MIPS Transition: CMS Cushions the Leap to Value

Oncology Business News®, December 2016,

The final rule for the Quality Payment Program authorized by the Medicare Access and CHIP Reauthorization Act of 2015 was recently released.

Linda Pottinger

The final rule for the Quality Payment Program (QPP) authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was recently released. This rule has two tracks for Medicare providers to choose from: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM). Fortunately, there are a lot of positives for community oncology practices in the final details. Additionally, there are now several options for providers to participate in 2017 at a pace that meets their readiness:

  • Participate fully in MIPS. Submit data for all required measures in all categories for the full year and be eligible for the maximum positive payment adjustment.
  • Participate partly in MIPS. Report a minimum of 90 days of data including one Quality measure, one Improvement Activity, or more than the required measures in the Advancing Care Information (ACI) performance category to avoid negative payment adjustment and be eligible for a modest positive payment adjustment.
  • Submit some data. Report on one measure in the Quality category, one Improvement Activity, or the required number of measures of ACI to avoid a negative MIPS payment adjustment.
  • Participate in an Advanced APM and avoid MIPS participation.

​Oncology practices participating in the Center for Medicare and Medicaid Innovation’s (CMMI) Oncology Care Model (OCM) also have some readiness choices. These practices now have the option to participate as Advanced APMs in 2017. An Advanced APM is a two-sided risk model that totally exempts practices from MIPS participation. Those considering this option need to look carefully at the pros and cons of moving more quickly to a two-sided risk model versus participation in MIPS. The upside of the two-sided risk option is that practices are eligible for an additional 5% bonus payment from CMS, but they must achieve cost savings and improve patient outcomes, or they will face a penalty.

Practices that do not participate at all in 2017 will receive a 4% negative payment adjustment in 2019.

Start Preparing for MIPS Today

Now that the final MIPS rule has been issued, there are various activities practices can undertake to ensure they are well positioned to succeed when the program launches in January. The following are several critical areas all oncology practices should consider.

Engage your electronic health record (EHR) vendor about readiness for MIPS.

Understanding the practice’s electronic health record (EHR) MIPS capabilities and knowing when program reporting functionality will be available are critical first steps, as they enable the practice to determine which participation option is best for them. Requirements for the different levels of participation for 2017 must be closely examined and compared with practice readiness, both from technology and process standpoints. Once the level of readiness has been determined, providers can then decide if they are capable of submitting a full year of data, which would allow the opportunity for the maximum incentive payment in 2019.

Examine practice performance in the Physician Quality Reporting System (PQRS)

If neither the practice nor its technology is fully prepared to begin reporting on January 1, an action plan can be created to identify areas in need of improvement and plan corrections during the first part of the year. Practices have until October 2, 2017 to start collecting performance data and still avoid a penalty. However, the more they report, the more opportunity there is for a higher incentive payment in 2019.Many oncology practices are participating in PQRS, a quality improvement incentive program providing rewards or penalties for reporting data to CMS. Those that are doing well in the program are in a good position to transition to MIPS because many of the quality reporting measures for MIPS are a continuation of PQRS, now called the Quality Performance Category.

Review and select measures for the Improvement Activities category

Practices not participating in PQRS may want to use the first nine months of 2017 to learn more about MIPS requirements and their readiness to meet these provisions. Start by looking at charting procedures. This will provide insight into which measures are the best fit for the practice based on patient volumes and other key factors related to MIPS quality measures. Part of this process involves engaging the practice’s EHR vendor to determine which measures are included in the EHR. Practices also need to make certain their EHR is fully certified for Meaningful Use, which is now called ACI.The Improvement Activities category represents 15% of the MIPS 2017 composite score. Practices have to attest they have completed up to four improvement activities for a minimum of 90 days; therefore, the selected activity must be started no later than October 2, 2017. Activities are worth 10 or 20 points each, for a maximum score of 40. Practices with fewer than 15 physicians have only to complete two activities.

Examine the ACI measures and prepare to do more than the minimum

There are 93 different activities practices can consider, so there should be no difficulty finding several that are a good match for any particular practice. Practices should consider reporting on measures they are already meeting and just need to formalize the process or make minor changes to meet MIPS requirements. The intent behind this category is to drive innovation that benefits both the patient and the practice. The best way to approach this task is to consider activities that make the practice more efficient and effective in providing quality care to patients.The final MIPS rule reduced the number of measures initially proposed for reporting in the ACI category, formerly called Meaningful Use. Practices will now be required to report on only five measures, representing 25% of their MIPS 2017 composite score. However, practices can raise their score by reporting on more than ve. The final rule included nine additional measures practices can submit. The maximum score is 100 points, but a score of up to 155 can be achieved by reporting on all 14 measures.

Decide whether to report as individuals or as a group

Value-based Care is Here to Stay

Practices should strive to do more than the minimum in this category. By talking to their EHR vendor now, they can make sure they are fully prepared to report on all of these measures. If their EHR is 2014 certified, these measures should be available. Practices should also make sure the vendor is prepared for the 2015 Edition Health IT Certification, which will be required in 2018.Another important decision to make between now and the start of MIPS is whether to participate through group reporting or as individuals. If the practice has been participating in PQRS, they may want to report the same way after analyzing how well that approach has worked. Those not participating in PQRS should closely examine the pros and cons of reporting as a group versus individually. Some of this decision making will be driven by the performance of different physicians in the practice. If a physician is an outlier because of a different patient mix or other factors, group performance may be negatively impacted, and reporting individually may be preferred.The MIPS final rule gives practices various options for participation, enabling them to transition into the program at their own pace. However, practices should be careful not to become complacent. While they may not have to participate fully in 2017, it is just a matter of time until they do. Value-based care is not going away, and this new way of reimbursement is only going to become more stringent and complex as time goes on.

Practices should immediately strive to gain an understanding of the various measures in each MIPS component, drilling down into the details. They should also be working closely with their EHR technology vendor to make certain they will be able to sufficiently report on MIPS requirements. If practices look at 2017 as an opportunity to learn and prepare for the future, they will be well on their way to building a strong foundation for value-based care while meeting the many challenges MIPS presents.

Linda Pottinger is director of Payer Initiatives, Innovative Practice Services, at McKesson Specialty Health.