MACRA Tidbits 2017 - American College of Gastroenterology

December 2, 2017

Is MACRA Hurting America’s Sickest Patients?

A recent article suggested that doctors are avoiding some of the nation’s sickest patients out of concern that deaths or other poor outcomes following treatment could cause Medicare to cut their payments, due to poor scores on quality/cost measures.

MACRA is new, so the data does not yet exist. However, a recent study concluded that doctors who served higher-risk patients under Medicare’s program formerly known as the Value-Based Payment Modifier had lower quality scores, ultimately giving them fewer bonuses and more penalties. The Value-Based Payment Modifier is essentially identical to the current MIPS’ Cost performance category at this time. In 2017, CMS assigned a 0% score for the MIPS’ Cost Performance category. However, in 2018, the weight will increase to 10% of your total MIPS score. In 2019+, it shoots up to 30% of your total score. Yet the performance category, as of today, uses the same metrics as the former Value-Based Payment Modifier.

A legislative fix is necessary: ACG Governors specifically discussed this issue with policymakers back in April, as part of the ACG Board of Governors’ Washington D.C. fly-in. ACG discussed this issue in its recent comments to CMS, as well. In September, ACG urged Congress to make necessary improvements to the MIPS’ Cost performance category.

ACG is currently working with CMS to improve this MIPS Cost performance category: ACG and other societies have physician representatives on a panel to improve the Cost performance category, replacing these metrics from the Value-Based Payment Modifier with GI-specific “episodes of care,” as mandated by MACRA.

CMS also finalized in the 2018 MACRA final rule that providers can earn a 5% MIPS score bonus for treating complex patients, based on medical complexity as measured by the Hierarchical Condition Category (HCC) risk score, and a score based on the percentage of dual eligible beneficiaries. Clinicians or groups must submit data on at least 1 performance category in an applicable performance period to earn the bonus.

October 7, 2017

MACRA and Your Employment Agreements

ACG strives to not only make sense of the exhaustive details of MACRA for you, but to also make $ense of the financial aspects of MACRA, too.

In the most recent edition of the ACG Magazine, health law expert Ann Bittinger, JD writes an article on MACRA called “The Incredible Shrinking Paycheck: MACRA and the link between accountability and physician compensation.” Ms. Bittinger provides an overview of why MACRA may have a greater impact on your employment agreement than reimbursement. Be sure to check it out!

Ann Bittinger, JD is a frequent contributor to the ACG Magazine on various practice management issues. She is a health care attorney practicing in Florida, and recently educated ACG Governors on MACRA’s impact on GI practices and employment agreements during the 2017 ACG Board of Governors Washington D.C. Fly-in and Spring Meeting.

ACG members are also encouraged to check out ACG’s Making $ense of MACRA and other MACRA educational material on the ACG website.

September 30, 2017

Don’t forget to use ACG’s MACRA resources for 2017

CMS views CY 2017 as a transition year to ease Medicare providers into MIPS. What does this mean?

ACG members who submit 90 consecutive days of 2017 data will avoid a payment cut, and may be eligible for a bonus in 2019. You will not get any extra points, or larger bonuses, for submitting 90 days vs. a full calendar year of data. It is simply a choice.

If you don’t send in any 2017 data, then you will receive a 4% payment cut in 2019.

If you submit a minimum amount of 2017 data to Medicare, you can avoid a payment cut. For example, submitting one quality measure for one patient, or attesting to one improvement activity will suffice.

ACG members are encouraged to use the various MACRA resources, including the detailed overview of MACRA, “ACG’s “Making $ense of MACRA”, the ACG-CMS webinar on MIPS program, and ACG’s “quality reporting checklist.” Check out the comprehensive list of ACG’s “MACRA Tidbit for the Week” here as well.

September 9, 2017

MACRA Revisions Are Already Necessary

As ACG members know, 2017 and 2018 (proposed) are “transition” years for MACRA and MIPS. This is welcomed news for ACG. It also appears CMS could really use the time to “transition” into MACRA. For example, let’s review the Cost (Resource Use) MIPS performance category.

This category is similar to the old “value-based payment modifier” that impacted medium and larger GI group practices in the past. It applies to all MIPS-eligible ACG members now. CMS looks at your Medicare reimbursement claims data to attribute costs to you and determine whether your practice is cost-efficient when compared to other practices submitting similar claims to Medicare. To address public comments on the cost performance category, CMS weighted this MIPS category at 0% for 2017, and proposes to do the same for the 2018 reporting year. ACG has voiced concerns regarding the level of familiarity and understanding of cost measures among clinicians, and agrees that an additional year in which costs do not count towards the final MIPS score will help ease providers into MIPS.

Looking ahead though, things look a bit frightening. Why?

MACRA provides CMS with flexibility in the first two years of the program. This may have major consequences, especially in the MIPS’ cost performance category: CMS is required to weigh the cost performance category to 30% for the CY 2021 payment year. ACG Governors discussed this issue with policymakers back in April, and will continue to work with like-minded organizations in urging Congress to extend CMS’ authority to re-weight MIPS performance categories in Year 3 of the Quality Payment Program and beyond. ACG discussed this issue in its recent comments to CMS as well.

