MACRA: Looking Back and Looking Ahead to 2018

When Physicians Practice recently asked readers what they thought the impact of the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) would be on their reimbursement in 2019, 62 percent of survey respondents said they weren’t sure and 28.8 percent said they expect it to be lower.

That level of uncertainty more than a year after the program - both part of the Medicare Quality Payment Program (QPP)-were first introduced could be seen as a troubling sign of the program’s overall complexity.  But Michael Munger, MD, a family physician in Overland Park, Kan., and president of the American Academy of Family Physicians, sees the glass as half full. "The fact that we are hearing more physicians saying they are not yet sure how this is going to impact their bottom line is a real positive because it means they are paying attention," he says. "They are becoming invested. They no longer look at you with a blank stare when you say the MACRA Quality Payment Program."

Before the MACRA final rule for 2018 dropped in early November, physicians, practice administrators, and consultants looked both back at the first year of the QPP for lessons learned and ahead at the next few years, with an eye on reducing physician uncertainty and helping practices respond to new elements of the program. For this article  we asked them what aspects of the QPP have proven most difficult or confusing in 2017 and what unintended consequences new elements might bring in 2018 and 2019.

Munger says that this past year the AAFP has had success working with member physicians on MIPS by breaking it down into its component parts, which makes it look more familiar. For several years there was the Physician Quality Reporting System (PQRS), which the quality section is based on; Advancing Care Information is the new Meaningful Use, which they have experience with. "In family medicine we have been working on improvement activities for years," he says. "All the practices that are recognized as patient-centered medical homes by one of the certifying bodies are already there."

Understanding how to report to CMS is one thing, but grasping how it will affect their reimbursement is another. Because the program is required to be budget-neutral, MIPS is actually a zero-sum game in which one physician's high performance score impacts another's payment.

 In 2019, 4 percent of revenue generated through Medicare fee-for-service payments will be redistributed under MIPS, escalating to 9 percent by 2022.  Funding for the positive payment adjustments is going to come from those who get the negative adjustment. It won't be clear how much money there will be for bonuses until the negative adjustments are collected, explains Amy Mullins, MD, AAFP's medical director of quality improvement.

"That is something we won't know year over year, until we know how many people scored above the threshold and how many below. What a score of 50 [gets] you one year may not get you the same amount the next year. No one likes uncertainty when it comes to revenue streams. That is never a comfortable place to be. But we do know that if you score above the threshold you are not going to get a negative adjustment," she says.

Lessons Learned

Looking back at 2017, Beth Houck, vice president of client services at Chicago-based consulting firm SA Ignite, says she has found physicians confused about not just looking at performance, but having to look at performance against a benchmark as they choose which quality measures to report on.

For example, Houck says small specialty practices tend to default to claims-based reporting because that is familiar to them and they know they can get the claims data. But in MIPS those have the highest number of "topped-out" measures. (A measure might be considered topped out if performance is so high and unvarying that meaningful distinctions and improvements in performance can no longer be made.)

Trying to improve on topped-out or nearly topped-out measures gives clinicians little to no opportunity to improve their MIPS score, because their performance cannot be significantly above the benchmark, she explains. Plus, a topped-out measure is more likely to be dropped from the measure set in the future, so any work done to improve on topped-out measures will not yield much benefit. Houck stresses that organizations should focus their efforts on measures where clinicians are performing well relative to the benchmark, not necessarily the highest-scoring measures, and project how improvements on those measures will impact their scores.

Some small practices are disheartened by the complexity of MIPS and although they participate in accountable care organizations (ACOs), those ACOs don't yet have the volume of patients to qualify as APMs. Kyle Matthews, CEO of 14-physician Phoenix Heart PLLC, in Glendale, Ariz., says his physicians are determined to do the minimum to avoid a MIPS penalty but otherwise are seeking to avoid the program.

Phoenix Heart cardiologists did an analysis and determined they would have to hire one or two more staffers to handle the administrative burden of MIPS. "You hire one nurse practitioner and a couple of new staff members and you have already taken up anything you could possibly make in bonuses," Matthews says. "We could get that 3- or 4-percent bonus, but we would have eaten up all that bonus money with the hires. My doctors are about to throw their hands in the air and say forget all this EHR stuff anyway because it slows them down. They have done it for years to avoid penalties, and they just do not want to do it anymore. It is not worth it to them. It is no longer an issue of how much bonus money can we get. It is becoming a quality-of-life issue and one that impacts patient care."

It is likely that many providers were relieved when the 2018 proposed rule called for expanding the low-volume threshold for exclusion from MIPS reporting to groups with less than $90,000 in Part B allowed charges or fewer than 200 Part B beneficiaries. This was confirmed by the final rule in early November, when CMS projected that 60 percent of clinicians billing Medicare Part B will be able to skip MIPS.

