By Susan R. Bradshaw, MS, MBA, RHIA; Donald G. Krause, MBA, CPA; and Michael Marron-Stearns, MD, CPC, CFPC
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) has created significant and complex changes to Part B Medicare reimbursement. As a result of MACRA, the Centers for Medicare and Medicaid Services (CMS) created the Quality Payment Program (QPP) that includes two reimbursement programs: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).
Health information management (HIM) professionals have a role in determining which clinicians are eligible for participation in the MIPS, MIPS APMs, or Advanced APMs in their organization. In an article published in the March 2017 Journal of AHIMA, the nuances of provider eligibility, exclusion criteria, and dates that determine provider eligibility for MIPS and APMs were reviewed extensively.1 Please refer to that article as a primer for provider eligibility of the QPP program.
This article will focus on clinicians participating in a MIPS Alternative Payment Model (MIPS APM), primarily on Medicare Shared Savings Program (MSSP) Track 1 Accountable Care Organizations (ACOs). The authors of this article will provide an enhanced discussion of MACRA implications for Qualified or Partially Qualified Advanced APM participants in a future publication.
HIM professionals that support organizations involved with APMs, such as Accountable Care Organization MSSP Track 1 entities, may be impacted by MIPS APM requirements. Payment reform is likely to accelerate. Physicians must decide whether to report under MIPS or try to participate in an APM to avoid penalties in 2018. As Medicare Shared Savings Program (MSSP) Track 1 participants are not eligible for the MACRA Advanced APM incentive payment, it is likely that more organizations will move toward greater risk sharing arrangements, such as the new MSSP Track 1+, 2, or 3, Next Generation model, or other Advanced APMs.2 As of January 2017, 91 percent of MSSP ACOs are one-sided Track 1 programs.3 Providers that participate in MIPS APMs are subject to the MIPS criterion but have different and significantly less cumbersome MIPS reporting requirements.
This article will explore MIPS APM provider eligibility, review MIPS APM reporting requirements, and identify key benefits and potential considerations that may impact MIPS APM participation decisions. It will also include an overview of MIPS APM score calculations focusing mainly on key components of the program that will benefit from the involvement of knowledgeable HIM professionals.
MIPS Alternative Payment Models (MIPS APMs)
Certain APMs include MIPS-eligible clinicians as participants and hold their participants accountable for the cost and quality of care provided to Medicare beneficiaries. This type of APM is called a MIPS APM. CMS has approved the following APMs as MIPS APMs for the 2017 reporting year:
- Medicare Shared Savings Program (MSSP) ACO Model Track 1
- MSSP ACO Model Track 2
- MSSP ACO Model Track 3
- Medicare-Medicaid Accountable Care Organization (MMACO) Model Track 1
- MMACO Model Track 2
- MMACO Model Track 3
- Comprehensive Primary Care Plus (CPC+) initiative
- Next Generation Accountable Care Organization (NGACO)
- Vermont Medicare ACO initiative (as part of the Vermont All-Payer Accountable Care Organization (ACO) Model)
- Oncology Care Model (One-Sided Risk Arrangement)
- Comprehensive End Stage Renal Disease Care (CEC) Model (LDO arrangement)
- Comprehensive ESRD Care (CEC) Model (non-LDO two-sided risk arrangement)
- Comprehensive ESRD Care (CEC) Model (non-LDO one-sided risk arrangement)
Also, the Medicare Shared Savings Program (MSSP) ACO Model Track 1+ was recently approved as a MIPS APM for 2018.
To qualify as an alternative payment model under the MACRA statute (primarily MSSP Track 1), a group of providers must use Certified Electronic Health Record Technology, report quality measures comparable to measures under MIPS (similar to PQRS), and share a financial risk determined by the ACO’s agreement with CMS. Minimum patient volume and reimbursement levels need to be met in order for clinicians to meet participation requirements, and the thresholds increase substantially over the initial years of the program.
Participants in MIPS APMs have MIPS special reporting requirements and receive special MIPS scoring under the “APM Scoring Standard.” All members of the same MIPS APM will receive the same MIPS performance score. Scores will be calculated by averaging the performance score for all clinicians in a group. Hence, final scores will be influenced by the performance of all clinicians within the MIPS APM.