ACG continues to work with CMS and has representatives on a “technical expert panel” in striving to develop accurate and more reliable cost metrics and episodes of care for the MIPS’ cost category. CMS concedes in the MACRA regulations that without new cost metrics in MIPS, CMS will only use measures that were in the value-based payment modifier and have a .4 reliability rating. CMS notes that a .4 reliability rating does not necessarily mean the measures are only 40% reliable, but rather, indicates “moderate reliability.” That is still not very comforting. Thus, we need better metrics, testing, and review prior to full implementation.

Key takeaway: Without necessary legislative and regulatory changes, one-third of your total MIPS score in 2021 will be based upon metrics that are, give or take, 40% reliable.

September 2, 2017

ACG urges CMS to help independent GI practices successfully participate in MIPS and APMs

ACG recently submitted the College’s comments to CMS’ proposed rule on Year 2 of the Quality Payment Program, the regulation outlining proposed requirements for the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) incentives under the Medicare Physician Fee Schedule. CMS will review these comments and publish the final rule in the fall of 2017.

The College’s comments are all rooted in this same theme of reducing administrative and financial burdens borne by GI practices across the nation. ACG’s goal is to let our membership focus on what they do best: providing high quality GI health care services to Medicare beneficiaries and patients.
ACG’s comments were also included in this recent article on the MACRA proposed rule.

August 19, 2017

Don’t forget to use ACG’s MACRA resources

August 12, 2017

How long does CMS think it takes for you to report Advancing Care Information (Meaningful Use) Measures?

When the MACRA rules are published, ACG reviews CMS’ time and burden estimates for participating in MIPS and APMs. It provides some insight into the policy decision-making, and whether or not CMS’ estimates are accurate or completely off-base (garbage in-garbage out theory).

For example, CMS burden estimates for CY 2017 assume that for the Advancing Care Information performance category, 3 hours of a clinician’s time would be required to collect and submit Advancing Care Information (Meaningful Use) data. ACG and ACG Governors continue to educate policymakers on the accuracy of these estimates. For CY 2018, CMS anticipates that “the year-over-year consistency of data submission processes, measures, and activities and the further alignment of the advancing care information performance category with other performance categories will reduce the clinician time needed under this performance category in the 2018 MIPS performance period.” In 2018, CMS estimates 3 additional hours of a computer analyst’s time above and beyond the clinician, practice manager, and computer system’s analyst time required to submit quality data.

Do these figures sound about right? How about the estimate of 3 hours time to collect and submit Advancing Care Information data? ACG wants to hear from you.

CMS assumes that the employee hourly rate of a practice’s analyst is $88.10 (or $264.30 in total). CMS also assumes that less than 5% of providers will receive a cut in reimbursement in CYs 2019 and 2020 due to gradually implementing MIPS requirements. The downside to this is that there is less money available in the bonus pool if there are few providers getting cut. So if you factor in the hourly rate of other employees needed to report Advancing Care Information data —as well as your time— does it actually cost you more to meet the Advancing Care Information requirements than you would receive bonuses in CYs 2019 and 2020? It is important to have this discussion with your colleagues at your practice. ACG is here to help!

July 29, 2017

A review of what it may take to get a MIPS bonus

The very first ACG MACRA Tidbit for the Week discussed the “other guy must fail first” reimbursement structure of MIPS. MACRA requires “budget neutrality,” or in other words, one provider must be cut for another to get a bonus. There is also a non-budget neutral “exceptional performance” pool of funds for higher MIPS scores. The “exceptional bonus” is a pool of $500 million (2019 – 2025).

As ACG has discussed in the past, CMS views both 2017 and (as of now) 2018 as “transition” years. ACG applauds CMS for this transition. It allows ACG members to avoid a payment cut by reporting a minimum amount of data until providers get their feet wet. In a time of lower reimbursement for GI services, ACG’s policy goals have focused on reducing the regulatory burdens and “hassle factor” of participating in Medicare quality reporting programs that are tied to reimbursement.

The flip side to this transition phase, however, is that there could be little bonus money available for those participating in MIPS, even for higher scoring providers. Recent CMS estimates demonstrate this dilemma:

CMS estimates that there are roughly 10,910 GI clinicians in 2018 that would be subject to MIPS (compared to 12,773 in 2017). Of this number, 96.5% are estimated to avoid a reimbursement cut or be eligible for a bonus, while 3.5% of eligible GI clinicians would be subject to a payment cut in CY 2020. What’s more, over 79% of eligible GI clinicians would qualify for the “exceptional bonus,” according to CMS estimates. These estimates are comparable to MIPS-eligible clinicians in all specialties: where 96% of all eligible MIPS clinicians (total: 554,846) will at least avoid a cut, and of this group, 77% will be eligible for the exceptional bonus.

