Payment & CMS Policy

 

SIX BEST PRACTICES TO PREPARE FOR THE MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) in 2017

As the first quarter of 2017 comes to a close, it is a good time to review your work flow, register with a MIPS registry, select your quality measures for 2017, consider investing in a population health solution, and consider hiring a Care Coordinator. Review the short article on these 6 steps and how they can help fine tune your practice, and even have a positive impact on your bottom line.

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MIPS REQUIRED ELEMENT FOR 2017: SECURITY RISK ANALYSIS 

Advancing Care Information, ACI, is a set of requirements dealing with the use of your EMR. ACI is worth 25% of your total Payment Score which then determines your penalty of incentive payment for Medicare Part B patients. There is a “Base Score” which is worth half of this category. The first requirement is a “Security Risk Analysis.” While there are companies which can provide this, you can complete this yourself at no cost using tools on the CMS website. There are 156 questions to answer, and depending on your answer(s), the program will tell you if you have a potential risk. This covers not just your EMR, but other devices in your office which store HIPPA information. The tools can be downloaded free from the CMS website in various formats which can help you complete the assessment. If you have identified a risk, consultation with an your EMR or IT provider may be required to correct it.

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TEN STEPS TO COMPLETING CMS PAYMENT REQUIREMENTS FOR 2016

What you need to know and need do to complete your CMS requirements for 2016. In plain and simple language, with just the required links and documents, you can avoid non-reporting penalties, complete Meaningful Use requirements, and understand Resource Use. Combined, these are the 3 areas that CMS uses to calculate your Value-Based Payment Modifier.

It is not too late to complete these 10 steps by the end of 2016. (If you have fewer than 100 Medicare Part B patients, or less than $30,000.00 in Medicare Part B revenues, you are exempt these CMS reporting requirements. Medicare Advantage patients do not count towards these thresholds.)

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UNDERSTANDING MACRA - THE NEW MERIT BASED PAYMENT SYSTEM
Presented by: Carol L. Henwood, DO, FACOFP dist. and Bruce R. Williams, DO, FACOFP 

Understand the new CMS changes affecting physician payment starting January 1, 2017. Identify which path your practice will follow, Merit-Based Incentive Payment or Advanced Payment Models, and the requirements for each. For 2017, there will be new requirements to be met by every physician. Quality will be more heavily weighted, Meaningful Use will change to Advancing Care Information, Resource use will be calculated via claims data, and Clinical Practice Improvement Activities is a new category for 2017.

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PAYMENT MODIFIER REPORTS FOR 2016 - 2017

The Annual Quality and Resource Use (QRUR) reports from CMS are available now. This report contains your Value Modifier which will impact your Medicare Part B payments starting in 2017. If you did not report through PQRS, you will receive the maximum penalty. To view your report you need to set up an Enterprise Portal account.

View a sample of QRUR report >>



PAYMENT MODEL TOOL KIT
Understand How MACRA, MIPS and APM will impact your payment now and in the future. Two new educational resources by Dr. Zimmerman and Dr. Williams will help you understand the different practice models and how each impacts your revenues. Penalties and Incentives will apply and will increase in 2017-2020. Important practice decisions need to be made now to survive and thrive in this changing environment.  

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MERIT-BASED INCENTIVE PAYMENT: FOUR PILLARS OF PAYMENT

As we continue to discuss the coming changes in payment for Medicare patients in 2017 and beyond, there are four specific practice areas which, when combined, will determine your Payment Modifier for all Medicare Part B patients. While each one is unique, they fit together much like a “report card.” Each counts for a certain percentage of your “GPA”. For, 2017, the largest portion of your payment will be determined by “Quality” – the aspects of quality which include: quality measure selection, quality tracking, quality improvement, and quality reporting. You want your quality trends to go up from the start of the year to the end. By choosing from a list of CMS quality measures at the start of the year, and monitoring patients with Quality Markers 7.0 you can best assure yourself of meeting, or exceeding, CMS quality benchmarks. In doing so, you will be rewarded by CMS with payment incentives on each Medicare Part B patient you see. If you do not report, you will receive the maximum payment penalty, or – 4% in 2017.  Learn about the other 3 categories which will affect your Medicare payment modifier. This is not a recorded program, but an excellent readable resource which describes the payment landscape for 2017 and beyond.

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COMPREHENSIVE PRIMARY CARE PLUS (CPC +)
PROS & CONS

There has been much discussion about CPC+. Most of the information shared has made CPC+ seem like it would save Family Medicine from the extensive workload coming in 2017:  1) Quality Reporting 2) Advancing Care Information (MU) 3) Resource Use 4) Clinical Practice Improvement Activities (CPIA). If you are considering registration in CPC+, which end Sept. 15, 2016, please review this 45 minute recorded presentation. You need to know the pros and cons of any payment model you consider.

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EMR IS STILL A KEY REQUIREMENT TO MAXIMIZE PAYMENT
In order to comply with the coming CMS requirements, you will need an Electronic Medical Record (EMR) system. Having an EMR will earn you credit for 3 out of 4 of the CMS categories for payment: 1) Advancing Care Information (previously Meaningful Use); part of the 2) Clinical Practice Improvement Activities; and would be needed for 3) Quality Reporting. 

CMS has just launched a new resource called the Health IT Playbook. It contains significant information on all aspects of obtaining an EMR which is right for your practice. It also has an overview of the CMS quality and payment requirements which comprise the Merit-Based Incentive Payment Program in 2017 (about 80% of practices in the US).



