MACRA_PhysicianQualityReportingPositioningYourPractice

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MACRA Physician Quality
Reporting: Positioning Your
Practice for the MIPS Merit-Based
Incentive Payment System
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This special report is based on a July 2016 Healthcare Intelligence Network (HIN)
webinar hosted by Melanie Matthews, HIN executive vice president and chief
operating officer. This report is aimed at presidents/CEOs, chief financial officers,
chief operating officers, vice presidents, medical directors, physician practice
leaders, strategic planning executives and reimbursement executives.
Contributor
Eric Levin, director of strategic services, McKesson
Moderator
Melanie Matthews
HIN executive vice president and chief operating officer
Editor
Patricia Donovan
Cover Design
Jane Salmon

Table of Contents
The New Physician Quality Reporting: Positioning Your Practice for
MACRA and MIPS...................................................................................................................................4
Payments Influence Delivery Models��5
Payment Reform Summary��6
Overview of Merit-Based Incentive Payment System (MIPS)��8
MIPS Performance Categories�� 10
Concerns for Small Practices�� 10
Preparing Now to Change Patient Outcomes�� 11
Estimating MIPS Scores with the QRUR�� 12
5 Steps to Prepare for MACRA Implementation�� 14
Rewards of Patient-Centered Medical Home Recognition�� 15
Chronic Care Management as MACRA Stepping Stone�� 15
Key Takeaways�� 17
QA: Ask the Experts........................................................................................................................ 18
MIPS and Meaningful Use�� 18
Clinical Practice Improvement Activities�� 18
MACRA Impact on Specialty Providers�� 18
Likelihood of MACRA Delay�� 19
Lessons from Existing Physician Reporting Programs�� 19
MIPS Success Strategies�� 19
Practice Work Flows for CCM, MIPS�� 20
More Advice for Small and Solo Practices�� 20
MSSP Lessons in Quality Reporting�� 21
Glossary................................................................................................................................................... 22
For More Information....................................................................................................................... 23
About the Contributor...................................................................................................................... 24

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No matter which participation level a physician practice chooses for the
first Quality Payment Program performance period beginning January 1,
2017, CMS’s September 2016 “Pick Your Pace” announcement means practices
should proactively prepare for the impact of the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA) on physician quality reporting and
reimbursement. This special report delivers a MACRA toolkit for physician
practices, with dozens of tips and strategies that lay the groundwork for
reimbursement under Medicare’s Merit-based Incentive Payment System
(MIPS), one of two payment paths Medicare will offer to practices.
The New Physician Quality Reporting: Positioning Your
Practice for MACRA and MIPS
Some of the hottest topics today in healthcare are the Medicare Access
and CHIP Reauthorization Act (MACRA), the merit-based incentive
payment system (MIPS), and alternative payment models (APMs). Today we will
focus on the shifting landscape and legislative updates and what’s happening
with payment reform. We’ll drill down into MIPS, which will be the bulk of the
conversation, as well as identify
resources you can use to take action
to prepare for MIPS, as well as
MACRA, which will start in 2017,
now just six months away.
To provide some background
on how we got to this place, Figure
1 illustrates some 2015 predictions
from the Department of Health and
Human Services (HHS). First, 30
percent of Medicare payments will
be value-based by this year. Fifty
percent of Medicare payments will
be value-based in just two years.
Eighty-five percent of Medicare fee-
for-service will be tied to quality
Eric Levin is director
of strategic services for
McKesson.
HHS Medicare Predictions
Source: Eric Levin, McKesson
Figure 1

and value by 2016, and 90 percent
by 2018.
As indicated by the note at
the bottom of Figure 1, Medicare
beneficiary volume is supposed
to grow significantly. Fifty-eight
percent of provider volumes
are expected to be composed of
Medicare patients. Sixty percent
of the patients will be 65 or older,
which is a significant population.
Payments Influence Delivery
Models
As shown in Figure 2, a range
of payment models influence how care is delivered, starting with fee for service.
Historically, this has been the way physicians have been paid; payment and
administrative complexity are relatively small. This has become more complex as
we’ve shifted toward payment for outcomes, which has gone from fee for service
to pay for performance to shared savings.
Additionally, we’ve seen the creation of accountable care organizations
(ACOs) and bundled payments, all the way to global risk and taking downside
risk. This evolution has changed what is being measured, accountability, the data
being shared, and provider responsibility. We’re now seeing a shift as payors
become providers and providers become payors. Everything is changing with
value-based and performance-based payment models.
This has created some new delivery models. We’ve seen Patient-Centered
Medical Home (PCMH), clinically integrated networks and narrow networks. All
of these are tied to specific incentives to increase outcomes, decrease costs or
improve the patient experience. We expect there certainly will be new delivery
models created. As we get into MACRA and MIPS, we’ll see what will happen
because of those regulations as well.
Very simply, as risk and reward increases, care coordination must follow.
This is illustrated in the bottom left of Figure 3 on the next page, which depicts
very limited care coordination with a very low financial risk and reward. That’s
your fee-for-service world, where many providers live today. However, as clinical
alignment and care coordination increase and you move toward the right, if
you are not participating in some type of value-based care program, most likely
you’re not being reimbursed or rewarded for that work. The payor is really the
sole beneficiary for that.
Payments Influence Delivery Models, From Fee-for-Service to
Performance-Based
Figure 2

