Value-Based Care in Uncertain Times: Navigating the Quality Payment Program

With the election of Donald Trump and a Republican majority in both houses of Congress, there is no doubt that the Affordable Care Act (ACA) will be drastically altered, if not fully repealed. However, The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), which replaced the Sustainable Growth Rate with a roadmap toward value-based payment, is a separate law that was passed with 92% bi-partisan support in 2015. Within the MACRA legislation, the Quality Payment Program (QPP) is a complicated yet considered step by CMS toward delivery system reform. The QPP updates the Physician Fee Schedule (PFS) and introduces 2 interrelated pathways that determine Medicare Part B adjustments: The Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APM). MIPS introduces an amalgam of quality incentive programs for clinicians or groups under the PFS, and APMs expand risk-based payments for various modalities of clinician groups.

Though there are many unknowns regarding how future administrations may affect policy, there is bipartisan support for lowering costs and increasing quality, and the healthcare industry is firmly on the path to value-based care. In the QPP design, CMS has made it clear that greater participation by eligible clinicians in Advanced APMs is its long-term goal. Here we will discuss recent changes to the MACRA final rule, and present a strategy that identifies existing organizational clinical priorities and strengths building upon the framework of MIPS to ensure future success in Advanced APMs.

MACRA: A Moving Target

Although research conducted in 2016 demonstrated that nearly half of physicians surveyed were not aware of the MACRA legislation, attention has gathered around the launch of the QPP and the approach of the first reporting year in 2017. Those stakeholders who were paying close attention had no shortage of concerns and suggestions, and for its part CMS was listening. Between the proposed rule announcement in April and the final rule release in October, CMS solicited and reviewed thousands of comments from more than 100,000 physicians.

A blog post published by the acting administrator of CMS, Andy Slavitt, titled Pick Your Pace, demonstrated plans for the QPP in 2017. Recognizing the influence of clinician feedback, he outlined the following 4 alternatives:

1. Test the QPP. Submit 1 quality measure from 2017 to avoid negative adjustment.
2. Participate for part of the calendar year. Performance period of 90-days to qualify for a small positive payment adjustment.
3. Participate for the full calendar year. Submit information for the entire year on quality measures, technology, and improvement activities to qualify for a modest positive payment adjustment.
4. Participate in an Advanced APM in 2017. Meet requirements for Medicare payment or patient volume to qualify for a 5% percent incentive payment in 2019.

Other changes introduced in the final rule include the following:

• MIPS eligibility requirements for individuals and groups have been changed to greater than $30,000 annual Part B payments and greater than 100 annual Part B patients.
• The replacement of “all-or-nothing” Meaningful Use requirements with a reduced set of measures in the MIPS Advancing Care Information category.
• The establishment of Medical Home Model standards that promote care coordination within MIPS Improvement Activities.
• The introduction of a Medicare accountable care organization (ACO) Track 1+ with limited downside risk for the 2018 performance year.
• The reduction to 20% percent of minimum Part B patient thresholds for APM participation.
• A financial risk standard intended to encourage movement into Advanced APMs by suspending requirements for marginal risk and minimum loss ratio in 2017.

It is the right course for CMS to minimize the burden of participation and strive for clinician buy-in. However, the reporting flexibility offered during the transition year of 2017 may only provide temporary relief. The net effect of reduced financial penalties in a budget-neutral program will be to lower the overall pool of incentive payments. If clinicians are disincentivized to compete for payments, some groups may choose to neglect transformation efforts while others attain maximum incentives through careful planning. This trajectory will add contrast to a fundamental choice: will an organization choose to chart a course that is incentive-seeking or penalty-avoiding?

MACRA’s long-term objective is higher Advanced APM participation by eligible clinicians. As MIPS adjustment percentages increase over time, the performance gap will widen for MIPS participants, creating preferable conditions for many to seek out the “more than nominal” risk-bearing, yet less volatile, payment terms of Advanced APM participation. Organizations will need a strategy to assess existing clinical priorities and strengths that build upon the MIPS framework in order to position themselves for this benefit structure.

A Practical Approach to MIPS: What Are You Doing Today?

How clinicians fare in the QPP is largely dependent on the quality initiative programs they are engaged in today. Considering that CMS estimates approximately 90% of all clinicians will be participating in MIPS, this should be an organization’s first consideration in developing a value-based management strategy. By concentrating efforts on existing quality incentive program participation, an organization will position itself to make strategic choices about future engagement.