So that means if 3-4% of all eligible clinicians are subject to a cut, clearly there is very little bonus money to distribute to other providers. Thus, unless you have a really high score, you can expect to simply avoid a cut in 2019 and 2020. If 77-79% of the 554,846 eligible MIPS clinicians (427,231) are eligible for the “exceptional bonus,” then that would mean each provider would receive roughly $1,170 per clinician. The less people who qualify for the “exceptional bonus,” the more this amount rises. These figures are also similar to CMS’ estimates for the CY 2019 MIPS payment year. For the 2019 payment year, CMS sets this “exceptional performance category” score at 70 (out of 100). So know what you need to do this year in order to get to a score of 70. ACG can help.

Participation in an approved registry like GIQuIC can help as well. Since GIQuIC submits the data to CMS for you, it also helps reduce the practice management submission burdens and administrative hassle factors associated with MIPS requirements. Click here to learn more.

July 15, 2017

Learn More about Using GIQuIC to Fulfill 2017 MIPS Reporting Requirements

In follow-up to the announcement that the GIQuIC Registry has been approved as a Qualified Clinical Data Registry (QCDR) for reporting to the Merit-Based Incentive Payment System (MIPS) for the 2017 reporting year, GIQuIC has hosted a series of webinars about the QCDR reporting option and provided further information on reporting via the GIQuIC QCDR.

The recording of the informational webinar “GIQuIC and the MIPS 2017 QCDR Reporting Option Part II” is now available on the GIQuIC web site. Listen to and view the presentation of Dr. Brett Bernstein and GIQuIC staff as they review program specifics and how the GIQuIC QCDR can serve as your reporting mechanism to the Quality, Improvement Activities, or Advancing Care Information performance categories. To access the slide deck from the webinar click here. To access a recording of the hour-long webinar click here.

The Registration and Consent Process for 2017 reporting via the GIQuIC QCDR will open in October and the Part III webinar in the series will be held at that time. In the interim, we recommend bookmarking the GIQuIC Quality Reporting Programs web page and visiting it often for the latest information.

July 8, 2017

The Transition into MACRA Continues

Last week, ACG highlighted the proposed MACRA eligibility requirements for the 2018 reporting year, and compared these to the current eligibility requirements for providers in 2017. CMS continues to ease providers into MACRA by providing low reporting thresholds in avoiding payment cuts. As you know, 2017 is a “Transition Year.” Providers can choose to report a full calendar year, or 90 consecutive days of 2017 data to potentially earn a bonus in 2019. If you don’t send in any 2017 data, then you receive a 4% payment cut in 2019. If you submit a minimum amount of 2017 data to Medicare, you can avoid a payment cut. You just need to submit one measure, one time, in the Quality performance category, or attest to any Improvement Activity performance category.

How would this change in 2018?

In 2018, CMS plans to slowly ramp up the requirements you need to complete in order to avoid a payment cut. Providers could earn a bonus by reporting a full year’s worth of data for the MIPS’ Quality performance category, and 90 continuous days of data for the MIPS’ Advancing Care and Improvement Activities performance categories. Providers who do nothing will receive a 5% payment cut in 2020. If you submit a minimum amount of 2018 data to Medicare, you can avoid a payment cut. To illustrate, CMS notes some ways that you could avoid a cut in 2020 (not an extensive list):

by meeting the MIPS’ Improvement Activities performance category,
or by meeting the MIPS Advancing Care Information performance category’s base score and satisfactorily submitting 1 measure in the MIPS’ Quality performance category,
or by meeting the MIPS’ Advancing Care Information performance category base score and submitting one “medium weighted” Improvement Activity,
or by satisfactorily submitting 6 measures in the Quality performance category.

Your 2017 reporting impacts your CY 2019 Medicare payments. Know what you need to know. ACG is here to help.

ACG members are encouraged to use the College’s various MACRA resources, including the detailed overview of MACRA, “ACG’s “Making $ense of MACRA,” the ACG-CMS webinar on MIPS program, ACG’s “quality reporting checklist,” a list of each measure in the MIPS Quality, Advancing Care, and Improvement Activities categories, as well as each measure’s specifications. Check out the comprehensive list of ACG’s “MACRA Tidbit for the Week” here as well.

July 1, 2017

CMS Estimates on MIPS Eligibility – Who has to participate in MACRA in 2017 vs. 2018?

On June 20th, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2018 Medicare Quality Payment Program (QPP) proposed regulation. This regulation outlines the proposed requirements for the Merit-based Incentive Payment System (MIPS), as well as for qualified or “advanced” alternative payment models (APMs) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

In 2017, if you bill more than $30,000 to Medicare, and provide care to more than 100 Medicare patients per year, and you are a: physician; physician assistant; nurse practitioner; clinical nurse specialist; or a CRNA. For 2018, however, CMS proposes to change this “low volume exclusion.” The proposed exclusion would include clinicians with ≤ $90,000 in Part B allowed charges or ≤ 200 Part B beneficiaries.

This is important for a few reasons:

First, it is encouraging to see CMS easing clinicians in small practices into MACRA. ACG has advocated for an orderly transition. In 2017, CMS estimated that the “$30,000 or 100 Medicare patients” low-volume threshold would exclude roughly 383,500 clinicians. The 2018 estimates are almost doubled. In 2018, CMS estimates that roughly 647,200 clinicians would be excluded from MACRA.