However, if you are able
to sustain that diagonal curve,
growing the care coordination
and alignment and moving toward
the right, as well as participating
in fee-for-value contracts and
value-based performance, there
are significant rewards available,
not only for patients but also for
providers and organizations.
Remaining in the upper left
quadrant of Figure 3 is just not
sustainable today. Taking on
capitation, bundled payments or
being part of an ACO without any
kind of clinical alignment and care
coordination simply won’t work.
There will be very limited rewards.
It will be very tough to keep going
and navigate.
Based on all these shifts, what’s
the big challenge facing everybody?
How can you invest in the right
business, the right service model,
the right care delivery, so that you
can get paid for volume now and
value in the future? Where are you
on that chart in Figure 3? Are you
on the bottom left? Are you shifting
toward the upper right?
You need to identify where you
are in the landscape of payment
reform, the improvements you can
make, and the programs you can
participate in.
Payment Reform Summary
To summarize as we move into payment reform, we’re going to see this
rapid transition away from fee for service. (See Figure 4.) We’ve already seen
that with many of the MACRA regulations. There are numerous questions; many
providers are not ready. They haven’t been doing some of the things that have
Financial + Clinical Transformation Drives Value-Based Care
Figure 3
Payment Reform Summary
Figure 4

been presented to them before. We’ve
seen a lot of the carrot first with
the reward, and then the stick later
with the penalty. We’re getting more
alternative payment models, which
you have seen from the previous
figures. By 2020, there will be a
significant number of those.
The focus is going to be
containing the total cost of care but
also achieving quality thresholds, so
there is that balance. If you do chase
value, the dollars will usually follow.
There are significant rewards; we
will go into some of those details
for actually performing that value
that’s been set forth. There’s an
essential consumer and physician
engagement. Patients and providers
will both have skin in the game
to participate and both can be
rewarded for participating in value-
based care.
Medicare has put forth these
goals for reform, which create an
extension of care between exam
room visits. (See Figure 5.) The
goals are focused on devising less
extensive visits and less costly visits. Telehealth, text messaging, remote visits,
phone calls by nurse practitioners, and the use of physician assistants (PAs) are
all options to try and bring down the total cost of care, reduce duplication of
testing, and incentivize providers to increase their care coordination. All of this
should increase patient-reported outcomes by doing the right thing for patients,
which is why most physicians went to school to begin with.
To achieve these goals, the Centers for Medicare and Medicaid Services
(CMS) created MACRA. (See Figure 6.) This is a two-party law that’s been signed.
MACRA will not be affected by the outcome of the 2016 presidential election. It
does change what was formerly known as the Sustainable Growth Rate (SGR)
and it’s changing the way physicians in Medicare Part B will be paid. It takes
what was previously known as several different fragmented programs and
combines them into one, and then also provides additional bonus payments for
participating in alternative payment models. Some of those are more advanced by
taking on downside risk as well.
Medicare Goals for Reform
Figure 5
MACRA
Figure 6

Proposed Rule: MIPS Summary
Figure 8
Overview of Merit-Based
(MIPS)
Next is an overview of MIPS,
which is what we’re going to focus on
here. (See Figure 7.) That is one of the
two choices or one of the two routes
you can follow under MACRA. The
MIPS path combines the Physician
Quality Reporting System (PQRS) and
the Value-Based Payment Modifier
(VBRM) with what was known as the
Meaningful Use Medicare Electronic
Health Record (EHR) Incentive
Program.
Meaningful Use is not totally
going away. It’s just being bundled
with these other groups, which
should simplify things. If you were
participating in these three programs
prior to today, life should be a little
simpler by participating in MIPS.
This single program will focus on
quality, resource use, Meaningful Use,
and clinical practice improvement
activities. We’ll go through some of
these examples shortly.
Eighty-eight percent of physicians
are expected to fall under the MIPS payment model versus alternative payment
models (APMs), which is why MIPS is the focus of that conversation today.
Please note: In summarizing MIPS, I am referring to the current proposed
rule. Every day, changes are being made. Suggestions are being made. Hundreds
of comments have been submitted by healthcare organizations and providers.
The final rule does not come out until later this year. I would encourage
everyone to definitely keep an ear to the ground. Get as much of an education as
you can. Follow CMS closely, because all of this can change. This is how we are
looking at the proposed rule right now. I’m sure some of this will change, but the
bulk of what has been proposed likely will stay in place.
Essentially, we’re working at chasing quality and having the data or the
dollars follow. This will start with 2017 data, beginning in January 2017,
which will affect your 2019 Medicare Part B payments. To qualify, if you are
Merit-Based Incentive Payment System (MIPS)
Figure 7

