MACRA and Your Practice


Join Ginny Mahaney of Smartlink Mobile, Autumn Bell of NueMD, and Jason Karn of Total HIPAA Compliance as they break down MACRA and discuss how the new legislation affects your practice.


About our Presenters

Ginny Mahaney is the VP, Products & Marketing at Smartlink Mobile and is a subject matter expert on MACRA. She is responsible for product strategy of Smartlink’s MACRA Suite. Her background includes a variety of product management, marketing, and business development roles in healthcare companies including Allscripts, Parata Systems, and Sutter Corporation (a subsidiary of Columbia/HCA). Ginny earned her bachelor's degree from The Pennsylvania State University with an emphasis in PreVet/PreMed, and an MBA from Duke University.

Autumn Bell is a senior project manager at NueMD and the company's resident expert on all things MACRA. In her role, Autumn is responsible for staying current on new healthcare legislation and helping her team design and implement creative solutions to keep her clients in compliance.

Jason Karn is the Chief Compliance Officer at Total HIPAA and has been active in HIPAA training since the inception of the 2013 HIPAA Rules. He is the co-author of all Total HIPAA 2.0 training for Agents and Brokers, Employers, BA/Subcontractors, Medical Providers and Dental Providers and is a regular speaker, blogger and a significant Twitter influencer on all things HIPAA.



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MACRA Resources



Q: We are signed up to be part of an Accountable Care Organization (ACO) in 2017. Does that mean we will not be subject to MIPS?​

A: If you are an advanced APM you will not be subject to MIPS. All other APMs are subject to MIPS. There are a couple of AMPs, such as MSSP Track One, which are considered MIPS APMs. For example, if you're MSSP Track One, the quality measure that you're going for as part of your APM, that will be your quality score for MIPS. They're not asking you to do MIPS quality measures and your APM quality measures. The goal of a MIPS APM is to align what the APM's performance goals are with the MIPS program. As I mentioned, there are five that are advanced APMs, five APMs that are considered advanced APMs. All others will either fall under traditional MIPS or a MIPS APM.​


Q: For MIPS, are payment adjustments on a sliding scale or is there just a straight four percent bonus or penalty?

A: There is a sliding scale. It's not linear. Because remember, there is quite a bit of upside in bonus potential. You can expect that that scale is going to slide quickly. The bottom 25 percent will get the max penalty.​


Q: Is there a minimum for providers that have to participate? 

A: Yes. If you are a Medicare Part B provider who bills more than $30,000 per year, or provides care for more than 100 Medicare patients, you will participate in MIPS.

Q: If I don't qualify for MIPS, will I still receive a payment adjustment?

A: If you don't qualify, then you are not subject to MIPS. Also, if it's your first year seeing Medicare patients, you are not subject to MIPS in 2017. For example, if you saw your first Medicare patient on March 1 of this year, you will start with MIPS on January 1, 2018.

Q: Do you have to use an EHR to participate in MACRA?

A: Yes, and it must be at least 2014-certified. Starting in 2018, your EHR must be 2015-certified. 

Q: Will all levels of Patient-Centered Medical Homes (PCMH) receive full credit for CPI?

A: PCMH is recognized if it's a nationally recognized accredited PCMH, Medicaid medical home model, or a medical home model. Nationally recognized, accredited by the Accreditation Association for Ambulatory Healthcare, the ​National Committee for Quality Assurance (NCQA), the Joint Commission Designation or the Utilization Review Accreditation Commission, the Utilization Review Accreditation Commission (URAC). Those all would count. ​


Q: Are federally qualified health centers (FQHC) subject to MACRA and MIPS?

A: The service provided under an FQHC under the all inclusive payment methodology are exempt from MIPS. Any Part B services that are provided would be subject to MIPS. The majority of an FQHC's billings would probably be under the all inclusive payment. ​


Q: Where should we submit data for MIPS? Is that done through our EHR or through CMS?

A: You can submit data through your EHR, or you can submit through the qualified registry via CMS.


Q: Do we still have to use the Physician Quality Reporting System (PQRS) if we don't qualify for MACRA?

A: If you fall under the $30,000 in billing and 100 patients, you do not have to report under MACRA. MACRA and MIPS replaces PQRS.




Jennifer Henderson: Thanks for joining us today! My name is Jen Henderson and I'm the senior marketing coordinator here at NueMD. Joining us for today's presentation is MACRA expert Ginny Mahaney. She's the VP of products and marketing at Smartlink Mobile. She is an expert on MACRA and is responsible for the product strategy of Smartlink's MACRA Suite. We also have Autumn Bell. She's a senior project manager here at NueMD. We have our resident HIPAA expert, Jason Karn. He's a technology expert and the chief compliance officer at Total HIPAA.

We'll also try and leave some time at the end to take a few questions.

With that, I'll go ahead and hand it off to Ginny.


Healthcare Expenditures

Ginny Mahaney : I think it's important to start with expenditures, just because there's so much talk about repealing or fixing Obamacare. One of the first questions I often get when I'm talking to people is, "What about MACRA? Is it really here to stay?" MACRA is here to stay. The reason for that is because the shift to value-based care is being driven by economic forces more so than political ones. I think Governor Leavitt articulated this very well recently when he said, "There is not a place on the economic leader board for a country that spends 20 to 25 percent of GDP on healthcare."

The overall healthcare expenditure in the US this year is going to be around $3.5 trillion. That's continuing to increase every year at an unsustainable rate. About half of that is paid for by our tax dollars. MACRA was passed with overwhelming bipartisan support. If memory serves, I think the Senate, for example, I think the vote was 92 to eight. Definitely overwhelming support. Keep in mind that it also replaces the SGR formula. MACRA is definitely here to stay. It's not going to go away. 