Second, CMS notes that, after all the exclusions, only 36-37% of the 1.5 million clinicians billing Medicare Part B services would actually be subject to MIPS. However, please note that CMS seems to include all Medicare Part B clinicians in this calculation instead of the subset of types of clinicians who have to participate in MACRA (see provider type above), which is roughly 1.3 million according to the proposed rule. Therefore, this would increase the percentage to roughly 42-44%. But still, less than 50% of Medicare Part B clinicians are estimated to participate in MIPS next year, which equals to approximately 555,000 to 572,300 clinicians (depending on data model). This is comparable to CMS’ estimate of 53-57% of clinicians excluded from MIPS in 2017. Thus, it is encouraging to see CMS continuing to ease providers into MACRA.

Of note: One major reason for these 2018 estimates is that roughly 572,300 Medicare Part B clinicians would be participating in an alternative payment model (APM). Is this a lofty estimate? CMS estimated that in 2017, a range of 70,000-120,000 clinicians would qualify for an APM, and thus be excluded from MIPS.

GI estimates: CMS estimates that there are roughly 10,910 clinicians in 2018 that would be subject to MIPS (compared to 12,773 in 2017).

June 24, 2017

Remember what you need to do in 2017

Your 2017 reporting impacts your CY 2019 Medicare payments. Know what you need to know. ACG is here to help.

To participate in MIPS via the CMS Web Interface and/or elect to administer the CAHPS for MIPS survey, you must register by June 30, 2017 (this is only for group practices with 25+ employees). You do not have to register prior to June 30th if you want to participate as a group via a different reporting mechanism.

June 17, 2017

MedPAC is not a fan of MACRA

This week, the Medicare Payment Advisory Commission (MedPAC) released its June 2017 Report to Congress and discussed MACRA. While the reports are mandated by Congress, these MedPAC reports are just recommendations to Congress and CMS. CMS and Congress are not required to implement these recommendations. It is worth noting that MedPAC concludes what ACG Governors and ACG members have been educating Congress and CMS all along:

“As CMS has begun to implement these two paths [MIPS and APMs], it has become clear that MACRA sets up a complex system in which some signals to improve value may not be well aligned. Although it is difficult to judge what sort of program will eventually result, the Commission is concerned by the direction the program is taking.”

ACG will continue to strive towards making MACRA less complex and administratively burdensome for ACG members and GI practices. Some other highlights from the MedPAC report:

“Clinicians are reporting data now for the first year of implementation for MIPS in 2019. Over 40 percent of clinicians are exempt from the program, and CMS created a very minimal standard that can be met by reporting information on one quality measure. Some stakeholders may view this approach as positive because the reporting requirements are minimal, and there will be very little effect on payment. Other stakeholders, who have invested in reporting infrastructure, may view this approach as negative. In the following years, if CMS proceeds to standards that are more difficult to meet, reporting will become more burdensome. It is not clear that the resulting data collected by CMS will be useful in detecting high and low performance, and minor differences in clinician scores could result in major differences in payment.”
MedPAC recommends eliminating the current set of MIPS measures, and instead would rely on a much smaller set of population-based outcome measures. The proposed outcome measures would be calculated from reimbursement claims or surveys, with the goal of reducing reporting burden.
MACRA requires clinicians to meet certain alternative payment model (APM) thresholds to qualify for the 5% incentive payment. The incentive payment is calculated as a percentage of all of a clinician’s streams of revenues. MedPAC recommends making this 5% reward based solely on the revenue coming through the qualified APM, and to instead make the incentive payment proportional to APM involvement. From the report: ”Under MACRA, a clinician must reach a threshold of revenue coming through a qualified APM (e.g., 25 percent, 50 percent) to be eligible for the 5 percent incentive payment, and this payment is based on all of the clinician’s PFS revenue, even that which does not come through a qualified APM. Therefore, if the threshold for revenue coming through the qualified APM is 25 percent, a practice with 24.9 percent of revenue generated through the qualified APM would not be eligible for the 5 percent incentive payment, while a similar practice with 25.0 percent of its revenue through the qualified APM would get a 5 percent incentive payment on all of its PFS revenue. This kind of payment cliff can introduce payment discontinuities, increase uncertainty, and appear inequitable. Therefore, we discuss making the payment reward proportional to the qualified APM-generated revenue. That is, there would be no threshold and the reward would be proportional: Any revenue coming through an qualified APM would secure the 5 percent payment incentive, but any other PFS revenue would not.”
As ACG members know from Making $ense of MACRA, there is a fund of $500 million per year (from 2019 to 2024) to reward clinicians with “exceptional performance” on their MIPS scores. MedPAC recommends that this fund instead go to qualified APMs, making the APM option more attractive. Note—this recommendation would very likely require a change in the MACRA statute (via Congress).
MedPAC also recommends an APM that would be more attractive to small practices.

June 10, 2017

Will my physician assistants and nurse practitioners be subject to MIPS?

