FEBRUARY 21, 2019

Welcome to the MACRA MIPS/APM Update eNewsletter
Editor: Philip L. Ronning
This issue sponsored by the
National Pay for Performance (PfP) Summit, the National Population Health Colloquium,
the National MACRA Summit and the National Bundled Payment Summit.

IT Investments Help Hospitals Steer Clear of Margin Cliff
With the transition to value-based payment models accelerating, hospitals and health systems without the right IT tools could be playing catch-up with competitors. Over just the past few months, I have noticed that hospitals and health systems are making bigger investments in virtual health and relationship tools that connect clinicians to patients, clinicians to other clinicians, and clinicians to virtual information that allows them to improve patient care. As traditional fee-for-service (FFS) gives way to payment models that reward value over volume, hospitals are also investing in new technologies that can manage tremendous amounts of data, produce detailed analytics, manage population health, and help coordinate patient care. The transition to value-based payment models is only going to accelerate, and hospitals that don't have the right technology could find themselves struggling to catch up. Consider this: On January 1, hospitals began seeing payment adjustments for the first performance year under the Medicare Access and CHIP Reauthorization Act (MACRA). Last month, Blue Cross Blue Shield of North Carolina said it had inked value-based payment agreements with five of the state's seven largest health systems. Growth in value-based contracts -- combined with an aging U.S. population and shrinking reimbursement from government payers -- could push hospitals and health systems toward a margin cliff if they don't keep pace with technology. (Wall Street Journal, February 5, 2019)

AMGA Seeks End of MIPS Exclusions to Promote Value-Based Care
MIPS exclusions mean limited incentives for high-performing medical groups to invest in and implement new health IT. - AMGA is calling on Congress to implement MACRA and the Quality Payment Program it introduced fully, beginning with the elimination of exclusions from the Merit-based Incentive Payment System (MIPS) that exempted more than half of eligible clinicians. "MIPS was designed as a viable transition tool to value-based payment in the Medicare program, where providers would be rewarded for their investments in health information technology (IT), care management processes, and people," wrote American Medical Group Association (AMGA) President & CEO Jerry Penso, MD, MBA. "However, the Centers for Medicare & Medicaid Services (CMS) has not implemented MIPS as Congress intended." The organization representing medical groups drew special attention to the budget-neutral provision of the Medicare Access and CHIP Reauthorization Act (MACRA) that means negative payment adjustments for some become positive payment adjustments for others. "Under the MIPS program, providers have the opportunity to earn an annual adjustment to their Medicare Part B payments based on their performance starting in 2019, with a positive or negative adjustment range of 4%. That range eventually increases to 9% in 2023," Penso reiterated. By excluding nearly 60 percent of eligible providers from the pool, the gains for high-performing medical groups were not as significant as planned. (EHR Intelligence, February 5, 2019)

The State of Radiology Reimbursement in 2019
For the third year running, radiology is seeing a lull in coding and reimbursement changes. But, while there are relatively few alternations to how you should code for -- and will get paid for -- your services, that doesn't mean there aren't things you should pay attention to this year to maintain a healthy bottom line. And, according to industry leaders, you can also take active steps in this direction. In a downgrade from last year, the Center for Medicare & Medicaid Services (CMS) has reduced the quality points awarded for some Merit-Based Incentive Payment System (MIPS) measures from 10 to 7. These decreases could impact whether you meet the 60-point requirement. "You definitely want to look at which MIPS measures you're reporting, whether their value has changed, and how it impacts your practice," says Sandy Coffta, vice president for client services at Healthcare Administrative Partners. "Even if you qualified for an incentive this year, you might not next year or you could be at risk for a penalty." The point drops affect the easier-to-complete measures, she says, indicating CMS wants you to invest deeper into technology and work closer with your hospitals to earn the same number of points. (Diagnostic Imaging, February 4, 2019)

AMGA: Full MACRA Implementation Needed to Advance Value-Based Care
Failing to execute full MACRA implementation by excluding over half of providers is impeding the transition to value-based care, the industry group told Congress. AMGA is urging Congress to enforce MACRA implementation as policymakers intended by no longer excluding providers from the Merit-Based Payment Incentive Program (MIPS). "MIPS was designed as a viable transition tool to value-based payment in the Medicare program, where providers would be rewarded for their investments in health information technology (IT), care management processes, and people," AMGA President and CEO Jerry Penso, MD, MBA, recently wrote to Speaker of the House Nancy Pelosi. "However, the Centers for Medicare & Medicaid Services (CMS) has not implemented MIPS as Congress intended." CMS has excluded more than one-half of providers (60 percent) from MIPS requirements in the past few MACRA implementation rules despite the original statute's intentions to increase MIPS participation. While the federal agency intended for the MIPS exclusions to ease providers into MACRA, the medical group association argued that the exclusions actually penalized high-performers. MIPS is a budget neutral program, so exclusions from the program resulted in lower payment adjustments for eligible clinicians who exceeded performance standards. (RevCycle Intelligence, February 7, 2019)

