Alongside the shift to value-based care, the method for provider reimbursement is being revamped with an effort to consolidate several quality programs into one, leaving us with an “acronym soup” that can be mind-boggling. In October 2016, the Centers for Medicare & Medicaid (CMS) published the final Quality Payment Program (QPP) as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which replaces the Medicare sustainable growth rate (SGR) formula and changes the way providers are reimbursed. This was the first year of performance tracking, and data submitted will be used to determine 2019 payment adjustments. The QPP is a value-based reimbursement system that has two options:
- Merit-based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models (Advanced APMs)
For more information, visit: www.qpp.cms.gov/.
Providers can select which path they want to take in the QPP based on their practice size, specialty, location, or patient population, and their level of participation in value-based models. The majority of providers will fall under MIPS. As of 2017, providers who bill more than $30,000 a year to Medicare or treat a minimum of 100 Medicare patients are subject to MIPS payment guidelines. MIPS participants will be compared with other providers and benchmarking standards. Initially, there is a phase-in for the categories of costs and resources; however, once MIPS is in full swing, providers will be evaluated on four categories:
1) Quality—replaces Physician Quality Reporting System (PQRS)
2) Cost—replaces Value Modifier (VM) Program
3) Advancing Care Information (ACI)—replaces EHR Incentive Program/Meaningful Use (MU)
4) Improvement Activities—new category
In 2019, physicians will receive a score that will result in a potential adjustment (up or down) to Medicare Part B reimbursements. Those above the threshold will see a 4% increase; those below will receive a negative payment adjustment. MIPS offers a “Pick Your Pace” transition in regards to reporting criteria for 2017; however, not reporting will result in penalties. Physician scores will be available to the public on the Physician Compare website: www.medicare.gov/physiciancompare/.
Different from Stage 3 of MU, MIPS requires reporting on five measures related to interoperability. Medicare payment adjustments for providers range from +/-4% starting in 2019, to +/-9% in 2022, going forward.
Advanced APMs will offer greater possible rewards for taking on greater risks. Organizations that participate through an Advanced APM can earn a 5% incentive bonus on Part B reimbursements and are exempt from MIPS. Eligible Advanced APMs involve downside risk, quality measurements, and health information technology (HIT) requirements. They are meant for providers who are participating in specific value-based care models.
Eligible Advanced APMs for 2017:
- Comprehensive ESRD Care Model
- Comprehensive Primary Care Plus Model
- Medicare Shared Savings Program Tracks 2 and 3
- Next Generation ACO Model
- Oncology Care Model
To be eligible, providers must receive 25% of their Medicare-covered services through Advanced APMs or see 20% of their Medicare patients through an Advanced APM in 2017. MACRA’s QPP intends to incentivize interoperability and reduce the administrative burden on physicians so they can focus on care improvement and the adoption of value-based care.
MIPS & MU
MIPS changes the name Meaningful Use to Advancing Care Information (ACI), and it focuses on grading providers on using HIT (such as an EHR) to improve care, rather than awarding simply for the implementation of HIT. MACRA/MIPS does not apply to hospital MU programs. The 25% attributed to the ACI category is based on MU Modified Stage 2 measures (for 2014 Edition CEHRT) and MU Stage 3 measures (for 2015 Edition CEHRT).
ONC 2015 Edition Certification
In 2017, providers may use software certified to the 2014 edition, the 2015 edition, or a combination of both. MIPS-eligible providers can report ACI objectives using software certified for the 2015 edition or a combination of the 2014 and 2015 editions. As an alternative, MIPS-eligible providers can report the 2017 ACI transition objectives using software certified for the 2015 edition, the 2014 edition, or a combination of the 2014 and 2015 editions.
For the 2018 performance period, MIPS-eligible providers must be utilizing software certified to standards specified in the ONC 2015 edition. For more information, visit www.healthit.gov/policy-researchers-implementers/2015-edition-final-rule. As part of CMS’s 2018 inpatient prospective payment system (IPPS), hospitals that are still subject to the EHR Incentive Program, can continue to meet Modified Stage 2 measures for MU, and the requirement to move to Stage 3 has been pushed to 2019. This means hospitals can use the 2014 edition, the 2015 edition, or a combination for another year.
Of note, Orchard Software is in the process of certifying Orchard® Harvest™ LIS v10 and v11 to the 2015 edition and expects to be certified well in advance of the 2018 requirement.
How the Lab & its LIS Support MACRA
Laboratories that maximize the use of their LIS to become as efficient as possible with rapid turnaround times can influence provider quality scores. In addition, LIS data can be used to identify patients who would benefit from preventive care as part of a population health management initiative. LIS data can also be used to track proper test utilization. For more information about how labs play into the new physician reimbursement model, please read the April 2017 MLO article: Medicare’s new Quality Payment Program.
Orchard is committed to keeping you informed and being a trusted resource that you can turn to for industry-related education. As always, we welcome your feedback. Follow us on Twitter at @orchardsoftware, and feel free to respond to this post by emailing us at news@orchardsoft.
Kim Futrell, BS, MT(ASCP)
Products Marketing Manager
Orchard Software Corporation