Nearly two years ago -- in April 2015 -- Congress passed a new law that set into motion plans to drastically change the way physicians are paid under Medicare.
Enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) brought a myriad of regulations and details that, since the release of the final MACRA rule in October 2016, have jelled into two payment tracks. The tracks, known as the Advanced Alternative Payment Model and the Merit-based Incentive Payment System (MIPS), come under the larger umbrella of the Quality Payment Program.
If you are a family physician and you've read this far, you've likely been slammed with information about these programs for months now. But that doesn't necessarily mean you've gained a complete grasp of what needs to be done and in what order.
That can change right now.
An article published in the January/February issue of Family Practice Management -- "Making Sense of MACRA, Part 2: Value-Based Payment and Your Future" -- aims to gently tease out the most important details of a decidedly complex program so that physicians can stop worrying and start doing.
- An article in the current issue of Family Practice Management can help physicians get started on the road to value-based payment.
- Author Amy Mullins, M.D., tells family physicians that performance in 2017 will affect payment in 2019, so what they do right now matters.
- She emphasizes the "pick your pace" methodology that CMS built into the Merit-based Incentive Payment System pathway to give physicians options for how they want to participate in 2017.
Readers can rely on Amy Mullins, M.D., the AAFP's medical director of quality improvement, to guide them through the regulation jungle.
Not so long ago, Mullins was taking care of patients in a small family medicine practice in Whitehouse, Texas. After 13-plus years in the clinical trenches, she knows all about the angst many physicians are experiencing today.
"I've been judged on quality measures before," Mullins said in an interview with AAFP News. "I've been through medical home certification. I've had my payment based on all these metrics in the past. I know it's hard and stressful, but I also know my quality wouldn't have improved unless I was measuring something."
She recalled once receiving advice that suggested a physician could improve only what he or she measured.
"That sentiment seemed to hold true for me," said Mullins. "And I think my patients benefited from some of these programs."
Embrace These Tips
First and foremost, Mullins wants her colleagues to hear this message: "Performance in 2017 is going to affect payment in 2019 -- so right now does matter!"
A phrase Mullins wants everyone to take to heart is "pick your pace" -- a methodology CMS built into the MIPS pathway to give physicians participation options for 2017. Physicians can choose to
- refuse participation in 2017, not submit any 2017 data and expect a negative Medicare payment adjustment of 4 percent;
- test the program by submitting a minimum amount of 2017 data on one quality measure and be exempt from a payment adjustment;
- partially participate by submitting more than the minimum amount of 2017 data for 90 consecutive days, be exempt from a negative adjustment and maybe earn a small positive payment adjustment, or
- fully participate by submitting all required 2017 data for 90 consecutive days, qualify for a larger positive payment adjustment and be exempt from a negative payment adjustment.
"You only have to do one thing to avoid the negative payment adjustment -- and it can be as little as attesting positively to one improvement activity that you've done for 90 consecutive days in your practice," said Mullins.
For example, did you consult your state's prescription drug monitoring program before issuing opioid prescriptions to your patients? Attest to that activity and you'll be spared a negative adjustment, said Mullins. A complete list of improvement activities(qpp.cms.gov) that qualify is available from the CMS website.
Mullins also pointed out that practices already certified as medical homes can get full credit for that certification as an improvement activity.
"It's an example of getting credit for work you're already doing," said Mullins.
At the same time, she also urged physicians to do more than just test in 2017.
"It's a 'no harm, no foul' year. You're not going to get penalized for anything you submit, so try to submit as much as you can to see how you do," said Mullins. "Discover where your data didn't get to CMS correctly, and identify the holes in your electronic health records that show where health IT infrastructure needs to be built up."
In other words, said Mullins, "Use this year to figure out process improvements, where your pitfalls might be and where you can make improvements before mistakes count against you."
Physicians would also do well to remember reporting requirements related to MIPS. According to Mullins, these are non-negotiable rules:
- If a physician submits data as a member of a group in one category, then data in all other categories must be submitted as a group, as well.
- If a physician submits as an individual, then all categories must be submitted as an individual.
- Physicians can use only one method for data submission per category.
"CMS has been very specific about how you're to give them data," said Mullins. "They are expecting so much data that they had to build guard rails. So if you're reporting on six quality measures, they want those to come all in one package from your EHR (electronic health record) or registry or however you plan to submit.
"Think about it; if everyone were to submit six measures in different ways -- say, two by claims data, one by registry and three by EHR -- it would be a mess," she added.
It is important that physicians start deciding right now if they're going to submit as a group or as an individual.
If physicians choose the group method -- even if it is a large multispecialty group -- there must be consensus among the group as to which measures to use.
"But don't worry, there are plenty of cross-cutting measures," said Mullins. "There are 271 measures from which to choose. My strong suggestion is that physicians pick measures they are familiar with."
Another point Mullins stresses to physicians is that if they are to partially or fully participate in MIPS in 2017, they have to submit at least 90 consecutive days of data.
"So the latest you can start is Oct. 2. After that, you're out of your 90-day window," said Mullins.
Lastly, Mullins said she gets lots of questions from physicians about where they will input all of the data they are collecting.
It's a question the AAFP is also asking CMS, but to date, there has been no firm answer.
"As soon as the AAFP has that information, we will pass that on to family physicians," said Mullins. "But there is plenty of reporting time built in; everyone has until March 2018 to report data from 2017."
You've Got This!
As Mullins traverses the country talking to family physicians about the Quality Payment Program, she tells them they've already been doing a lot of this work for years.
"We've just been calling it something else. CMS has simply tweaked the programs and given them new names. Everything is now together under one program, so instead of having physicians report to multiple programs in multiple places, they now will report to just one," said Mullins.
"It is a lot to absorb, but physicians were doing all of this separately before. Now with all of those pieces pulled together into one big chunk, it looks more daunting."
But don't be fooled, said Mullins. "It can't be bigger than the sum of its parts -- physicians can do this."
Related AAFP News Coverage
MACRA: The Medicare Access and CHIP Reauthorization Act
More From AAFP
MACRA Ready: The Shift to Value-Based Payment
CMS: The Merit-Based Incentive Payment System (MIPS)(www.cms.gov)