By: Christine KellyEarlier this month, the Center for Medicare and Medicaid Services announced a final ruling that made changes to the 2018 Quality Payment Program. We dig into what has changed, what is the same, and what impacts digital health can have on this value-based initiative.
Preparing for 2018The past few years have brought legislative initiatives and shifts that change the way we think about healthcare delivery. The Center for Medicare and Medicaid Services (CMS) has supported the transition from fee-for-service care to high-value care, and, as a result, organizations have the opportunity to digitally deliver care to supplement traditional face-to-face care delivery. At the beginning of November, CMS released a final rule making changes to the 2018 Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), impacting both the Merit-Based Incentive Program (MIPS) and Alternate Payment Models (APMs). MACRA was originally signed into law in 2015, with final ruling changes in 2016. The first payment adjustments based on performance are slated to go into effect on January 1, 2019. CMS will use 2017 data to determine clinician payment adjustment for 2019. Clinician’s medical groups will fall into one of the two tracks. What is changing?According to Health Affairs, the QPP has wide-ranging effects on Medicare clinician performance measurements. In its second year, the program will continue to apply the current, low standards that physicians and clinicians are required to meet in order to avoid penalties, including limited quality reporting requirements, shortened reporting periods for certain performance categories, and broader exemptions for physicians who treat relatively few Medicare patients. MACRA standards will be much more robust in 2019. As CMS stated, a “second year to ramp-up the program will continue to help build upon the iterative learning and development of year 1 in preparation for a robust program in year 3.” MIPS track: 2018 performance data will be used to impact 2020 incentive payments and penalties. At this point, the MIPS final score will be broken down as follows: 50% quality, 25% adoption of health information technology (HIT), 15% implementation of clinical improvement activities, and 10% will be derived from controlling costs. Additionally, CMS introduced a MIPS “bonus” for clinicians who treat complex Medicare patients, for rural practices, and a virtual group option as a means to inclusive participation.
APM track: providers who participate in Advanced APMs (a subset of APMs that let practices earn more for taking on some risk related to their patients’ outcomes), known as Qualifying Participants (QP), are excluded from MIPS and will receive a 5% bonus payment. The qualifying metrics for the advanced APM track is similar to MIPS, including the reporting periods. CMS has estimated that between 185,000 and 250,000 clinicians will be exempt from MIPS as QPs in 2018.
How are the tracks different?For clinician groups who fall under the MIPS track, Medicare will expand and strengthen clinician pay-for-performance metrics (Meaningful Use, the Value-Based Payment Modifier, and the Physician Quality Reporting System) into a single revenue neutral program. Clinicians and groups will be scored in four performance areas: 1) Quality, 2) Cost, 3) Improvement Activities (IA), and 4) Advancing Care Information (ACI). These physicians will be subject to a range of payment adjustments that will reflect penalties of -4% and bonuses up to 12% starting in 2019. The penalties and bonuses will grow to payment reductions as much as 9% and increases of up to 27% after the first subsequent years of the program. Those qualified for the Advanced APM track will have the ability earn financial rewards, but only the clinician or groups participating in the risk-based payment models will qualify. According to CMS, QPs will be eligible to receive a 5% APM Incentive Payment in 2019, further incentivizing the shift towards risk-based models. Where does digital health come into all of this?Under MACRA, digital health companies have an opportunity to help clinicians and groups meet the new requirements by driving valuable, patient-centered care. MACRA is rewarding clinicians and groups for using information technology and data in this reimbursement approach. A Ram Technologies report discusses how the data collected on patients needs an upgrade as healthcare shifts. EHRs are currently the technology backbone in these clinician groups, but a shift must occur to also accommodate patient questionnaires, activity tracking, other medical devices and demographic data. In general, CMS is easing up on EHR technology requirements for clinicians and groups, but is providing incentives to ramp-up technology efforts. It is in the best interest of clinicians and groups to incorporate digital technologies that engage patients once they leave a facility, enhance care coordination efforts, and improve patient outcomes. Physicians must start thinking about how technology can help them improve the care they provide. Putting patients at the center of care is becoming increasingly important, and there is no better time to make the shift to include digital technologies in practices. Clinicians and groups have 2018 to implement changes and workflows in their practices for further success in MACRA for 2020. Now, more than ever, we must iterate on proving high-value care while improving health outcomes for patients.