But some observers point to potential pitfalls for practices if they don't get on the onramp early in the program.

The main issue is that after 2019, there will be no increase to the physician fee schedule for providers that are not participating in MIPS - even those excluded due to low volume. "This means that by raising the low-volume threshold, CMS has removed the opportunity to earn any level of increase in the foreseeable future," explains Jeanne Chamberlin, a practice management consultant with MSOC Health in Chapel Hill, N.C.  She notes that the proposed rule for 2018 said that CMS would "consider" allowing those that meet one but not all of the low-volume exclusion criteria to participate on an optional basis, but the final rule stated that the agency decided to seek additional comments on the best approach of implementing a low-volume threshold opt-in policy.

Another lesson from the first year of the program, Chamberlin says, is that small practices need to rely heavily on their EHRs - for both the ACI and Quality areas, but many EHR vendors are struggling to catch up with CMS on the MIPS program. This is especially the case with having more than nine electronic clinical quality measures available and keeping those up to date. The biggest compliance problem in 2017 has been how to collect the quality data, she says. "Even if they have an EHR, practices often don't know how they are supposed to enter the data in order to have the system count it properly – this is a training issue and raises the 'too many clicks' mantra of most clinicians," she says.

Looking Ahead to 2018

So what are some new elements of the QPP that could catch practices by surprise in 2018?

In 2017, CMS weighted the Resource Use or Cost category at zero because it wanted more time to create better measures. In the proposed rule for 2018, it proposed to weight the category at zero again before deciding to allocate 10 percent to Cost for next year.  Practices will need time to understand how the Cost category impacts them before it ramps up to 30 percent of the total MIPS score in the 2019 reporting period.

Michael Abrams, co-founder and managing partner of St. Louis-based consulting firm Numerof & Associates, expects physician practices to struggle with the Cost category. "Providers are having difficulty getting their arms around the current categories, and Cost is a brand new one that they have to accept CMS's data for," he says. "For these other categories, the physicians are providing the data, and they probably feel that they have more control over that because the data is a reflection of what they doing clinically. Cost, however, is something that comes from CMS, and they are going to have to accept that on faith, and that is going to make it that much more difficult."

Another new wrinkle the MIPS program will bring is publication of physicians' individual "Final Score" and the consequences that flow from that in the industry. "We are trying to educate members that their final score does follow them," Mullins says. "That MIPS score is going to affect your payments in 2019, even if you change jobs."

As this data becomes available on Physician Compare, it has the potential to impact physician practices in a number of different ways, Abrams says.  Created in 2010, Physician Compare offers online performance scores to help consumers make informed decisions and to encourage clinicians to provide the best care.

That information could and is intended to influence consumer choice of which physician to go to, so it could influence volume, he adds. "It might become a consideration in choosing which physicians are included in payer networks and could even influence the volume of referrals by hospitals and other individual physicians."

Another unintended consequence that healthcare analysts will have an eye on is industry consolidation. Physicians sell their practices to hospitals in part because that means there is somebody on the payroll to worry about compliance. "All the mechanics of compiling, aggregating and filing the data and making the difficult choices every year in terms of what metrics to choose to characterize your practice makes being part of a larger entity more attractive," Abrams says.

On the other hand, AAFP's Mullins notes that CMS does realize that MIPS is more difficult for small practices, and the 2018 final rule offers 5-point bonus points for practices with 15 or fewer clinicians.

Some small provider groups also may opt for MIPS "virtual group" reporting. The idea is that physicians in smaller practices who may not have enough patients to get statistically valid quality measurement results would join together to get statistically valid results on more measures. Participants in virtual groups, however, would have to decide by Dec. 31, 2017, less than two months after the final rule was released. Perhaps that is why CMS estimated that nationwide only 16 virtual groups made up of 765 MIPS-eligible physicians would participate in 2018. "If you are a small practice and want to join another small practice or even a little larger practice, how do you make that happen?" asked Abrams. "Put an ad in the paper? And how can you be assured that if there is one bad actor in the group, you don't all pay a penalty for it? There are a lot of uncertainties involved in that process."

As the final rule for 2018 approached, Phoenix Heart's Kyle Matthews was hoping that CMS would stick with a 90-day reporting period. But like many others, he was disappointed when the final rule called for a full-year reporting period for Quality and Cost measures. "It is just impossible for a rule to come out Nov. 1 and within 60 days change the behavior of 14 doctors and 75 staff members and to work with the EHR vendor to do a full-year reporting period," he says. "If they want full-year reporting, they need to release a rule on Nov. 1, 2017, that is effective for Jan. 1, 2019. You need time to do this."