The shift to value-base care has fueled discussion among many experts who claim providers do not have enough time or resources to succeed under a pay-for-performance system. A Deloitte 2016 survey found 50 percent of physicians have never heard of CMS' Medicare Access and CHIP Reauthorization Act of 2015, and a Medscape survey found 59 percent of physicians in practices with less than 25 clinicians expect to receive a performance penalty as high as 4 percent under MACRA.
Failure to meet CMS' reporting standards could result in hefty fees for practices, and many providers have called on CMS to delay the shift to pay-for-performance.
"Many organizations' level of knowledge is relatively low regarding MACRA and MIPS [the Merit-based Incentive Payment System], which is a key barrier to performing successfully under the program," says Tom Lee, PhD, founder and CEO of SA Ignite, a company dedicated to helping healthcare organizations succeed under value-based care. "There are numerous discussions and inbound questions around MACRA, and many healthcare executives are quite focused on their financial future."
CMS has heard the healthcare community's concerns and is offering providers flexibility by allowing them to choose from multiple options as to how they can participate in the first year. Providers can choose from four options to participate in MIPS, which, as part of MACRA's Quality Payment Program, is set to begin Jan. 1 for the performance calendar year 2017.
"CMS has had a lot of conversations with provider organizations, advocacy organizations and consultants," Dr. Lee says. "The consensus is that this is a positive move by CMS and they appreciate the guidance they have put forward."
The first option allows providers to submit "some data" for MIPS after Jan. 1, thereby avoiding a negative payment adjustment in 2019. No incentive is earned for this option.
The second option allows providers to participate in the program for part of the calendar year. In the second option, providers can submit performance measure and improvement activity data across all required MIPS performance categories for a reduced number of days while still qualifying for a "small" positive payment adjustment.
Those organizations ready to fully participate can participate in the third option. Under the third option, providers submit data across all MIPS performance categories for the full calendar year and qualify for a "modest" positive payment adjustment.
Finally, the fourth option allows providers to join Advanced Alternative Payment Models in 2017. If providers sufficiently participate in Advanced APMs, they qualify for a 5 percent incentive payment in 2019 and are exempt from MIPS.
Dr. Lee explains providers typically fall into two categories regarding MACRA — incentive-seeking and penalty-avoiding. SA Ignite’s clients primarily consist of incentive-seeking provider organizations who are set to start fully participating on Jan. 1. Incentive-seeking providers will likely choose the third or fourth options, as they are more prepared for the shift.
"Penalty avoiders selecting the first option still must continually improve MIPS performance in 2017 because they don't want to fall too far behind their competitors," he adds. "They could fall off the treadmill really fast if they haven't been improving and then see negative financial consequences in 2018."
To help alleviate the stress providers have meeting MACRA standards, Dr. Lee says one of the most popular comments submitted on the MACRA proposed rule is to reduce the quality data completeness threshold. As MIPS stands, the proposed data completeness thresholds mandates clinicians report at least 90 percent of all patients for each quality measure, which many providers feel is too high a standard.
Although providers may struggle to prepare for MACRA, the program's overall goal is to improve patient care, which is why the legislation was approved by an overwhelming bipartisan majority. Dr. Lee says tying payment to value-based care is overall a "good thing", and providers eagerly await the publication of the MACRA final rule by Nov. 1.
"The recent announcement is a signal that we may not hear from CMS until the final rule comes out," Dr. Lee says. "This is a good time for organizations to evaluate the four MIPS options for next year. Create the decision framework and start planning with the information you have."
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