As ACG highlighted in a previous MACRA Tidbit for the Week “Am I included in MIPS?,” you can use an online tool to help determine whether or not you will be required to participate in MIPS this year. Click here and enter your 10-digit National Provider Identifier (NPI) number.

What about your physician assistants and nurse practitioners? It is essential to determine if your colleagues will need to participate in MIPS as well. This is especially important for those practices choosing to report MIPS via a group reporting option—this “one for all, all for one” reporting option could trigger reimbursement cuts in 2019 if your practice’s physician assistants and nurse practitioners are neglecting to report MIPS measures in 2017.

Background: Who has to participate in MACRA?

If you are a: physician, a physician assistant, a nurse practitioner, a clinical nurse specialist, or a CRNA; and
If you bill more than $30,000 to Medicare, and provide care to more than 100 Medicare patients per year.

CMS reported in May that 806,879 clinicians will not be evaluated under MIPS in 2017. That’s an increase from the October 2016 predictions of 780,000 clinicians. In October 2016, CMS also estimated that 642,000 physicians were subject to reporting MIPS data, but that number has now dropped to 418,849.

If you’re exempt from MIPS with the first review, you won’t need to do anything else for MIPS this year. CMS will do another round of reviews later in 2017. If you are included in MIPS, you may be exempt from the second review of eligibility determinations at the end of 2017.

Do my physician assistants and nurse practitioners need to participate? Click here.

What do I need to do if my practice WANTS to report MIPS measures as a group?

Important notes on group practice reporting:

Under MIPS, a group is defined as a single Taxpayer Identification Number (TIN) with 2 or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their NPI, who have reassigned their Medicare billing rights to the TIN.
For 2017, groups are able to choose from a list of available data submission mechanisms, including: a CMS web interface (only available to groups with 25 or more eligible clinicians), a Qualified Clinical Data Registry (QCDR) like GIQuIC, an electronic health record (EHR), by administrative claims, and the CAHPS for MIPS Survey (only available to groups with 2 or more eligible clinicians).
To participate in MIPS via the CMS Web Interface and/or elect to administer the CAHPS for MIPS survey, you should register between April 1 – June 30, 2017. You do not have to register prior to June 30th if you want to participate as a group via a different reporting mechanism. (remember this is for groups practice 25+)
Click here to learn more and stay tuned for additional information from ACG on group practice reporting.

ACG members are encouraged to use the various MACRA resources, including the detailed overview of MACRA, “ACG’s “Making $ense of MACRA,” the ACG-CMS webinar on the MIPS program, ACG’s “quality reporting checklist,” a list of each measure in the MIPS Quality, Advancing Care, and Improvement Activities categories, as well as each measure’s specifications. Check out the comprehensive list of ACG’s “MACRA Tidbits for the Week” on our website as well.

Learn more about MIPS eligibility by visiting the CMS’ “Quality Payment Program” website.

June 3, 2017

The Benefit of the QCDR

In February, ACG provided some guidance on how your MIPS Quality score is actually calculated. ACG also hosts on our website an ACG Members Checklist: Improving Your Quality Reporting under MIPS.

Since the Quality category represents 60% of your total MIPS score and payment in 2019, it is important to know what you need to do in order to get the most of your score for this category. TIP: Know the measure’s specifications! It is important to stress that ACG members should study the denominator for each measure and understand what exactly needs to be performed in order to meet the measure’s requirements. One option to reduce these administrative burdens is to use a qualified clinical data registry (QCDR). The benefit of a QCDR like GIQuIC is that the registry helps to simplify the process and submits the data on your behalf. Learn more here.

May 20, 2017

Preparing your practice for MIPS “Improvement Activities” Performance Category

The MACRA final rule requires CMS to provide the criteria that the agency will use to validate and potentially audit your participation in MIPS. Under MIPS, CMS will conduct this process annually. Additionally, ACG members could receive a request from CMS for an audit, which requires an initial response within 10 business days. How can you prepare?

CMS recently released the validation steps when attesting to your MIPS Improvement Activities performance category. Here are the MIPS Data Validation Criteria for the Improvement Activities performance category. CMS will release the validation criteria for the Quality and Advancing Care performance categories later this year.

It is important that you and your practice review this document and have in place the appropriate document retention policies.

An example: Let’s use, as an example, the MIPS’ Improvement Activity “use evidence-based decision aids to support shared decision-making.” ACG members can attest to doing this and meet 1 medium weighted MIPS Improvement Activity. What do you need for validation and documentation? CMS says you will be required to provide “documentation (e.g. checklist, algorithms, tools, and/or screenshots) showing the use of evidence-based decision aids to support shared decision-making with beneficiary.” You also must include the dates to demonstrate that this was performed during either your continuous 90 reporting period, or during the 2017 calendar year, if you are choosing the full year reporting option.

Key take-away: Documentation and record retention are crucial

According to CMS, the documentation activities should include the dates during the selected continuous 90-day period that you are reporting MIPS measures in 2017, or if you intend to the 2017 year long reporting option.

How long should I retain documentation?

