a guide to 2019 macra, qpp, and mips...a guide to 2019 macra, qpp, and mips introduction there are a...

Learn more about Henry Schein’s solutions provider by calling your local representative or visiting HenryScheinSolutionsHub.com.

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A Guide to 2019 MACRA, QPP, and MIPS

INTRODUCTIONThere are a lot of acronyms in healthcare, and each of them seems to carry a lot of rules and regulations to keep straight as well. When those acronyms are tied to regulatory programs that affect a provider’s payments, they become even more important to know. MACRA, QPP, and MIPS are just a few of those acronyms that can have a financial impact on your practice. We here at MicroMD thought it would be a good idea to make sure you’re familiar with each of these programs. In this eBook we’ll look at MACRA, QPP, and MIPS, first examining what brought about the start of these programs before taking a closer look at what each of these programs actually is. From there we’ll look at why these programs were necessary for both patients and providers. Then we’ll look at some of the challenges with these programs and how the programs have changed over the past three years, including how those changes have both benefitted and challenged providers. We’ll finish up by looking at the hopes for the future of these programs and how technology plays a role. Let’s get started.

Discover. Connect. Transform.Learn more about Henry Schein’s solutions provider by calling your local representative or visiting HenryScheinSolutionsHub.com.


What led to MACRA: A Brief HistoryPrior to MACRA, physicians were paid for Medicare services according to the Sustainable Growth Rate (SGR) formula. This system was designed to make sure that Medicare expenditures wouldn’t radically exceed the United States’ Gross Domestic Product (GDP). Under the regulations of the SGR, payments under the Medicare Physician Fee Schedule (MPFS) would be cut if Medicare spending was outpacing the GDP. However, if the reverse were true, providers would receive a greater reimbursement. The issue with the SGR, though, is that it provided no way to adjust payments based on the value of care provided to patients. This meant that providers who were performing poorly saw no risk and those providing a higher quality of care saw no reward, as all providers were lumped together and paid the same. This added up to a deeply flawed system. Congress wanted to find a way to repeal the SGR and propel physicians into a value-based pay system away from the traditional fee-for-service system that had been in place for years. This was important to not only eliminating the flawed SGR but also improving patient health outcomes and lowering healthcare costs overall.

What is MACRA?The Medicare Access & CHIP Reauthorization Act (MACRA) was signed into law on April 16, 2015 as part of a bipartisan effort to repeal the Sustainable Growth Rate (SGR) formula. Basically, MACRA autho-rized the Department of Health and Human Services to implement value-based incentives with the goal of improving the access to care received by Medicare and CHIP patients. The goal was that physicians who provide a higher quality of care would earn higher reimbursement under the MACRA framework, which includes the Quality Payment Program, featuring two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs).

What is QPP?The Quality Payment Program (QPP) is the payment program that providers participate in under MACRA. The goal of QPP is twofold: to create a more realistic plan for payments as Medicare moves forward and to accelerate the transition from fee-for-service to the value-based model, with the intention of helping providers to focus more on quality of care. Under the Quality Payment Program, eligible clinicians (ECs) must participate in either the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (Advanced APMs). By participating, they will receive either a positive, negative, or neutral adjustment to their Medicare payments in subsequent years, depending on their performance in the program.

In addition to the goal of improving Medicare by helping pro-viders to concentrate more on quality of care, the QPP pres-ents other benefits as well, including reducing the burden that providers were feeling from regulatory programs carried and making it easier to maintain independent practices. These benefits come into play as the QPP replaces the for-mer regulatory programs such as Meaningful Use, the Physi-cian Quality Reporting System (PQRS), and other value-based programs and eliminates the challenges they presented.