participating in Part B, unless
it’s your first year or unless you
have a low threshold of Medicare
patients, and I’ll show you those
numbers shortly, you are expected to
participate in either MIPS or APMs.
There is a CMS link I would
highly recommend bookmarking
or subscribing to by e-mail to make
sure you are updated and remain
current on any changes or new
proposed rules that go into effect.
CMS regularly communicates MACRA
changes via this link:
http://go.cms.gov/
QualityPaymentProgram
The proposed rule for eligible
clinicians who can participate
either as an individual or a group
has not changed. (See Figure 9.)
An individual is a unique national
provider identifier (NPI) or tax
ID. If a group has two or more
providers, it is defined by a tax ID
and would participate in all four
MIPS categories. CMS is expected to
provide more information for virtual
groups. They haven’t necessarily
defined what those will look like.
Virtual groups will not be ready for Year One, but for Year Two going forward.
Who will not participate in MIPS? If you are in the first year of Medicare Part
B participation, if you have less than $10,000 in Medicare billing charges (not
collection charges), and if you have 100 or fewer Medicare patients in one year,
then you do not hit the MACRA threshold and do not have to participate in MIPS.
This has prompted many providers to look at going into concierge medicine as
well as perhaps taking on more commercial patients to avoid having this high
volume of Medicare.
Certain participants in advanced Alternative Payment Models (APMs) also
will not participate in this. This is similar to a track 2 or higher ACO. If you’re
taking downside risk, this will also move you toward the APM model under
MACRA, versus the MIPS track.
Proposed Rule: MIPS-Eligible Clinicians
Figure 9
Proposed Rule: MIPS Performance Categories
Figure 10

MIPS Performance Categories
Your MIPS performance is
factored across four weighted
categories, which range from a 0- to
a 100-point scale. (See Figure 10 on
the previous page.) These categories
are quality, resource use, clinical
practice improvement activities,
and advancing care information.
All of these will make up a MIPS
composite performance score that
will determine physician payments.
Figure 11 shows the Year One
performance category weights for
MIPS: 50 percent will be quality.
Each measure will have one to
ten points. Zero points are not
reported. Any of these are based on
a threshold: your resources, your
advancing care information, which is
really reporting, and then 15 percent
will be clinical practice improvement
activities. CMS has defined about
90 different types of activities. I’ll
provide some examples of what can
count toward the MIPS score for
these as well.
The MIPS submission options for quality and resource use comprise a lot
of activities providers are doing today for both PQRS, using claims reporting, a
qualified clinical data registry, an EHR vendor or a qualified registry population
health management analytic system. (See Figure 12.) The same submission
options hold for individual as well as group reporting. However, with groups, you
can participate in the Consumer Assessment of Healthcare Providers and Systems
(CAHPS) for MIPS Survey as well as administrative claims that do not have to be
submitted under the resource portion.
Concerns for Small Practices
Many small practices have voiced concerns about their ability to participate
in the initial requirements. Most of these concerns are centered around
technology. Do they have the necessary resources now? Are they able to afford
what will be required of them for both reporting as well as monitoring their
Proposed Rule: MIPS Year 1 Performance Category Weights
Figure 11
Proposed Rule: MIPS Track and Submit Data
Figure 12