CMS cites the False Claims Act and encourages MIPS-eligible clinicians to keep documentation up to 10 years. What’s more, the MACRA final rule says that CMS may request any records or data retained for the purposes of MIPS for up to 6 years.

More Background on Improvement Activities

The Improvement Activity performance category counts for 15% of your MIPS final score this year. You’ll be able to choose from 90+ activities, which are weighted at various levels. You can find these activities on the ACG website, or CMS’ quality payment program website. The activities that are divided into 9 subcategories:

Expanded Practice Access
Population Management
Care Coordination
Beneficiary Engagement
Patient Safety and Practice Assessment
Participation in an APM
Achieving Health Equity
Integrating Behavioral and Mental Health
Emergency Preparedness and Response

Important to note: While there are 9 different subcategories, you can choose to attest to the set of activities that are most meaningful to your practice. There are no subcategory reporting requirements. In other words, you don’t have to select activities in each subcategory, or select activities from a certain number of subcategories.

Submitting Improvement Activities

Eligible clinicians can submit their improvement activities by attestation, via the CMS Quality Payment Program website, a qualified clinical data registry (QCDR), a qualified registry, or from their certified electronic health record system. Groups of 25 or more may also choose to use the CMS Web Interface.

Reporting criteria

You must attest by indicating “Yes” to each activity that meets the 90-day requirement (activities that you performed for at least 90 consecutive days during the current performance period).

Understanding Your Score

Your score will range from zero (not reporting anything) to a maximum of 40 points.

Groups with more than 15 clinicians:

Each activity is weighted either medium or high. To get the maximum score of 40 points for the Improvement Activity score, you may select any of these combinations:

2 high-weighted activities
1 high-weighted activity and 2 medium-weighted activities
Up to 4 medium-weighted activities

Each medium-weighted activity is worth 10 points of the total Improvement Activity performance category score, and each high-weighted activity is worth 20 points of the total category score.

Groups with 15 or fewer clinicians (and certain others):

The threshold is easier to meet. To achieve the maximum 40 points for the Improvement Activity score, you may select either of these combinations:

1 high-weighted activity
2 medium-weighted activities

For these clinicians, each medium-weighted activity is worth 20 points of the total Improvement Activity performance category score, and a high-weighted activity is worth 40 points of the total category score. These clinicians may select two medium-weighted activities or one high-weighted activity to receive a total of 40 points of the total category score.

May 13, 2017

Am I included in MIPS?

This week, CMS reported that 806,879 clinicians will not be evaluated under MIPS in 2017. That’s an increase from the October 2016 prediction that 780,000 clinicians would not have to comply with MIPS requirements. CMS also previously estimated that 642,000 physicians were subject to reporting MIPS data, but that number has now dropped to 418,849.

Find out your status:

CMS this week released an online tool to help ACG members and others determine whether or not you need to participate in MIPS this year. Click here and enter your 10-digit National Provider Identifier (NPI) number.

If you’re exempt from MIPS with the first review, you won’t need to do anything else for MIPS this year. CMS will do another round of reviews later in 2017. If you are included in MIPS, you may be exempt with the second review of eligibility determinations at the end of 2017.

Who has to participate in MACRA?

If you are a: physician, physician assistant, nurse practitioner, clinical nurse specialist, or CRNA; and
If you bill more than $30,000 to Medicare, and provide care to more than 100 Medicare patients per year.

CMS estimated that roughly 12,168 GI clinicians would be subject to MIPS in 2017. Do you have to participate? Click here.

ACG members are encouraged to use the various MACRA resources, including the detailed overview of MACRA, “ACG’s “Making $ense of MACRA,” the ACG-CMS webinar on MIPS program, ACG’s “quality reporting checklist,” a list of each measure in the MIPS Quality, Advancing Care, and Improvement Activities categories, as well as each measure’s specifications. Check out the comprehensive list of ACG’s “MACRA Tidbit for the Week” here as well.

Learn more about MIPS eligibility by visiting the CMS “Quality Payment Program” website.

April 29, 2017

CMS Notifications Forthcoming

This week, CMS announced plans to notify ACG members by late May if they must participate in MACRA’s Merit-based Incentive Payment System (MIPS). Letters will be issued starting this week, and will come from Medicare Administrative Contractors. ACG members must participate in MIPS if you bill Medicare Part B more than $30,000 and care for more than 100 Part B enrollees each year. CMS released the draft template letter ACG expects to receive, along with some FAQs:

April 22, 2017

Learn More about the MIPS “Improvement Activities” Performance Category

Many ACG Members have questions on the MIPS category of “Improvement Activities.” This category is new and was established in MACRA. MACRA defines a “clinical improvement activity” as: an activity that relevant eligible clinician organizations and other relevant stakeholders identify as improving clinical practice or care delivery, and that the Secretary determines, when effectively executed, is likely to result in improved outcomes.

The Improvement Activities performance category is 15% of the total composite MIPS score in 2019+.

