prevention for MIPS points
Eligible clinicians can earn points under MIPS for their hypertension prevention efforts using the Quality measures, the AMA’s “Disease focus: Hypertension” report shows.
In the Quality performance category, eligible clinicians can select on any six quality measures relevant to their practice and patient population.
For clinicians focusing on hypertension prevention in their practice, the AMA suggests that they report on the following Quality measures to up their MIPS score:
- Controlling high blood pressure (#236)
- Hypertension screening and recommended follow up plan (#317)
- Improvement in high blood pressure (#373)
To earn the maximum points on the three Quality measures, the industry group advises clinicians to assess how well their practice takes blood pressure and implements improvement initiatives. For example, clinicians should take the AMA’s practice assessment tool for M.A.P. (Measure, Act, Partner) to determine how well providers measure blood pressure, act to treat elevated blood pressure, and partner with other stakeholders to improve high blood pressure.
Providing clinicians with easily accessible resources on proper blood pressure measurement techniques, such as proper positioning, should also help clinicians maximize their Quality measure scores, the industry group states.
Eligible clinicians can also report on the patient-generated health data (PI_CCTPE_3) and patient-specific education (PI_PEA_2 or PI_TRANS_ PSE_1) measures in the Promoting Interoperability performance category to have their hypertension prevention efforts count towards MIPS scores.
The measures allow clinicians to earn MIPS points for incorporating patient-generated health data or data from non-clinical settings into a certified EHR system, as well as using clinically relevant information from a certified EHR to identify patient-specific educational resources.
Additionally, MIPS offers Improvement Activities targeting hypertension prevention efforts, the AMA reports.
Like clinicians focusing on prediabetes, providers in MIPS who engage in hypertension prevention initiatives should report on the chronic care and preventative care management for empaneled patients (IA_PM_13) measure. The measure gauges general chronic disease prevention efforts, such as developing personalized care plans, using pre-visit planning to optimize care delivery, and reminding patients about medical service needs.
Eligible clinicians can also report on the following Improvement Activities to earn credit for their hypertension initiatives:
- Use of certified EHR to capture patient-reported outcomes (IA_BE_1)
- Engagement of patients through implementation of improvements in patient portal (IA_BE_4)
- Use evidence-based decision aids to support shared decision-making (IA_BE_12)
- Completion of the AMA STEPS Forward program (IA_PSPA_9)
For the hypertension-related Promoting Interoperability and Improvement Activities measures, the AMA recommends that clinicians implement a seven-day reporting log to score maximize MIPS points. The scoring log helps patients record their blood pressure readings and engage in preventative care.
Clinicians should also offer blood pressure resources to patients to facilitate reporting. Resources on how to properly measure blood pressure, identify high blood pressure, and monitor readings should be given to patients along with the seven-day reporting log.
Preventative care is the name of the game in the current healthcare environment. Providers are already engaging in chronic disease prevention efforts to shift away from fee-for-service payments and improve care quality.
Providers can align their preventative care efforts with their value-based reimbursement goals by focusing on MIPS measures relevant to their chronic disease prevention initiatives.