patients? They’ve announced there
could be a delay in MACRA’s starting
date because of the smaller physician
base. In a Black Book™ survey, 67
percent of physician groups believe
MACRA threatens some of their
independence, and 89 percent of solo
physician practices said they expect
to minimize Medicare volumes. (See
“For More Information.”)
Others say they will consider
going into concierge medicine,
becoming employees of hospitals
or joining another group. However,
a provider who is doing nothing
today—no PQRS or Meaningful Use—
would receive a higher penalty today than it actually would under MIPS. It would
drop from about a minus 9 percent penalty to about a minus 4 percent penalty
under MIPS. It is interesting to know that these providers could be rewarded
under the MIPS performance scores.
While there are legitimate concerns, help is available. (See Figure 13.) CMS
has provided numerous resources, with the promise of many more to come.
Education and training materials are available. CMS is promising $100 million
in technical assistance over the next five years. They’re establishing practice
transformation networks, which are very similar to regional extension centers
(RECs) that helped physicians with Meaningful Use. The RECs helped practices
to adopt and implement the necessary technology so they could qualify for
Meaningful Use. They also made sure they were reporting that as well.
They are supposed to create virtual groups, which will be a collaborative
between specific specialties and could help with the virtual group formation.
Studies will also be available to accumulate points. If you want to participate in a
MIPS study for CMS, you can gain points for doing so. I would highly recommend
looking into that. Reach out to CMS to see how you can participate.
Preparing Now to Change Patient Outcomes
Why prepare now? Why talk about this now? In reality, we’re only six months
away from the proposed rule. Of course MACRA could be delayed. It could get
changed, but as it stands today, we’re looking at submitting January 2017 data;
six months from now, data is going to affect 2019 reimbursements. There’s a very
short window of time to start changing patient outcomes, changing the way you
report, and implementing technology.
MACRA Resources from CMS
Figure 13

All of that should be baked now
to determine how you will be part of
MACRA in 2017. Your payment ranges
can go from minus 4 percent to plus
4 percent initially; that’s going to
change to minus 9 percent and plus
9 percent, which is a huge swing.
As well, there will be very large
bonuses for the top 25th percentile
of providers, who can earn up to an
additional 10 percent reimbursement
on their Medicare payments.
Figure 14 identifies some
strategies providers can implement
now to take immediate action. These
strategies are focused on aggregation
of data. Don’t just focus on claims
data. Make sure you’re using clinical
data as well as lab data. Make sure
you’re looking at how this data can
help quality improvement.
Estimating MIPS Scores with
the QRUR
The Quality and Resource Use
Report (QRUR) report allows you to
see where you are today in relation to
your peers. (See Figure 15.) You can
see what your MIPS score might be,
based on your activities today. Look
at the data. Learn how to risk-stratify.
Identify the gaps in care you currently have and determine where those can be
filled in so you’re not just measuring but actually improving quality. Previously,
physicians were paid for reporting with PQRS, but that now has transitioned to
actual pay for performance, where the outcomes will affect the reimbursement.
The Quality and Resource Use Report in Figure 15 can be found on CMS’s
Web site. (See “For More Information.”) Use the QRUR to see where your scores
would put you. The instructions are included with the form. This example is
a hypothetical provider and how they would relate to their peers. The upper
right-hand section is where they would shift with high quality and low cost. The
bottom left reflects lower cost and lower quality. It’s a pretty self-explanatory
chart.
Taking Immediate Action
Figure 14
Determine Value with Quality and Resource Use Report (QRUR)
Figure 15

Ideally, CMS would like providers
to focus on where that diamond is.
That’s the goal for Medicare. As you
can see, many providers are probably
going to be lumped somewhere in
that middle range, that minus 1 to
plus 1 percentage.
There are several things physician
practices can do before the carrot
comes, before the stick comes. (See
Figure 16.) Right now we’re looking
at having both, as proposed with the
minus 4 to plus 4 percent swing.
Number one, look at the NCQA
requirements for Patient-Centered
Medical Home. (See “For More
Information.”) If you are a primary
care office and have not yet done
this, the PCMH is a great way to earn
points. You can obtain full points for
that. Use the data you have now for
other payor incentives. See what Blue
Cross Blue Shield, Aetna, Cigna and
other major payors are offering.
Second, insure that your data is
being consolidated into one system.
Use claims data, and use clinical
data. Then, start with your providers
to make sure everybody in your
organization understands that it’s not
just about reporting any more, but
about actual outcomes and measures.
Next, know the national benchmarks, so when you’re reviewing that QRUR
report, you know where you will be relative to other physicians. Then, start
looking at the quality measures to determine which six you will report under
MIPS. That will allow you to start focusing on that data and determining how you
can improve those scores as they stand today.
Take Action Before the Carrot and the Stick
NCQA requirements for Patient-Centered Medical Home.
Use data for other payor incentives.
Ensure disparate data is consolidated into one system.
Start at provider level with physicians to ensure they understand
and that it’s not just about reporting.
Know national benchmarks.
Determine six quality measures to report.
Figure 16
5 Steps to Prepare for MACRA Implementation
Make certain you are successfully participating in existing Medicare
quality and EHR programs.
Factor alternative payment model (APM) participation bonus into
risk-based payment model adoption strategy.
Understand which track your organization will likely fall into.
Educate providers in your group on your payment track and what it
means for provider payment in 2019.
Stay current on forthcoming CMS proposed and final MACRA
implementation rulings.
Figure 17