ACG members select from a list of 93 Improvement Activities in certain areas of care, such as “Expanded Practice Access,” “Population Management,” “Care Coordination,” “Beneficiary Engagement,” “Patient Safety and Practice Assessment,” “Participation in an APM or Medical Home,” “Achieving Health Equity,” “Emergency Preparedness and Response,” and “Integrated Behavioral and Mental Health.” Each activity is individually weighted to determine a score within this category.

What do you need to know for 2017?

The Improvement Activities represents 15% of your MIPS score for 2019.
ACG members can be eligible for a bonus in 2019 if you submit 90 continuous days of 2017 data, and at a minimum, and report more than one measure in the Quality Performance category, more than one clinical Improvement Activity, or more than the required measures in the Advancing Care Information performance category.
ACG members can avoid a payment cut in 2019 if you report one measure in the Quality Performance Category; one clinical Improvement Activity performance category; or report the required measures in the Advancing Care Information performance category.

What are the individual “Improvement Activities”?

ACG can help. Go to the ACG’s educational guidance on MACRA to learn more about clinical Improvement Activities. The ACG website also hosts the full list of Improvement Activities to choose from. CMS’ “Quality Payment Program” website also lists these activities. CMS recently released a fact sheet on the Improvement Activities performance category.

How do I get full credit in this performance category?

Each activity is weighted to be either “medium” or “high.” To get the maximum score of 40 points for the Improvement Activity score, you may select any of these combinations: Attest that you completed up to 4 “medium-weighted” improvement activities, 1 “high-weighted” activity and 2 “medium-weighted” activities, or 2 “high-weighted” improvement activities for a minimum of 90 days.

Groups with fewer than 15 participants or those in a rural or health professional shortage area:
Attest that you completed up to 2 “medium weighted” activities or 1 “high-weighted” activity for a minimum of 90 days.

CMS Webinars

ACG members are encouraged to watch the ACG-CMS webinar on MIPS.

April 15, 2017

MACRA and the Physician-Focused Payment Model Technical Advisory Committee

MACRA creates incentives for physicians to participate in Alternative Payment Models (APMs), including the development of “physician-focused payment models” or PFPMs. MACRA also creates the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to make comments and recommendations to HHS on proposals submitted by individuals and stakeholder entities. HHS is required by MACRA to establish criteria for PFPMs and to respond to the recommendations of PTAC (but does not have to accept the recommendations). The final MACRA regulation outlined 10 criteria to guide the PTAC.

The PTAC recently completed a 2 day public meeting on April 10 and 11th to deliberate and vote on proposals for physician-focused payment models, including:

Project Sonar: PTAC recommend for limited-scale testing. Project SONAR is currently being used in the private commercial market and aims to support patients with inflammatory bowel disease (IBD). SONAR uses software to “ping” patients to hopefully intervene early.
The American College of Surgeon-Brandeis Advanced APM: PTAC recommended for limited scale testing. The proposal is designed to pay physicians based upon “episodes” of care via Medicare claims, potentially including GI procedures such as colonoscopy an EGD, and chronic care conditions in GI.

The next step is for PTAC to draft its report to the Secretary of HHS with recommendations and rationale for those recommendations. CMS will consider these recommendations, but is not obligated to accept them. PTAC’s next public meeting is June 5, 2017.

ACG supports innovative payment models if ACG members believe these models benefit their patients and fit into their practices. In comments to the PTAC, ACG urged the panel to remember the key criteria of flexibility and choice. The Project SONAR submission also emphasized voluntary participation. ACG members practice in a variety of settings, from large academic institutions to independent solo practices. Each setting poses unique practice-management and fiscal challenges. ACG members should participate in payment models that are most suitable for their respective practices and patients. Some recently implemented Medicare initiatives, however, have required participation for certain physicians depending on the specialty or area of the country in which they practice. For example, there are mandatory Medicare bundled payments underway in cardiology and orthopedic surgery. CMS has delayed the start time for two of these models — a signal that HHS Secretary Tom Price, MD may not agree with mandatory participation. ACG remains opposed to mandatory participation, as this is not likely to further the goals of increasing flexibility and reducing reporting burdens as recently stated in MACRA.

March 25, 2017

ACG Working to Reduce Burdens Heading into MACRA’s Full Impact

ACG and 86 state and specialty medical societies recently submitted a letter requesting the Centers for Medicare and Medicaid Services (CMS) reduce the administrative burden and provide for hardship exemptions for the 3 Medicare programs that will sunset by the end of 2018 (by name at least) and before MACRA adjusts your reimbursement in 2019.

Remember: there is a two-year lag in the “reporting year” versus the “reimbursement year.” Thus, CY 2017 is the first reporting year under MACRA, but will impact CY 2019 Medicare fee-for-service reimbursement.

The letter requests CMS to establish a hardship exemption due to regulatory burdens of these programs: Meaningful Use, the Physician Quality Reporting System (PQRS), and the Value-based Payment Modifier for 2018— the final year in which these programs will impact your reimbursement. Thus, there should be no penalty in 2018 as GI practices deal with the full reporting requirements under MACRA (impacting your 2020 reimbursement).

