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Tuesday, May 31, 2016

CMS releases list of approved 2016 PQRS registry vendors

The Centers for Medicare & Medicaid Services (CMS) has released the 2016 lists of approved Qualified Registries and Qualified Clinical Data Registries for the Physician Quality Reporting System (PQRS). Physicians and group practices may use these third-party vendors to submit quality measures for PQRS in 2016 and potentially avoid payment penalties associated with PQRS and the Medicare value-based payment modifier in 2018.

There are a number of other PQRS reporting options. For those new to the program, the AAFP provides a PQRS overview, and CMS has instructions on how to get started.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, May 17, 2016

Small practices face potential headaches under MACRA

For solo and small physician practices, the recently published proposed rule for how the Centers for Medicare & Medicaid Services (CMS) plans to implement the Medicare and Children’s Health Insurance Program Reauthorization Act (MACRA) set off some alarm bells. According to the proposed rule’s regulatory impact analysis, 87 percent of solo practice clinicians who are eligible for the Merit-Based Incentive Payment System (MIPS) – one of two payment tracks under MACRA – will receive a penalty; for groups of two to nine clinicians, the percentage is almost 70 percent.

Responding to the concerns generated by this analysis, CMS has now issued a fact sheet that attempts to show it is sensitive to the unique challenges that small practices face in different types of communities. The fact sheet is also meant to show that the agency’s proposed implementation of MACRA, including MIPS and alternative payment models (APMs), provides accommodations for various practice sizes and configurations. Among the provisions that CMS highlights in its defense are:

• Clinicians or groups that have $10,000 or less in Medicare charges and 100 Medicare patients or fewer are excluded from the MIPS payment adjustment.
• When a practice is scored for MIPS, it will only be scored for categories where it has a sufficient number of applicable measures and activities.
• Small groups will have more flexibility within each of the MIPS performance categories. For example, CMS will calculate only two population measures based on claims data for solo physicians and groups of nine or fewer physicians instead of the three population measures required for larger groups under the quality performance category of MIPS.

CMS also notes that the proposed rule allows small practices or practices in rural or healthcare professional shortage areas to participate in the Advanced APM track – and receive incentive payments – by providing special rules for these practices to qualify as Advanced APMs under medical home models.  

Ironically, CMS plans to delay implementing one provision of MACRA specifically intended to help solo and small group practices succeed under MIPS. Specifically, MACRA allows MIPS-eligible professionals to combine into “virtual” groups to participate in the payment track. However, as noted in the fact sheet and the proposed rule, CMS will not make this option available until the second year of the program.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, May 13, 2016

Medicare physician use and payment data for 2014 now available

The Centers for Medicare & Medicaid Services (CMS) has released its annual report on Medicare physician utilization and payment data.

Covering calendar year 2014, the public file lists Medicare Part B payments and submitted charges for more than 986,000 individual physicians and other health care providers who collectively received around $91 billion. By comparison, the report for 2013 included $90 billion in payments to 950,000 physicians and other providers.  

The latest report uses Medicare standardized payment amounts, which adjusts for geographic differences to make payments to physicians in different parts of the country comparable.

As we’ve discussed in the past, these annual payment reports show not only the range and complexity of care that family physicians provide but also the variation in reimbursement among medical specialists. For example, family physicians received an average of $61,804 in total Medicare payments during 2014. By comparison, internists received an average of $92,760 and cardiologists received an average of $222,373. As in the past, physicians weren't given an opportunity to review the information tied to their names for errors and the amounts don't reflect risk-adjustment, Medicare not covering the full cost of certain treatments, or other factors.

As CMS moves to tie physician reimbursement more closely to value, presenting accurate individual physician payment and utilization data to patients and other interested parties will become more critical.

Thursday, May 12, 2016

Some help understanding the proposed MACRA payment reforms

Last month, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule that describes how CMS intends to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repealed the Medicare sustainable growth rate methodology with a new approach that pays clinicians for the value and quality of care they provide. The proposed rule would implement these changes through a unified framework called the “Quality Payment Program,” which includes two paths – the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). Comments on the proposed rule are due to CMS by June 27.

In the regulation, CMS says it expects that most Medicare physicians will initially participate through the MIPS. The MIPS consolidates three existing programs, the Physician Quality Reporting System, the Physician Value-based Payment Modifier, and the Medicare Electronic Health Record (EHR) Incentive Program. MIPS will pay Medicare physicians for providing high value care through success in four performance categories:

•  Quality (50 percent of total score in year one): For this category, physicians would choose to report six measures from among a range of options.
•  Advancing Care Information (25 percent of total score in year one): For this category, physicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting. CMS created a summary specific to the Advancing Care Information category.
•  Clinical Practice Improvement Activities (15 percent of total score in year one): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Physicians may select activities that match their practices’ goals from a list of more than 90 options.
•    Resource Use (10 percent of total score in year one): For this category, the score would be based on Medicare claims, meaning no reporting requirements for physicians. This category would use 40 episode-specific measures to account for differences among specialties.

CMS would begin measuring performance for physicians and other clinicians through MIPS in 2017, with payments based on those measures beginning in 2019.

Under the APM pathway, MACRA authorizes incentives for physicians who take further steps towards care transformation. To qualify as an Advanced APM, an APM must 1) require participants to use certified EHR technology, 2) pay covered professional services based on quality measures comparable to those in the quality performance category under MIPS, and 3) mandate that participating APM entities bear risk for monetary losses of a more than nominal amount – or that the entity must assume risk for potential financial losses – under the APM. CMS proposes three dimensions of risk – marginal risk, minimum loss rate, and total potential risk – to determine if an entity meets the more than nominal risk standard. Medicare physicians who sufficiently participate in an Advance APM would be exempt from MIPS reporting requirements and qualify for a 5 percent Medicare Part B incentive payment.

CMS notes that physicians who participate to some extent in APMs may not meet the law’s requirements for sufficient participation in the most advanced models. But it says the proposed rule is designed to provide these clinicians with financial rewards within MIPS. CMS expects that the number of clinicians who qualify as participating in Advanced APMs will grow as the program matures.

As an alternative to reading the more than 900 pages of regulations, the CMS issued a press release and the Health and Human Services secretary published a blog post, which includes the video, “Delivery System Reform: Paying for What Works.”

Keep an eye on this space for additional information on MACRA as we more fully understand how this law will affect family physicians for years to come.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

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