MIPS for Quality Improvement: Some Practices like It, Others Not so Much; Why the Reviews Are Mixed
Not all neurologists are fans of the MIPS program. But one practice that has found it beneficial discusses its strategies for success with the program. The federal government's Merit-based Incentive Payment System (MIPS) has many detractors but the folks at First Choice Neurology, a large practice in South Florida, are not among them. In MIPS' first year, the practice expects to score the maximum number of points, with bonus points to spare, in all three categories -- quality, improvement activities, and use of electronic health record (EHR) technology. The Centers for Medicare & Medicaid Services (CMS) will announce final results later this month. But, based on the points accrued, Jose Rocha, First Choice Neurology central business office director, is confident the physicians will receive a 4 percent positive payment adjustment to its Medicare Part B billings in 2019, reflecting their MIPS scores in 2017. And he hopes -- though he is still not certain -- they will have earned "exceptional performer" status: another 10 percent of Medicare Part B billings. "We had bonus points to throw away because it caps you at a certain level," Rocha said. "I can't imagine we would not." Moreover, Rocha said First Choice's participation in the MIPS program has improved the quality of patient care, improved care coordination with other providers, and impressed private payers who want to develop value-based payment programs for specialty care. Figuring out the logistics of the MIPS program was Rocha's job, but the practice's physicians are the key to First Choice's success, he said. (Neurology Today, July 18, 2018)

AHA Wants More Alternative Payment Models for Rural Hospitals
In its 2019 Rural Advocacy Agenda, the American Hospital Association (AHA) called for more opportunities for rural hospitals to successfully participate in bundled payment models, the Quality Payment Program, and other alternative payment models. "As the healthcare field moves toward value-based care and population health, hospitals are participating in alternative payment and care delivery models that have different incentives than the traditional fee-for-service system, and often connect patients to services beyond the walls of the hospital," the AHA wrote. "However, many new models either exclude rural providers or overlook the unique challenges of providing care in rural communities." "New rural models need to be developed and those currently being tested by the Centers for Medicare & Medicaid Services (CMS) need to be evaluated for success, and if appropriate, expanded and extended," the hospital association continued. Specifically, the AHA is urging the industry to create voluntary bundled payment models for rural hospitals. Bundled payments generally pay providers a single, comprehensive payment for all the services involved in an episode of patient care, such as a knee replacement or coronary artery bypass graft surgery. (RevCycle Intelligence, February 7, 2019)

Download AAFP's 2019 MIPS Playbook Today

The AAFP once again is offering family physicians a valuable resource that can make a big difference when it comes to their optimal participation in the Merit-based Incentive Payment System (MIPS). Better yet, this instructional gem, dubbed the 2019 MIPS Playbook, is absolutely free to members. Playbook creators aim to guide readers through the MIPS track of CMS' Quality Payment Program -- established after passage of the Medicare Access and CHIP Reauthorization Act in April 2015. If this all sounds familiar, that's because the 2019 version of the playbook is a follow-up to the 2018 iteration. Co-author Amy Mullins, M.D., is the AAFP's medical director for quality improvement. She told AAFP News that it's important for physicians to have the right information at their fingertips. "The playbook needs to be updated every year because the regulations change every year," said Mullins. "Our job is to ensure members have the most current and accurate details about MIPS participation." For instance, major changes for 2019 are listed right up front and include updates in categories including:

  • eligible clinician types,
  • low-volume threshold,
  • opt-in participation,
  • performance period,
  • bonus points and
  • payment adjustment ranges.

Additionally, said Mullins, "There is new information in the 2019 Playbook that points out how physicians who are providing services like chronic care management and Medicare's annual wellness visits can choose quality measures and improvement activities that align with those programs."

(American Academy of Family Physicians, February 4, 2019)

MACRA MIPS/APM Update e-Newsletter is one of a family of free e-Newsletters providing a complimentary video presentation and regularly updated news and key resources on major health care issues such as ACOs, patient safety, pay for performance, bundled payment, readmissions, and Medicaid. To view and subscribe to other e-Newsletters go to healthcareeNewsletters.com.

Is the Value Movement Delivering Value?

Joseph J. Grogan
Associate Director, Health Programs, Office of Management and Budget, The White House