When the Centers for Medicare & Medicaid Services issued its final rule for the new Quality Payment Program, the need for oncology and specialty physicians – as well as other eligible clinicians – to know how the value-based reimbursement system works rose exponentially.

With the program's January 1, 2017 start just weeks away, community practices must learn the program's requirements if they're to be on the right side of nearly $200 million in payment adjustments in 2019 and be eligible for a share of $500 million in bonus payments for high performers.

The combined $700 million is in play for practitioners who participate in the program's Merit-based Incentive Payment System (MIPS). CMS said it anticipates that most eligible clinicians (ECs) will participate in MIPS rather than the Quality Payment Program's other and more complex value-based reimbursement track, Advanced Alternative Payment Models (APMs). They expect 70,000 to 120,000 qualifying participants (QPs) to choose APMs in 2017. By comparison, the agency said it expects 592,000 to 642,000 ECs to choose MIPS next year.

Under the provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which created the Quality Payment Program, participation in the program regardless of the track is mandatory for any practitioner who bills Medicare Part B medical services to beneficiaries. We recommend that oncologists and specialty providers - from rheumatology to ophthalmology - take these five steps to prepare themselves and their clinicians for MIPS.

Five Steps to Prepare Oncology and Specialty Practices for MIPS Quote
Determine Whether the Practice and its Clinicians Are Required to Participate in MIPS

The final rule defines a MIPS EC as a physician, physician assistant, nurse practitioner, clinical nurse specialist or a certified registered nurse anesthetist. The final rule raised the volume threshold for MIPS participation, exempting additional small practices or those with small Medicare patient volumes. Groups or individual ECs are exempt if they bill $30,000 or less for Medicare Part B or treat 100 or fewer Medicare patients annually. That's up from $10,000 or 100 patients in the proposed rule.

For most community practices, information about their Medicare patient population should be easily accessible, including how many Medicare patients they see and their total Part B claims submitted to Medicare for payment. If they don't meet the thresholds, they automatically are excluded from MIPS. There is no voluntary participation for small groups that don't meet the thresholds. If a group or individual meets or exceeds the thresholds, they are automatically included in MIPS.

Educate and Engage the Practice's Clinicians and Staff on MIPS Participation Requirements

A number of industry surveys have found a significant lack of provider awareness about MACRA, the Quality Payment Program, APMs and MIPS despite the fact that they're mandatory and effect how physicians will be reimbursed. The most widely cited was a survey of 600 physicians by the Deloitte Center for Health Solutions. Some 50 percent of the physicians said they had never heard of MACRA, and another 32 percent said they were familiar with the name but not the requirements. That's a big red flag for practice administrators who will likely be responsible for ensuring providers and other eligible clinicians are complying with MIPS rules. Oncology and specialty practice administrators should hold educational sessions with their ECs as soon as possible. Those sessions should:

1. Reinforce that MIPS is a mandatory performance-based reimbursement system that pays providers based on how well they treat Medicare patients and how their results compare with other medical practices.

2. Emphasize that ECs must become keenly aware of how they treat Medicare patients for the purposes of collecting and reporting their required performance measures to the CMS.

3. Explain that MIPS will score their performance in three areas in 2017: quality, improvement activities and advancing care information. Cost will be included as a fourth performance area in 2018. Practices will select, collect and report measures in the first three categories; CMS will extract cost measures from adjudicated Medicare claims.

Five Steps to Prepare Oncology and Specialty Practices for MIPS GraphicSelect the Pace of MIPS Participation in 2017 That's Appropriate for the Practice

Many community practices are well-versed in collecting and reporting performance measures to CMS from participating in other programs like the Physician Quality Reporting System and Meaningful Use incentive program. Others may not be as prepared if those programs didn't apply or they opted out of voluntary initiatives. Recognizing that practices may be at different places in terms of reporting capabilities, the CMS created four paths into the new mandatory program. To quote and paraphrase CMS's descriptions of the four paths:

1. Submit something: If practices submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity), they may avoid a negative payment adjustment.

2. Submit a partial year: If practices submit 90 days of 2017 data to Medicare, they may avoid a negative payment or earn a small positive payment adjustment.

3. Submit a full year: If practices submit a full year of 2017 data to Medicare, they may earn a moderate positive payment adjustment.

4. Participate in an Advanced Alternative Payment Model (APM): Practices must participate in a 2-sided risk model and meet required percentage of payments and patients in the APM. They will receive a 5% payment adjustment in 2019 for participating in an Advanced APM.

If an eligible clinician chooses not to participate at all in 2017, they will receive a negative 4% payment adjustment in 2019.

Though some experts advocate jumping in with both feet, becoming an early adopter and learning as you go, the determining factor on which MIPS path to choose is preparedness. Is the practice as prepared as it needs to be to participate fully in the program? If the practice is not ready to submit a full year of performance data, for example, then a less demanding path may be best. This would give practices the time they need to make thoughtful changes and be successful in the long run. Another advantage to participating at the practice's own pace is the fact that MIPS is evolving. Future requirements will be shaped by early experiences of participating practices. Practices that choose a less demanding path may benefit from not wasting resources on requirements that may change or disappear.

Choose the MIPS Performance Measures That Are Most Appropriate for the Practice

The final rule requires most eligible oncologists and specialty physicians – in addition to other eligible clinicians – to select, collect and report performance measures in Quality and Advancing Care Information categories, and to attest to completion of up to four Improvement Activities. The measures collectively add up to a maximum score of 100. Practices should pick up to six quality measures that count for up to 60 percent of the final score. They will also pick up to four improvement activities that count for up to 15 percent of the final score. Finally, they will select up to nine advancing care information measures (in addition to five mandatory EHR measures) that count for up to 25 percent of the final score.

We suggest practices go through a decision-making process to determine which measures of the hundreds available are most appropriate:

1. Eliminate measures that don't apply. An example would be specialty-specific measures. What's right for oncology practices may not be right for orthopedics.

2 Consider measures the practice already is reporting under a previous program to avoid an unnecessary compliance burden.

3. Consider quality and improvement activity measures in areas in which the practice performs well.

4. Choose measures that benefit both the patient and the practice in terms of clinical and financial outcomes.

Optimize EHR Systems to Collect and Report MIPS Performance Measures

After educating practice staff on the program's requirements, determining what initial path the practice will take into MIPS and selecting the most appropriate performance measures to report to the program, the last step is making sure the practice's EHR system is capable of collecting and reporting the selected performance measures to CMS.

We recommend practices meet with their EHR vendors as soon as possible to learn whether their systems are capable of performing those functions. If not, the practices will have to work with their EHR vendors to upgrade, modify or optimize their systems to make complying with all MIPS requirements as seamless and efficient as possible.

Oncology and specialty providers, as well as individual eligible clinicians, who follow the five steps outlined above should feel prepared to make the right decisions for their practice and their patients as Medicare launches a new era in value-based reimbursement in 2017.

Related: Learn about McKesson's Innovative Practice Services

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About the author

Linda Pottinger is the Director of Payer Initiatives with the Innovative Practice Services team of McKesson Specialty Health, providing operational and educational support to practices as they prepare for value-based and quality payment programs, such as OCM and MIPS. Previously, she served as a Regional Finance Director for The US Oncology Network supporting the Central Region. Linda has 35+ years of experience in the healthcare industry and, over the course of 19 years, has held various financial team roles, ultimately serving as Chief Financial Officer at two Chicago-area hospitals.