MACRA Under the Hood, Part II

How does the math work for emergency physicians in CMS’s new MIPS program?

Last month we introduced you to the Medicare Access and CHIP Reauthorization Act (MACRA), likely the biggest change to physician payment in the United States since the creation of Medicare in 1965. In addition to replacing the Sustainable Growth Rate (SGR), which was the subject of endless annual lobbying efforts, MACRA also creates two new pathways for physician payment: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs). You and your group will have to soon decide whether and how to participate in the new payment programs. Unlike the previous voluntary Physician Quality Reporting System (PQRS) program that you likely peripherally heard of or participated in—this time participation is mandatory and the stakes are high with an up to 18% swing in Medicare payments at risk by 2022.

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First off—who’s in?
While several exemptions from the new MIPS payment program exist—it is very unlikely that any emergency physician or emergency clinician group will meet any criteria for exclusion. All clinicians in their first year of participation in the traditional Medicare Part B program are exempt, but they all are required to participate the following year. Therefore, waiting will only likely leave you behind. Also, any clinician that bills Medicare Part B less than $10,000 and cares for fewer than 100 traditional Medicare patients per year is exempt. Given CDC statistics showing that over 20% of all ED visits are by traditional Medicare beneficiaries, it seems highly unlikely than all but a few emergency physicians who work limited shifts in select geographies will be exempt. So while CMS estimates that 225,615 clinicians will use this exemption next year, unless you plan on working in or staffing an ED that doesn’t have rising visits by older adults (let us know if you find this unicorn), you will have to change your practice to participate in Medicare.  Lastly, clinicians participating in an AAPM will be exempt from MIPS bonuses and penalties, but without a shovel-ready AAPM that specifically includes emergency care, this is a future option for most.

MIPS Math
The MIPS program replaces several previous CMS programs including the PQRS program, which is well known to most emergency physicians, and the Meaningful Use and Value Modifier programs.  Forget the past though—how will the math work in the future?

Every year each emergency physician, or likely emergency clinician group, will receive a Composite Performance Score (CPS) that is a weighted score across 4 categories:

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• Quality (50% of CPS in 2019)
• Advancing Care Information (25%)
• Clinical Practice Improvement Activities (15%)
• Cost and Resource Use (10%)

Each year the relative proportion of each category will change as will the regulations defining what counts for “Points” within each category. Each category has a different number of points available, and given the program is budget neutral, point allocations are likely to follow a symmetric distribution with equal numbers of winners and losers.  For now, here’s what we know about maximizing your CPS for each category:

Quality (maximum 80-90 points):
There are a lot of changes going on in quality measurement. CMS is moving to transition physicians away from traditional “claims based measures,” where a billing company would manually review each chart and add a quality code to each claim submitted to Medicare, to electronic clinical quality measures in which richer clinical data already structured within the electronic health record (EHR) can be used to measure and report performance with lower burden and more accuracy. With this move, there are fewer measures specific to emergency care available for clinicians to report. As such, most emergency physicians and groups, like other specialties will turn to CMS-approved qualified clinical data registries (QCDRs) such as the ACEP Clinical Emergency Data Registry (CEDR) that offer both e-measures as well as a much larger menu of measure options.  Next year, emergency physicians will likely need to select at least six out of the over 30 measures available in a QCDR to count towards their CPS. One measure must be an outcome measure (such as lactate clearance for patients with septic shock) or a high-priority measure (such as appropriate CT imaging for minor head injury). Each individual measure will be worth up to 10 points based on performance compared to a historical benchmark score set by CMS. If groups select measures of outcomes, patient experience, or appropriate use (i.e imaging for low-risk PE) then they can also earn additional “points” towards the CPS. Many emergency clinicians may choose to report as groups so that they can take advantage of reporting more measures such as the Central Venous Cather Insertion Protocol for which no individual physician will have enough cases or the ED throughput measures that better reflect team-based care of the entire group. Ultimately, most emergency clinician groups that allow their data to be pulled into large data aggregators like CEDR will be able to look at their performance across all measures and select the six measures for which they perform best. End result—most emergency physicians will do very well in this category and are likely to achieve near maximum points if using a QCDR.