5 Steps to Prepare for MACRA Implementation
Figure 17 on the previous page outlines five more steps to prepare for MIPS
today.
First, make certain you are successfully participating in any Medicare Quality
and electronic health record (EHR) programs, including the Physician Quality
Reporting System (PQRS), Meaningful Use, and Patient-Centered Medical Home.
Next, try and factor in the alternative payment model (APM) participation
bonus into a risk-based payment model adoption strategy to see if you qualify.
Rewards can be significantly higher under the APM track.
Third, make sure you know which payment track your organization will seek.
Explore APMs; if you can do one of those, great. If not, then MIPS still can provide
a relatively high incentive.
Next, start educating providers, employers, nurses and staff members on
the chosen payment track and quality measures, as well as expectations for
outcomes.
Finally, stay very close to CMS. Check their Web site, subscribe for e-mail
updates and check their Twitter feed for MACRA rule updates so you are aware of
and can react to changes as needed.
There are many more MACRA resources out there today. Relationships
between providers and technology vendors should become closer, to make sure
you know what can be done and what’s available to you. Whether it’s an EHR,
analytics registry or population health management vendor, make sure you
constantly communicate your needs to them.
Take advantage of the many available MIPS calculators, including the one
on the CMS Web site. The American
Academy of Family Physicians (AAFP)
and other organizations are always
issuing resources that can help
providers prepare for MIPS and what’s
to come.
Additionally, there are many
recorded webinars you can view. Look
on YouTube.®
This is a great way to
review specific topics or high-level
overviews or even to show to your
staff to make sure they’re aware of
the changes. And then, pay attention
Patient Centered Medical Home
Figure 18

to the CMS-designated consultants. The recipients of these grants should be
announced, as well as the resources that will be available to you.
Rewards of Patient-Centered Medical Home Recognition
I mentioned Patient-Centered Medical Home earlier. If you’re not already a
recognized PCMH, this is highly recommended, because you will need to prove
for MIPS and under NCQA you are taking action in this area. (See Figure 18 on the
previous page.)
Previously, PCMH was questionable, as there were not specific rewards
tied to it. However, over the past four to five years, that has changed. Now
private payors are reimbursing for organizations to become a NCQA level three-
recognized PCMH. There’s a lot of value in doing this. It’s great for the patients.
There’s a huge patient engagement piece. It does change some of the practice
functions; however, now there are specific rewards tied to it. The ROI is great.
The patient benefits are great, too,
and then NCQA recognition will
earn maximum points under MIPS
and clinical practice improvement
activities (CPIA) as well.
Chronic Care Management as
MACRA Stepping Stone
This ongoing shift toward
performance affects chronic disease
and chronic disease management
as well. (See Figure 19.) This is
becoming a big focus. These patients
are frequent users of the healthcare
system. The 80/20 rule really applies
here; these patients are costing the
healthcare system the most money.
They are the patients to focus on to
turn that dial on their outcomes and
turn that dial on cost.
Managing them is an easy
transition; to chase quality and be
rewarded for it. CMS has issued some
specific CPT reimbursement codes.
(See Figure 20.) CPT code 99490 is
for chronic care management (CCM).
As you can see in Figure 20, two-
Pay-for-Performance Shift for Chronic Disease
As U.S. healthcare shifts to value-based reimbursement, chronic care
management is a main focus.
Chronic care management is first step for many providers on path to
value-based care and reimbursement.
Provides new opportunity to improve quality of care and increase
efficiencies.
Figure 19
Chronic Care Management (CCM)
Figure 20

thirds of Medicare beneficiaries had
two or more chronic conditions,
which would qualify under that
code. Transitional Care Management
(TCM) is managing care transitions
from a discharge to either a primary
care provider (PCP), a nurse setting,
or the home. The TCM code can pay
approximately $150 to $250 per visit
as well. These are hitting measures
under quality, and they’re also
hitting some high priority measures
under MIPS just by participating in
them, and you’re being reimbursed
under the fee-for-service method
today. This is almost a double win on
both sides; plus, it’s better care for
the patient as well.
The CCM services entail about
20 minutes of non-face-to-face
care coordination. (See Figure
21.) This must be comprised of a
comprehensive care plan, medicine
reconciliation, transition of care, and
care coordination between providers
as well as 24/7 access to an urgent
care facility, either via an on-call staff
or operating an urgent care or open
ER. Medicare has relaxed some of
these requirements as this program
has developed, so I highly encourage
everybody to participate in it.
Patients love CCM; it’s also a nice revenue stream for clinicians.
Chronic Care Management will help you launch your value-based journey
if you have not yet started. (See Figure 22.) The revenue streams by doing TCM
can create annual wellness visits. It can create new evaluation and management
(EM) code visits, as well as the CCM code that’s reimbursed an average of about
$43 per patient per month. It’s going to give you a nice ROI for programs that
usually are hard to quantify.
There is not a downside risk to this. It is not based on patient outcomes. It is
simply under fee for service, but it’s value-based care work that puts you on the
path toward the work you would be doing with MIPS. It’s helping you prepare
for MIPS. It’s helping to train the practice to operate under that MIPS umbrella as
CCM Services Under CPT Code 99490
Figure 21
Why Enroll in CCM Under CPT Code 99490?
Figure 22