What strategies are currently being used for Meaningful Use and PQRS? The combined performance of Advancing Care Information (MU) and Quality (PQRS) equals 85% of the MIPS Composite Performance Score (CPS) in 2017. The following are some practical benchmarking exercises that all organizations should be applying today:

Quality

• Identify historically high-percentage PQRS measures, and measures that can realize the most gains with marginal improvement. Are there measures more clinically relevant for an individual or a group than those which are currently being submitted to CMS?
• Analyze the relative weight of Part B payments across the organization’s clinicians. A typical group will have a range of revenue that follows an 80/20 curve, or a small percent of high-earners followed by a “long tail.” It is important to prioritize quality improvement activities for top earners as this will have the biggest impact on overall adjustments for the group.
• Does the organization have a track record of administering the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey? MIPS clinicians can receive bonus points for electing CAHPS.

Advancing Care Information (ACI)

• Meaningful Use objectives that comprise the ACI performance score include: Patient-Specific Education (renamed Coordination of Care Through Patient Engagement), Patient Electronic Access, and Health Information Exchange (renamed Patient Care Record Exchange in ACI).
• These will comprise the performance score of the ACI section (90/155 points). It’s important for organizations to ask: How well is the organization performing on these measures in 2016 Meaningful Use? What gaps must be addressed in clinical workflows and information technology infrastructure?

Improvement Activities

• Clinical Practice Improvement Activities is a new category, and closely aligned with elements of the Patient Centered Medical Home (PCMH). Currently-certified PCMH entities will receive full credit for this element. CMS has provided a list of 93 available Improvement Activities on the QPP website.

Cost

• Value-based metrics will be added to CPS calculations in 2018. Has the organization’s Quality and Resource Use Report been reviewed to determine cost and quality scores against the national benchmarks?

Ramping Up to Advanced APMs

MIPS engagement will be used as a baseline for future APM activity, but is the organization ready to assume financial risk? Are policies, processes, and analytics in place to measure if actual costs will exceed projected expenditures? These are critical questions that must be answered to determine whether the transition to Advanced APMs can happen.

After developing a MIPS-based strategy in 2016-2017, an organization can make better-informed decisions on if and how to participate as an APM or Advanced APM entity. Intermediary models such as Track 1 MSSP ACO or CPC+ may provide a means for many to test the waters of performance-based payment arrangements. Using experience in these and other programs, strategies can be aligned with inherent strengths based on historical performance in clinical quality measurement and utilization.

For example, a MIPS organization can transition to a MIPS APM by participating in an MSSP Track 1 ACO in 2018. By comparing quality measures that crosswalk between those available via Direct CEHRT reporting and GRPO Web Interface, a focus on quality improvement can begin now with this future objective in sight. Likewise, improving efforts to close the referral loop by electronically sending and receiving patient records will guarantee higher performance within the ACO or medical home by way of improved care coordination.

Additionally, public reporting of quality ratings on CMS’s Physician Compare website will be a factor in how practices compete in the marketplace, and non-participation will delay any favorable reviews. Before dismissing the accuracy or contextual validity of these reviews, organizations would be well-advised to consider the potential future uses. The consumer-generated ratings that CMS makes available on the Physician Compare website will be the same dataset that innovative tech start-ups will have available to them. Consumers shopping for healthcare providers may not be going straight to the Physician Compare website for reviews, but they may be using an app that does.

Learning by Doing

CMS doesn’t expect organizations to make the leap to Advanced APMs overnight. The QPP is designed to reward increased measurement, improvement, and risk assumption over time. Take a learning-based approach and begin planning a transformation from existing quality initiative efforts now. Leverage the analytics and workflow redesign capacity of the electronic health record to develop a clinically appropriate and cost-saving strategy to value-based care. Lastly, take a cue from CMS and solicit input from customers, in this case patients and caregivers.

Healthcare Reform Under a New Administration

What remains to be seen is how the mechanisms for controlling spending will change—will Congress continue with downside risk models (eg, MSSP ACOs) or focus its reform efforts on reimbursement cuts? Since there is little evidence to show that they have reduced costs for CMS, the future of ACOs may be in doubt if a full repeal or thorough dismantling of the ACA is achieved. Emphasis may instead be placed on bundled payments for episodes of care.

An important entity common to the ACA and MACRA is The Center for Medicare & Medicaid Innovation (CMMI). The CMMI is authorized by the ACA to test and scale new models in fee-for-service Medicare, including the Advanced APMs designated in MACRA. With a remaining budget of $3 billion through 2019, CMMI programs are not subject to congressional approval. There is uncertainty about whether Congress will choose to assume greater authority over these pilot payment reform programs or act to eliminate the CMMI along with the ACA. Early indicators of the HHS transition team appointees suggest that fundamental elements of market competition, data transparency, and patient access will remain central to any future legislation.