Advancing care information (maximum 100 points):
Because emergency departments were included with hospital in th this category’s predecessor program, the Meaningful Use program, emergency physicians have not historically had to report individual measures of health information technology use and it remains unclear how emergency physicians and groups will earn points in this new category. 50 “Base” points can be earned this category by reporting use on an EHR that can protect patient information, perform electronic prescribing, make information accessible to a health information exchange (if applicable), send information to other clinicians for coordination, report data to a clinical registry and be accessed by a patient portal. In the case of emergency physicians who largely use hospital-based EHR products or have adopted EDIS systems integrated into a hospital EHR, achieving the Base points should be easy. For the remaining Bonus points available in this category, however, the details for emergency medicine remain murky. Given the relative standardization of EHR features and dependence on EHR vendors to implement solutions, we anticipate only modest variation between emergency physicians or groups in this category.

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Clinical practice improvement activities (60 points maximum):
CMS has not fully designated what activities will count for points, but many have been proposed. Activities can be considered “high” weight worth 20 points) or “medium” weight (worth 10 points). The maximum points achievable is 60 and there is no extra credit. For emergency physicians and groups, many current and planned quality improvement activities will meet this requirement. Participation in a QCDR like CEDR alone will earn 10 points, the collection and follow-up on patient experience data can earn 20 points, and completing your MOC Part IV activities is worth 10 points. Furthermore, joining a CMS sponsored quality collaborative initiative like the ACEP Emergency Quality Network (E-QUAL) may even help meet several targets worth numerous additional points.  Emergency physicians are all likely to perform well in this category and we expect little variation in this category’s contribution to the CPS.

Cost and resource use (no point maximum): 
CMS will create, set and calculate these measures based on the claims data they have for Medicare beneficiaries. While this will be low-burden for clinicians, the devil is in the details—and the details are few for the measurement of emergency clinician or group cost. Will these measures be limited to professional payment or also include facility payment influenced by emergency physician decisions to order imaging or administer medications?  Will the costs attributed to emergency physicians be limited to discharged patients only or also include hospitalization costs that result from the emergency physician decision to admit the patient?  CMS has stated that this category will be scored between 1 and 10 points based and by comparing similar physicians or groups. Again, given the budget neutrality of the MIPS program, we expect that this category may drive most of the variation in the ultimate CPS if emergency physicians perform well on the other three categories. It also may be the category where emergency physicians have the least control, particularly if costs are attributed for downstream care in high-cost or critically ill patients.

Putting it all together
Once each of the detailed categories is scored and rolled up into a CPS, the calculations don’t stop. Each individual clinician or group’s CPS is then compared to the “performance threshold” set by CMS—say 250 points out of a possible 300, and payment bonuses or penalties are made based on whether or not you fall above or below the benchmark, respectively.  If you do really well, and your CPS is among the highest in emergency medicine then you qualify for a 10% Exceptional Performance Bonus on all of your Medicare Part B payments.

What about the advanced APMs option?
Have all these point systems left you in a dizzying, Pokemon-like state? One alternative to MIPS is to participate in an Advanced APM (AAPM).  To date, however none of the approved AAPMs are specific to emergency medicine, so it is unlikely that any emergency clinicians group would be able to or want to sign up to be a Next Generation ACO or a Track 2 Medicare Shared Savings Program entity without the ability to manage the cost of primary and specialty care as well as hospital care.  For some medical specialties such as nephrology or oncology, CMS has approved AAPMs and the emergency medicine community through ACEP has pulled together a Task Force to propose several acute care specific AAPMs. However, the detailed structure and execution of these AAPMs are several years away.

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Ultimately, data collection for MACRA goes into effect January 1, 2017 whether we like it or not. And, while the results and payments may not be felt until 2019, now is the time to focus on how your group will meet the MIPS requirements. Delaying this could end up costing physicians considerable income in the near and distant future.