well as create more transactions that are
less costly and less time-consuming with
that patient.
McKesson offers some chronic care
management services for practices that
are not able to do this themselves. There
is help out there if needed as a resource
to any primary care specialty group that
does want to participate in this. (See “For
More Information.”)
Key Takeaways
In summary, don’t wait for the final
MACRA rule to come out. There are
plenty of things to do today to focus on
MIPS and MACRA and determine where
you stand, what you need to do and what steps you need to take. You can have
your practice learn how to focus on quality outcomes and costs, increasing focus
on the patient as well as that patient-provider relationship. Look at how you
can identify ways to increase those inexpensive encounters by incorporating
telehealth, chronic care management, and PCMH; how to enhance communication
with patients via patient portals, texts and e-mails—whichever mode best suits
your facility.
This change, the likes of which we have not seen before, will create a need
for a deeper partnership with any technology or outsourced revenue cycle
management (RCM) vendors. The end of reimbursement under fee-for-service
and the shift toward value with different payment models will likely change
how RCM vendors do business with practices as well. As we’ve seen, these new
regulations change how care is delivered. We’ve had ACOs, which have had mixed
success. We’ll see what comes next. There’s certainly plenty of opportunities
for things to improve, for things to change, for new care delivery models to be
created as well.
Historically we’ve seen commercial payors always follow CMS’s lead. CMS
tends to be the innovator when it comes to these efforts. As we saw with Chronic
Care Management, the Patient-Centered Medical Home, and ACOs, first it was
CMS and Medicare behind these initiatives, and then commercial payors fell in
line and began to reimburse providers for them as well. Expect more payment
reforms from Blue Cross Blue Shield, Aetna, Cigna and other major payors.
Key Takeaways
Do not sit and wait for final rules– we are six months away.
Focus on quality, outcomes, and cost.
Identify opportunities to increase inexpensive encounters:
OO Telehealth, CCM, PCMH, text/e-mail
Unprecedented changes and market flux create need for deeper
partnerships with technology and RCM vendors.
Monumental shift in care delivery and incentives.
Commercial payors will continue to follow CMS’ lead
(value-based reimbursement).
Figure 23

QA: Ask the Experts
In this roundtable discussion, HIN’s expert panelist provides additional
clarification on concepts raised in this report.
MIPS and Meaningful Use
Question: How does MIPS affect the hospital Meaningful Use program?
Response: (Eric Levin) MIPS does not affect Meaningful Use. MIPS is all
Medicare Part B. The hospital reimbursement program as we know it from
Medicare will stay the way it is today.
Clinical Practice Improvement Activities
Question: Would billing for transitional care management count toward a
clinical practice improvement activity?
Response: (Eric Levin) Absolutely. Transitional Care Management would
count under the care coordination piece. It’s also going to count under managing
care transitions. It’s also going to count because of the phone calls that take place,
which would reduce that cost of care and reduce that visit. It’s several measures
that are going to happen as that patient is transitioned from a hospital to another
care setting. It also gives you a CPT code to bill for, which is about twice as much
as a typical office visit, so there are multiple benefits to doing that.
MACRA Impact on Specialty Providers
Question: How will MACRA and MIPS impact specialty providers, such as
neurologists?
Response: (Eric Levin) They will impact specialists the same way they will
impact primary care providers. Specialty providers will still be paid based on
the outcomes set forth by MIPS. Certainly there will be different reimbursements
as well as different care delivery models from primary care to specialties, but a
lot of this will be dependent on care coordination between both specialist and
primary care doctors, as well as physicians employed in hospitals.