All MIPS-eligible clinicians that are on a MIPS APM’s participant list as of March 31, June 30, or August 31 will be required to report through their MIPS APM. CMS has proposed adding a fourth date—December 31—in the Quality Payment Program Proposed Rule for 2018, but only for “full TIN” MIPS APM participating groups. Participants may qualify for positive MIPS payment adjustments and “exceptional” performance adjustments, based on the APM entity’s final score. Benefits to participating in a MIPS APM may include receiving full credit for the MIPS Clinical Improvement Activity (CIA) category and a reduction in the quality measure reporting burden on the practice.
Practices will still be required to report Advancing Care Information (ACI) performance data via a registry or other mechanism. (ACI was formerly referred to as “the Meaningful Use of Certified EHR Technology.”) CMS will calculate one MIPS composite score for each ACO (at the APM Entity level) based on performance in the Quality and ACI categories. This score will be applied to all MIPS-eligible clinicians in the group that are enrolled in the MIPS APM. MIPS payment adjustments will be applied at the unique TIN/National Provider Identifier (NPI) level for each MIPS-eligible clinician in the APM Entity.
HIM professionals may be tasked with helping their organizations determine the optimal MACRA-related payment model that should be used by their organization, and assessing whether an Advanced APM, MIPS APM, MIPS group reporting, or individual clinician MIPS reporting is in their best interest. Regardless of the model chosen by their organization, HIM professionals will be central to efforts to achieve high levels of MACRA-related performance.
Using the APM Standard Category Weightings
Using the APM Scoring Standard, the final score for the APM entity is based on performance in the Quality, ACI, and/or Improvement Activity categories. This final score is applied to each provider within the APM entity regardless of the provider’s individual MIPS score. The weighting of each of the four MIPS performance categories (Quality, Advancing Care Information, Improvement Activities, and Cost) are different for MIPS APM entities than for individual clinicians or groups reporting under MIPS (i.e., those that are not participating in a MIPS APM).
MSSP Track 1-3 ACOs and Next Generation ACO MIPS APMs have the following performance category weightings:
- Quality: 50 percent
- Advancing Care Information: 30 percent
- Improvement Activities: 20 percent
- Cost: zero percent
For MIPS APMs other than MSSP and Next Generation ACO models, including the Comprehensive ESRD Care Model, the Comprehensive Primary Care Plus Model (CPC+), and the Oncology Care Model, the category weightings are:
- Quality: zero percent
- Advancing Care Information: 75 percent
- Improvement Activities: 25 percent
- Cost: zero percent
In the 2018 Quality Payment Proposed Rule, CMS has proposed reweighting the categories for the Comprehensive ESRD Care Model, the Comprehensive Primary Care Plus Model (CPC+), and the Oncology Care Model, to be the same as ACOs, starting in 2018. In other words, the weighting for the quality performance category would change from zero percent to 50 percent, ACI’s weighting would change from 75 percent to 30 percent, and improvement activities’ weighting would change from 25 percent to 20 percent. Cost would remain at zero percent.
The 2018 Quality Payment Proposed Rule also lists tables that contain the specific quality measures for each of the non-ACO MIPS APMs.
A large subset of MIPS-eligible clinicians—specifically, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse anesthetists—have the option of reporting ACI (“meaningful use” EHR Incentive Program) performance category data in 2017. If they do not submit data, the ACI category will be weighted at zero percent during the 2017 performance year; however, these clinicians may be required to fully engage ACI in 2018.
The importance of HIM professional activities related to coding, clinical documentation improvement (CDI), ACI, interoperability, and cost containment in their enterprise have been increased under MACRA. For example, HIM professionals engaged with MIPS APMs—in particular MSSP Track 1-3 and Next Generation ACOs—are positioned to assist these organizations and their participating clinicians by providing assistance in the following areas:
- Attaining optimal ACO quality scores
- Achieving optimal ACI performance
- Providing support for cost measures
Quality Scores in MIPS APMs
For the MIPS APM Scoring Standard, ACOs will submit CMS Web Interface measures on behalf of their participating MIPS-eligible clinicians. No additional quality reporting will be required. ACO quality performance is determined by performance on a specific set of quality measures compared to benchmarks. Many of the benchmarks make achieving high performance scores for the quality measures challenging. Quality measure performance can be improved through staff education, workflow assessments, EHR customization, analytics, and an iterative process where feedback is provided to clinicians when performance is less than optimal. It is also very important that reporting and documentation be synchronized to prevent “check box” recording of measure compliance activities by clinicians without supporting documentation.