 ACOFP COMMENTS ON MACRA PAYMENT RULE BY CMS – JUNE 27, 2016
The ACOFP sent a comment letter to CMS to share members’ views on payment model changes for January 1, 2017. Many of the requirements for 2017 and beyond require practice level changes to be. This poses special concerns for solo and small group practices. The Rule was very vague on what was required to be an “Advanced Alternative Payment Model” (Advanced APM). Patient Centered Medical Home would continue to qualify. 

Most physicians would, by default, fall under the Merit-Based Incentive Payment System (MIPS) where penalties and incentives are imposed on a sliding scale basis. There is clearly more financial risk for those in the MIPS model. Small and solo practices would need to make monetary investments to become a Medical Home or other Advanced Alternative Payment Model. Regardless of the model, Quality Reporting will be 50% of what physicians will be measured on for their payment modifier in 2017.

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PROCESSING QUALITY MEASURES COSTS $40K PER PHYSICIAN PER YEAR
A survey from Health Affairs of physician practices showed that physicians and staff average 15.1 hours per week conducting quality reporting. This is an annual average of 785.2 hours, or $40,000 per year per doctor. Primary Care physicians spent more time than orthopedic surgeons on quality reporting, which translated into more dollars.   

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MAKING SENSE OF MEDICARE PAYMENT REFORM

The Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA) has left physicians a choice of two value-based payment models. By January 2019, all physicians will need to be in an Alternative Payment Model (APM), like PCMH or ACO or fall into the Merit-Based Incentive Program (MIPS). This is a clear and concise article, which will clarify the CMS acronyms and evaluate the pros and the cons of APMs versus MIPS. New higher negative adjustment rates are discussed. 

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CMS FACT SHEET – VALUE-BASED PAYMENT FOR 2016

As we continue the transition from Fee for Service (FFS) to Value-Based payment, the focus shifts from volume based incentives to quality and cost of care with an eye towards reducing resource utilization. 

Starting January 2016, the Value Modifier will affect practices with 10 or more physicians. In 2017 it will apply to practices with two or more physicians. The Value Modifier takes into account the cost of care and the relative risk of treating specific patient populations.  Practices with higher-risk, sicker patients will be given an adjustment to take into account the additional resources needed. Practices that have a low-risk population (younger, less chronic and comorbid conditions) should require fewer resources. These considerations will determine either upward, downward, or neutral payment incentives based on cost of care for the year.  
For more information see the CMS Fact Sheet.



A CALL TO ACTION TO ADDRESS TRUE PATIENT NEEDS
Dr. Robert Pearl, the Permanente Group’s Executive Director and CEO, shares the four attributes top healthcare programs in the U.S. have in common.

View lecture (7 minutes)



ESTIMATING POTENTIAL PRACTICE REVENUE FROM NEWER MEDICARE CODES
Physicians can improve revenue through appropriate use of codes for Initial Patient Physical Exam, Annual Wellness Visit, Chronic Care Management, and Transitional Care Management.

The amounts of the codes are toward the end of the article. Midway through the article, there is a link to a very useful excel spreadsheet, which can be used for recording and managing the codes. You can also estimate the revenue from these codes for your practice based on geography and other factors. (For the excel link, look just below the sample chart, or again at the end of the article).

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HUMANA SHOWS COST-SAVINGS WITH MEDICARE ADVANTAGE & OTHER VALUE-BASED SAVINGS MODELS
Medicare Advantage is a plan which is administered by private insurance companies. It is also referred to as “Medicare Part C”. When a patient signs up for Medicare Advantage, the insurance company takes their Medicare benefits and allocates them to cover more services (dental, vision, medications). The goal is to provide better Primary Care and preventative care to reduce overall medical costs. This includes reduction of ED and hospital visits, reduction of infections, etc. so that there is a net savings. This is the Humana experience in a recent study.



NATIONAL HEALTH SPENDING IN 2014: FASTER GROWTH DRIVEN BY COVERAGE EXPANSION AND PRESCRIPTION DRUG SPENDING
US health spending grew 5.3 percent in 2014 to $3 trillion. In the last 5 years growth averaged around 3.7 percent per year. The increase was largely due to strong increases in the number of individuals covered by insurance under the Affordable Care Act (ACA). This, coupled with the increase in specialty drug costs, were cited. 

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IN THE NEWS


Family Medicine to Have More Support for Identifying & Treating Mental Health

Mental disorders top the list of the most costly conditions in the U.S., accounting for $201 billion in healthcare spending in 2013, far more than was spent on heart disease or cancer, according to federal data. An estimated 8.1 million adults have schizophrenia or bipolar disorder, and 3.9 million go untreated in any given year, according to data from the National Institute for Mental Health.

The Helping Families in Mental Health Crisis Act 2016  steps-up the requirement for insurers to cover mental healthcare on the same level as physical health. Additional support for screenings, programs to provide early intervention for children, and initiatives to prevent suicide are included in the Act.



Great News for Primary Care

Some encouraging news for Primary Care – Many hospital systems across the country are opening various types of clinics to provide greater patient access and value to patients. Strength in numbers, law of supply and demand, all come to mind. CMS is looking at models which bring more revenue to Primary Care. It is great to be part of an organization where there is such a bright future for Family Medicine – ACOFP! 



Competition for Family Physicians Pushes Salaries Higher

Demand for Family Medicine and Rural Health Care Providers have pushed salaries higher for these specialties, and several others says Modern Healthcare Physician Compensation Survey, July 18, 2016. Family Physicians saw a 7.1% pay increase from 2014-2015. Physician recruiting firms reported that Primary Care/Family Medicine ranked 3rd as specialty most in demand from employers. This all good news for ACOFP members!
(Conn, J. “Competition for New Docs Pushing Pay Higher.” Modern Health Care. July 18, 2016. Pg. 12-18.)