Likelihood of MACRA Delay
Question: Based on the feedback from CMS, how likely is it that the MACRA
start date will be delayed?
Response: (Eric Levin) I think it will be. I don’t know how far out it would
be delayed, but I would think they are determining that based on the comments
they’ve gotten. Organizations as large as the AAFP have been very vocal that
providers simply are not ready.
I would expect a delay—six months, a year, or even longer, but it looks like
based on those comments and based on the feedback they’ve gotten, they might
give providers a little more time to prepare.
Lessons from Existing Physician Reporting Programs
Question: What lessons can practices take from the Physician Quality
Reporting System, Meaningful Use and Value-Based Payment Modifier
programs to help them succeed under the new program?
Response: (Eric Levin) I would look at the data in terms of its collection
reporting, sources, and effectiveness for your specific practice or organization.
If you’re just relying on claims data or are able to obtain both clinical and claims
data and aggregate that into one system, it’s going to make your life a lot easier.
People have learned this over time with PQRS and Meaningful Use. We’ve
gone from a kind of ‘check the box’ mentality to pay-for-reporting and now
to pay-for-performance. It’s not just reporting those scores, but becoming
dependent on those scores. Learning how to measure and change delivery based
on those scores will be crucial.
MIPS Success Strategies
Question: What characteristics will help practices succeed under the
MIPS program and conversely, what won’t help?
Response: (Eric Levin) What won’t help would be a very antiquated system
of care delivery where you still focus on completing as many transactions as
possible, getting patients in there in 15-minute slots, and filling up your calendar
with 70 to 100 patient visits a day. That’s not going to work. What will work is
highly coordinated care between a provider using a nurse team and performing
team-based medicine, where they’re working with specialists and with hospitals
to improve that patient experience, reduce the total cost of care, and help
focus on those patient outcomes. That’s going to be the key driver influencing
reimbursement.

Practice Work Flows for CCM, MIPS
Question: What practice work flows do you recommend to succeed under
Chronic Care Management and MIPS?
Response: (Eric Levin) I would look at the Patient-Centered Medical Home
model. Especially, there’s a lot of overlap with CCM and PCMH, where you use
more team-based care. You’re using nurses to do a lot of what used to be typical
doctor-patient communication. With CCM, there is a lot of telephone work, as it is
specifically non face-to-face, versus patients in a medical home, where you can do
a lot of that in the practice.
Consider implementing monthly phone calls to patients, which can help with
CCM and also help to follow up with those patients so you know they’re taking
their medications and understanding the doctors’ instructions. All of this will
help to engage that patient in their care as well as reduce the cost of that care,
which will help to improve your MIPS score at the end of the day.
More Advice for Small and Solo Practices
Question: What do you recommend for small and solo practices?
Response: (Eric Levin) I would wait to see what happens with the final rule.
There may be some changes to help small and solo practitioners. For right now,
keep doing what you’re doing, hopefully with Meaningful Use and PQRS. (A solo
provider could participate in both programs.) As long as you are up to date with
the technology and your patient outcomes, you’ll be fine. I would recommend
doing some chronic care management. Try to obtain some discharge information
from your hospitals so you’re able to follow up with those patients after
discharge in a timely manner. That way, you can keep tabs on those patients.
If an EMR does not have a registry or population management module, look
into something that isn’t too expensive, where you can see your gaps in care and
focus on reducing those and driving down that total cost of care while improving
those patient outcomes. That will help your practice overall. It’s going to help you
chase that quality score and, at the same time, the dollars will come. You will be
rewarded from both Medicare as well as private insurance carriers for it.
Editor’s Note: In a September 2016 blog post, Andy Slavitt, Acting
Administrator of the Centers for Medicare and Medicaid Services, announced that
during 2017, eligible physicians and other clinicians will have multiple options
for participation. Choosing one of these options would ensure practices do not
receive a negative payment adjustment in 2019. (See “For More Information.”)
These options and other supporting details will be described fully in the MACRA
final rule, expected by November 1, 2016.

MSSP Lessons in Quality Reporting
Question: According to CSM, many MSSPs were not eligible for shared
savings because they did not report quality measures correctly. How can
physician practices better structure their quality reporting process?
Response: (Eric Levin) With accountable care organizations (ACOs) and
Medicare Shared Savings Programs (MSSPs), it was a mixed bag. That’s going
to evolve over time. We’ve seen the creation of Next Generation ACOs. Some
organizations are able to take downside risk to improve their mechanisms of
payment. It comes back to being able to coordinate that care and perform true
patient care coordination. Those organizations could not successfully do that and
that is why they weren’t able to successfully demonstrate those shared savings.
You almost have to go back to the roots of the Patient-Centered Medical
Home, which is the foundation of an ACO, to see how these practices coordinate
care between each other, to see the tools they use to measure that data and how
they act on that data. You can focus on those quality measures for MSSP for your
ACO and then make those changes for the second and third year that the data is
reported.
The delay in reporting, for receiving actual scores and results, was a little
tough. Hopefully that’s something that will change so that feedback will be more
immediate so you can make those necessary changes as you move forward.