In general, providers who bill Medicare Part B are likely to need to participate in the Quality Payment Program, but each track has its own individual requirements for eligibility. In the first two performance years of 2017 and 2018, five types of clinicians were eligible to participate in QPP through the MIPS track: • physicians • nurse practitioners • physician assistants • certified registered nurse anesthetists • clinical nurse specialists

Beginning with the 2019 payment year, CMS added the following additional eligible clinicians to the pack: • physical therapists • occupational therapists • clinical psychologists • qualified speech-language pathologists • qualified audiologists • registered dietitians or nutrition professionalsFor those providers participating in QPP through the Advanced APM track, there are additional provider types that are eligible, including clinical social workers and certified nurse-midwives.

What is MIPS?The Merit-based Incentive Payment System (MIPS) is the component of QPP that most closely resembles the former regulatory programs issued by CMS including the EHR Incentive Programs, Physician Quality Reporting System (PQRS), and Value Modifier Program. MIPS is comprised of four performance categories that are used to determine a provider’s score and payment adjustment. Currently, those four categories are Cost, Quality, Promoting Inter-operability, and Improvement Activities. Depending on the provider’s performance in each of those categories and their overall score, a provider is awarded either a positive, negative, or neutral payment adjustment for a future payment year. This performance is determined based on practice specific data collected from the provider and how that data stacks up against previously set performance benchmarks.

Providers who follow the MIPS track largely follow a fee-for-service structure, however CMS adjusts the provider’s pay based on their score so that a value-based component is in play. It’s important to remember that there’s a two year lag between the performance year and its corresponding payment year. For example, a provider’s performance in 2019 will affect their pay in the year 2021. Also, this payment adjustment applies only to Medicare Part B covered services.

Why were these regulatory programs necessary for patients?The traditional fee-for-service model paid all providers equally based on the services they provided with no connection whatsoever to patient outcomes. Obviously, the goal of medicine is to provide positive outcomes, so it seems only fitting that providers would be paid according to the quality of care provided rather than the number of services they performed. For this reason, MACRA was necessary to move to a value-based system.

Value-based healthcare is a delivery model that pays providers based on the outcomes of their patients. Providers see financial rewards for things such as helping patients improve their overall health and reducing the incidents and effects of chronic diseases. The “value” part of value-based healthcare is determined by comparing the health outcomes against the cost of achieving those outcomes. This type of system is important for patients as it allows them to achieve better health while spending less money. While managing a chronic condition can be financially overwhelming, a value-based care system seeks to help patients recover from illness more quickly and, ideally, avoid chronic illnesses to begin with. This leads to less office visits, procedures, and tests and less money spent on medication. MACRA provides an efficient path to achieve these important patient goals.

Why were these regulatory programs necessary for providers?Change is always challenging, particularly when it involves moving from a familiar system to something that seems risky. For providers, working under a fee-for-service system meant that they knew what to expect with regard to reimbursement. A certain service carried a certain fee. There was no risk, no guess work. Value-based healthcare, while absolutely better for patients’ health outcomes, comes with a sense of risk for providers. For this reason, MACRA, QPP, and MIPS were necessary to provide incentive for clinicians to transition to a value-based system. This gives providers the necessary push to adjust their care model while helping them understand how to progress into this new era of healthcare.

Additionally, these programs help providers achieve greater patient satisfaction, something important in today’s consumer driven health landscape. It’s arguable that providers may need to spend additional time on services that are prevention-based, but in exchange they’ll spend less time managing chronic illnesses because their patients will be healthier. When the focus is on providing value instead of performing volume, patient engagement increases. Finally, because these programs feature a clear system for how these payment adjustments are determined and clear standards that must be reached, much of the risk typically perceived with value-based systems is taken out of the equation.



What challenges have been experienced?While there are challenges faced by all providers participating in the Quality Payment Program to some degree, the biggest challenges are faced by small and rural practices, as is typically the case with these type of practices and regulatory programs. The good news is that these practices are likely to perform better in QPP and its tracks than they did in any of the former regulatory programs such as Meaningful Use and PQRS. It is still expected, though, that they will be outperformed by larger practices and practices in more populous areas.