CY 2017 is the MACRA “Transition Year”: Here is what you need to know

CMS views CY 2017 as a transition year to ease Medicare providers into MIPS. What does this mean? ACG members who submit 90 consecutive days of 2017 data will avoid a payment cut, and may earn a bonus in 2019. You will not get extra points, or larger bonuses, for submitting 90 days vs. a full calendar year. It is simply a choice. If you don’t send in any 2017 data, then you will receive a 4% payment cut in 2019. If you submit a minimum amount of 2017 data to Medicare, you can avoid a payment cut. For example, submitting one quality measure for one patient, or attesting to one improvement activity will suffice.

March 6, 2017

Use ACG’s MACRA Resources

ACG members are encouraged to use the various MACRA resources, including the detailed overview of MACRA, “ACG’s “Making $ense of MACRA”, the ACG-CMS webinar on MIPS program, ACG’s “quality reporting checklist,” a list of each measure in the MIPS Quality, Advancing Care, and Improvement Activities categories, as well as each measure’s specifications. Check out the comprehensive list of ACG’s “MACRA Tidbit for the Week” here as well.

February 18, 2017

How is your MIPS Quality score actually calculated?

Since the Quality category represents 60% of your total MIPS score, it is important to know what you need to do in order to get the most of your score for this category. Let’s walk through an example of how the points are allotted from each measure that you report.

An ACG member reports MIPS Quality Measure #113, “Colorectal Cancer (CRC) Screening” via Medicare reimbursement claims forms.

First, the member must make sure that data is submitted on at least 50% of applicable patients (the denominator). This is what CMS means by “data completeness.” For measure #113, this is 50% of the Medicare Part B fee for patients aged 50 to 75 years for whom the member provided care for during the reporting period.

A “data completeness” note: ACG members will receive the minimum number of points for this measure if this minimum level of data completeness is unmet, and/or if the number of patients on which the measure reports is less than 20. The minimum number of points for CY 2017 is 3 points.

Otherwise, benchmarks based on historical performance scores will be used to determine the maximum number of points available. Your performance score will be compared to this “benchmark.”

These benchmarks are then assigned to a decile, and the total number of points that can be achieved will be based on the decile in which a physician’s performance rate is found. On the quality reporting program website, the deciles for the CRC screening measure are available for download. Deciles range from “3” to “10” for 2017.

Using the same example, the ACG member would have achieved a performance score of 75% in 2017. This means that 75% of all patients in the dominator were also confirmed to have received a CRC screening, and met the data completeness as well as the minimum case number. The 2017 benchmark results place a 75% performance score in decile 6 (decile 6’s range is 64.41 – 75.4%).

Thus, the provider would receive roughly 6 points for that measure.

TIP: Know the measure’s specifications! It is important to stress that ACG members should study the denominator for each measure and understand what exactly needs to be performed in order to meet the measure’s requirements. For example, measure #113 does not require you to actually perform the screening, but instead, to confirm that the patient has been screened for colorectal cancer. Since 60% of your total MIPS comes from the Quality category, you need to understand how to maximize your points. ACG is here to help.

February 4, 2017

How will repealing the ACA impact MACRA?

MACRA will stay put. Why?

MACRA has significant bipartisan popularity on both sides of the aisle in the U.S. House of Representatives and U.S. Senate. The U.S. Senate passed MACRA in April 2015 by a 92 to 8 margin. The U.S. House passed MACRA in March 2015 by a 392 to 37 margin. Both Democrats and Republicans have stated that their hope is to transition into a more “value-based care,” and see MACRA as the “vehicle” to do this. So there appears to be little incentive for President Trump or the Republican-controlled Congress to repeal this law.

Repealing the ACA could very well impact MACRA. How?

Remember: MACRA does not create new alternative payment models; it provides greater incentives to join one. While the 2017 health care issues focus on the ACA and access to health care via greater access to health insurance– not necessarily how Medicare pays providers. President Obama’s 2010 health care law authorizes the Medicare ACOs (“shared savings program”) as well as the Center for Medicare and Medicaid Innovation (CMMI). Republican leaders in Congress have already started putting the wheels in motion to repeal parts of the ACA, and throughout 2016, Republicans criticized the CMMI for having too much authority. So repealing the ACA could also repeal CMS’ authority to implement ACOs and other APMs under MACRA. However, please note that Republicans have started speaking with a softer tone regarding CMMI, now that they control both Congress and the Oval Office. CMMI may likely still exist, but with some “guardrails,” according to many Republican health policy staffers on Capitol Hill.

Also: there may be an opportunity to reduce MACRA reporting requirements and administrative burdens. The Trump Administration has already stated its intention to lower regulatory burdens for health care providers. This may be good news for ACG members and GI practices. Stay tuned.

January 21, 2017

2017 is a “Transition Year”: Here is what you need to know

CMS views CY 2017 as a transition year to ease Medicare providers into MIPS. What does this mean?

ACG members who submit 90 consecutive days of 2017 data will avoid a payment cut, and may earn a bonus in 2019. You will not get extra points, or larger bonuses, for submitting 90 days vs. a full calendar year. It is simply a choice.

If you don’t send in any 2017 data, then you will receive a 4% payment cut in 2019.