Glossary
HIN Healthcare Intelligence Network
AAFP American Academy of Family Physicians
ACO Accountable Care Organization
APM Alternative Payment Model
CAHPS Consumer Assessment of Healthcare Providers and Systems
CCM Chronic Care Management
CMS Centers for Medicare and Medicaid Services
CPIA Clinical Practice Improvement Activities
EM Evaluation and Management
EHR Electronic Health Record
FFS Fee for Service
HHS U.S. Department of Health and Human Services
MACRA Medicare Access CHIP Reauthorization Act of 2015
MIPS Merit-Based Incentive Payment System
MSSP Medicare Shared Savings Program
NPI National Provider Identifier
PA Physician Assistant
PCMH Patient-Centered Medical Home
PCP Primary Care Provider
PQRS Physician Quality Reporting System
QRUR Quality and Resource Use Report
RCM Revenue Cycle Management
REC Regional Extension Center
SGR Sustainable Growth Rate
TCM Transitional Care Management
VBPM Value-Based Payment Modifier

For More Information
This section provides more detail on resources mentioned in this report. A
listing here does not constitute an endorsement by the Healthcare Intelligence
Network of a company, product or organization.
http://www.hin.com
Physician Reimbursement in 2016: 4 Billable Medicare Events to Maximize Care
Management Revenue and Results details the ways in which Bon Secours Medical
Group (BSMG) leverages a team-based care approach, expanded care access
and technology to capitalize on four Medicare billing events: transitional care
management, chronic care management, Medicare annual wellness visits and
advance care planning. For more information, please visit:
2015 Healthcare Benchmarks: Chronic Care Management captures tools,
practices and lessons learned by 119 healthcare organizations related to the
management of chronic disease. For more information, please visit:
Black Book™ Market Research
http://www.blackbookmarketresearch.com/
Black Book Rankings offers complete quantitative and qualitative research
services to meet specific client needs in healthcare, pharmaceutics, biomedical
devices, managed care, health insurance, and technology.
CMS Quality and Resource Use Report (QRUR)
https://portal.cms.gov
Individuals can access a QRUR on behalf of a group or solo practitioner.
QRURs are provided for each Medicare-enrolled Taxpayer Identification Number.
CMS MACRA “Pick Your Pace” Announcement
https://blog.cms.gov/2016/09/08/qualitypaymentprogram-
pickyourpace/
In recognition of the wide diversity of physician practices, CMS intends
for the Quality Payment Program to allow physicians to pick their pace of
participation for the first performance period that begins January 1, 2017.
During 2017, eligible physicians and other clinicians will have multiple options
for participation. Choosing one of these options would ensure physicians do
not receive a negative payment adjustment in 2019. These options and other
supporting details will be described fully in the final rule.

CMS MACRA Information
http://go.cms.gov/QualityPaymentProgram
CMS posts updates to the Medicare Access and Summary CHIP
Reauthorization Act of 2015 (MACRA) here. MACRA bipartisan legislation
replaced the flawed Sustainable Growth Rate formula with a new approach to
paying clinicians for the value and quality of care they provide.
McKesson Chronic Care Management Services
http://www.mckesson.com
McKesson Chronic Care Management Services™ help providers improve
patient engagement and quality of care while getting paid through the new CMS
program under CPT code 99490. The services will help clinicians meet CMS’
billing requirements and capture revenue that might have otherwise been missed
—all with no up-front costs.
NCQA Patient-Centered Medical Home Requirements
http://www.ncqa.org
The Patient-Centered Medical Home (PCMH) is a model of care that
emphasizes care coordination and communication to transform primary care
into “what patients want it to be.” NCQA PCMH recognition is the most widely
adopted model for transforming primary care practices into medical homes.
Research confirms medical homes can lead to higher quality and lower costs, and
can improve patients’ and providers’ experience of care.
About the Contributor
Eric Levin is a strategic services director for McKesson’s Business Performance
Services division, which provides value-based care solutions to both hospitals and
physician groups.
In this role, Mr. Levin focuses on comprehensive and strategic healthcare
sales and business development. He has over 15 years of healthcare experience
specializing in value-based reimbursement, technology and primary care strategy.
With McKesson, Mr. Levin led the advanced primary care team in creating
payor and provider collaborations that resulted in successful pay-for-performance
plans. He also served an integral role in commercializing data warehouse and
population health management platforms.
Prior to McKesson, Mr. Levin held strategic sales roles at NueMD and FSC
Pediatrics.

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While others wait for the healthcare industry to complete its transition to
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Positioning for Value-Based Reimbursement: Leveraging Care
Management for Clinical and Financial Outcomes describes how
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maximize quality and clinical outcomes and reduce spend.
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panel instead of just patients seen daily;
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