It’s estimated by CMS that between 80% and 90% of small practices that are eligible for MIPS will receive a positive or neutral payment adjustment. This is pretty good, but even so stakeholders have identified a number of challenges that can affect providers as they participate in the MIPS program: • Unsatisfactory EHR support and updates, in addition to poor technological functionality • The inability to be able to hire enough staff to meet the time needs for program reporting due to financial limitations • Difficulty staying up to date on changes to the requirements of the program and thus staying in compliance • Lack of control on the part of the provider for metrics that deal with issues such as patient behavior • The high cost of investing in appropriate technology • The feeling among providers that some measures in the program don’t necessarily align well with patient care

In relation to these challenges, stakeholders made a number of suggestions to CMS that they felt would help providers with the program, particularly those providers working in small or rural practices. Some of those suggestions included that CMS be sure to provide timely updates about the program requirements, that increased standardization and functionality of EHRs be pursued, and that more personalized assistance be made available for practices, especially those that are small or rural.

In addition to these concerns, CMS also received additional feedback regarding these programs. First, some stakeholders were upset with the relative lack of incentive when comparing the MIPS track to the Advanced APM track. Providers taking part in the APM track receive financial incentives for participating in that track each year between 2019 and 2024, while those participating in MIPS see no such incentives and also face the reality that their reimbursement will be lower overall than those providers participating in APMs beginning in 2025. Next, there’s the lack of alignment among payers. MIPS is a Medicare only program. Providers see different pay models from Medicaid and all private payers. This leads to an increased burden on providers as they work to improve performance as there’s a great deal of differing information to keep straight on getting paid. Finally, a number of stakeholders expressed concern that there aren’t enough measures in place to encourage patient engagement. Patient engagement is vital when dealing with chronic illnesses as it’s up to patients to ensure they’re taking the correct medications at the correct time, getting to their appointments as they should, and living as healthy a lifestyle as possible. For this reason, more measures that deal specifically with patient engagement would do a great deal to serve the goal of improved patient outcomes.

What major changes have taken place over the last three years of the program?

Most of the major changes in the MIPS program have taken place beginning with the 2019 performance year. Among those changes, one of the biggest was the addition of more eligible clinicians, including physical therapists, occupational therapists, qualified speech-language pathologists, qualified audiologists, clinical psychologists, and registered dietitians or nutrition professionals. Another major change in 2019 was the transformation of the former Advancing Care Information category into Promoting Interoperability. With this change came the requirement for 2015 Edition CEHRT to be used when participating in MIPS. Finally, and also in 2019, an additional criteria was added to the low-volume threshold, allowing clinicians who provided a total of 200 or fewer covered professional services under the Physician Fee Schedule (PFS) to be exempt from the MIPS program. Along with this change to the low-volume threshold came the change that providers who exceed at least one, but not all, of the criteria for the low-volume threshold can elect to participate in the MIPS program, even though it isn’t mandated for them to do so.

These changes have provided a number of benefits for clinicians. The addition of more ECs to the pool not only creates a greater amount of data to help improve healthcare overall, but also allows more providers the opportunity to get a piece of the pie when it comes to positive payment adjustments. The change to increase interoperability is working toward the more connected healthcare landscape that has been sought for years, one that will allow for easier collaboration between providers on a given patient’s care team. Finally, the changes to the low-volume threshold provide both an out for providers who don’t perform many covered services and would have difficulty finding success in MIPS, while also giving clinicians the benefit of choice with the o pportunity to opt-in if so desired.

Of course there is also the other side of the coin where these changes add challenges for providers. One challenge comes to the new ECs for the year 2019. While the original clinician types that were eligible from the beginning had the benefit of a transition year in 2017, these new clinicians have no such adjustment period and jump in when success is necessary to avoid negative payment adjustments. It’s also possible that the transition to requiring 2015 Edition CEHRT is proving to be a challenge for many providers, namely those whose software vendors have not yet achieved that level of certification as they have to work with the vendor to learn if and when that certification will be in place or they are forced to scramble to choose and invest in a new vendor.

What are the hopes for the future of this program?The biggest hope of this program moving forward is to reach widespread interoperability throughout the country. The ability for a patient’s full care team to collaborate freely is of the utmost importance in improving patient outcomes, however this can be difficult when each provider is using a different EHR system and none of those systems communicate well with one another. This is why the regulations put in place by MACRA, QPP, and MIPS were designed to allow for widespread interoperability as well as the benefits that such connectivity will produce. Benefits from widespread interoperability include reduced errors and improved efficiency, more accurate reporting of trends and data, access to more complete patient records, and improved patient safety. Each of these benefits increases patient safety and improves health outcomes, the overarching hope for this program. Essentially, MACRA, QPP, and MIPS are relatively young programs and as their scale and scope expand over the next several years, the hope is that providers will carry a greater portion of the financial risk associated with caring for patients and a larger emphasis will be placed on the performance of providers when considering how they should be paid.

How does technology play into this?Technology is an incredibly important piece of MACRA, QPP, and especially MIPS, particularly when we’re talking about the importance of 2015 Edition CEHRT. EHR technology is central to the Quality Payment Program, as many of the metrics in the program are measured with the data collected within an EHR. Additionally, with the new requirement under the Promoting Interoperability category of MIPS to utilize 2015 Edition CEHRT, without the appropriate healthcare technology it’s nearly impossible to see success under these new regulations.

To this end, practices must ensure that if they are not already using up to date, robust healthcare technology that they are making plans to remedy that. Whether discussing with their current software vendor when the appropriate updates will take place or planning to invest in and implement a new system, there’s really no time to waste as the importance of up to date technology will only expand in the years to come.

ABOUT HENRY SCHEIN MICROMDHenry Schein MicroMD, a subsidiary of Henry Schein, Inc., provides simple yet powerful EMR and Practice Management solutions that facilitate the delivery of superior patient care, automate incentive and quality reporting activities, and streamline operations for today’s busy providers. Full-featured, time-tested, and budget-friendly, MicroMD EMR is 2015 Edition CEHRT certified software that helps small practices, large medical groups, community health centers, and billing services accelerate progress toward a paperless environment and health information exchange with minimal disruption and stress. Learn more at www.micromd.com.



CONCLUSIONIt’s easy to want to tune out whenever an acronym is mentioned as there are just so many in healthcare today. But when MACRA, QPP, or MIPS are being discussed, it would be wise to listen and take note. The Medicare Access & CHIP Reauthorization Act, passed in 2015, is revolutionizing the way providers are paid for their Medicare services. Quickly passing are the days of fee-for-service payments. Patient outcomes are a top priority to government officials, and as such value-based payments are taking hold and this trend is only likely to continue to grow. Changing the method of payment for providers isn’t all MACRA achieved, though; prior to MACRA, providers could be saddled with multiple regulatory programs to participate in. MACRA eliminated the burden of multiple programs and brought all of the goals of those programs together in the Quality Payment Program, working to make this program simple as well as assisting practices that typically struggle with regulatory programs, namely small and rural practices, as much as possible.

Perhaps one of the most important things to note, as it’s foundational to success in the Quality Payment Program, is the importance of having up to date technology in your practice. Beginning with the performance year of 2019, it’s all but impossible to see success, and thus a positive or neutral payment adjustment, without the use of a 2015 Edition CEHRT. Don’t put in all that hard work meeting metrics only to be taken out by subpar technology. If you’re using a system that isn’t 2015 Edition certified, it’s time to change that. Henry Schein MicroMD EHR is 2015 Edition certified, robust enough to meet all of your needs, and flexible enough to do it your way. Ready to learn more? Visit micromd.com or call 1-800-624-8832 to get started.

a guide to 2019 macra, qpp, and mips...a guide to 2019 macra, qpp, and mips introduction there are a...

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