What is MACRA?

Ginny Mahaney: Let's talk about MACRA and what exactly it is. The Medicare Access and CHIP Reauthorization Act of 2015, MACRA, it's also referred to as the Quality Payment Program, completely reforms Medicare Part B payments for more than 600,000 clinicians across the country. It repeals the SGR formula. It streamlines multiple quality programs, including the Physician Quality Reporting System, the Value-Based Modifier and Meaningful Use. It links the majority of fee-for-service payments to value and quality via two different payment tracks. We'll talk about each of those in a second. Then, lastly, it provides bonus payments for participating in one of those tracks, the advanced alternative payment models. ​

MACRA Payment Tracks

Ginny Mahaney: As I mentioned, there are two tracks to choose from under MACRA. The first one is the advanced alternative payment models. These are APMs that accept both risk and reward for providing coordinated, high-quality, and efficient care. They're already taking on downward risks. MACRA does not change how any APM functions or rewards value. It simply creates extra incentives for participation. They receive a five percent bonus. To be considered a qualifying professional, a QP, under an advanced APM, you have to receive 25 percent of your Part B payments through the advanced APM or see 20 percent of your Medicare patients through an advanced APM.

Currently there are five APMs that qualify as advanced APM. Those are the comprehensive ESRD models, the large dialysis organization arrangement only, the CPC plus, Medicare-shared savings program Track Two and Three only, next-gen ACO, and the Oncology Care Model two-sided risk arrangement. Note that Medicare Track One does not qualify as an advanced APM. The expectation is roughly five to 15 percent of eligible clinicians are going to fall under this payment track.

The second payment track is the Merit-Based Incentive Payment System, or MIPS. Medicare Part B clinicians of course who are not a QP in an advanced APM will fall under MIPS. Those that bill more than $30,000 a year or provide care for more than 100 Medicare patients will participate in MIPS. The expectation under MIPS is that about 85 to 95 percent of eligible clinicians will fall under MIPS. That includes physicians, PAs, nurse practitioners, clinical nurse specialists, CRN anesthetists, and groups that include such clinicians. 

MIPS Scoring Components

Ginny Mahaney: Since the bulk of providers will be subject to MIPS, let's take a deeper dive into MIPS specifically. MIPS scores eligible clinicians on a scale of zero to 100. That score is based on four different categories. Those categories are quality, which makes up 60 percent of the score in year one, and decreases to 30 percent over the first three years, cost, which starts at zero percent in year one and increases to 30 percent by year three, advancing care information, which is previously Meaningful Use, is 25 percent of the score, and clinical practice improvement activities are 15 percent of the score. ​


Participation in MIPS in 2017

Ginny Mahaney: 2017 is the performance year for MIPS payments beginning in 2019. It's also considered a transition year. You can pick your pay participation this year. We'll talk about that more on the next slide. MIPS has to be budget-neutral. That means that very few people will experience a zero adjustment. The negative adjustments will pay for the positive adjustments. Lastly, the scores will be ... Providers will be ranked against each other nationally and payment will be based on performance versus peers nationally. That performance will be publicly available. As I mentioned, there are several options for participation in 2017. During this first year, which CMS refers to as a transition year, you can pick your pay for participation in order to build capabilities and gain experience with the program.

Eligible clinicians have three flexible options to submit data under MIPS. The first is to just submit something. You can choose to report just one measure in quality, one activity in the clinical practice improvement category, or report the five required measures in advancing care information in order to avoid a negative payment adjustment. Alternatively, providers that choose to not report even one measure or activity will receive the full negative adjustment, which is four percent in the first year.

The second option is to submit a partial year. Eligible clinicians can choose to report to MIPS for a period of time less than the full performance year but it has to be at least 90 days. You can report more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information category. If you do that, you both avoid a negative adjustment and you could potentially receive a positive adjustment.

Then, the third option is to submit for the full year. You would report all measures in all categories for the full year. If you do that, you maximize your chance to get a positive adjustment. Then you're also eligible for the bonuses as well. The last option of course is to participate as a QP in an advanced APM.


MIPS Payment Adjustments and Performance Thresholds

Ginny Mahaney: The payment adjustment, in order to determine those payment adjustments there is a performance threshold set for MIPS. You're above the threshold, you get a positive adjustment. If you're below it, you get a negative one. It's also important to note that the bottom 25 percent will receive the max penalty. The adjustment for 2019, based on 2017 performance, or minus four percent to plus four percent, for 2020 it goes to five percent, then seven percent, and then every year after it will be nine percent.

There's also some really good opportunities though for greater upsides. For top performers there's the potential for an additional three times the base adjustment amount. That bonus is subject to budget neutrality. But then on top of that there is an additional 10 percent performance bonus from a separate budget. That's for those that exceed the additional performance threshold score, which is for 2017 is 70 points in 2017. Out of that zero to 100 performance score, if you get above 70 you have the potential to get up to an additional 10 percent additional bonus.

While there's been a lot of doom-and-gloom talk about MIPS, it's also I think important to note that if you're doing the right things to drive quality and value and you get ahead of the pack, there's some serious upside potential. It continues to increase year over year.

Also, as I mentioned, there's a lot of talk about the potential downside penalties. I think the bigger impact also to keep in mind is that the scores will be publicly available. While a four or a five percent negative adjustment in the early years may not be a big deal, depending on Medicare volume, the fact that commercial insurers and patients will be able to see and compare MIPS scores between your clinic and others in the community can have a significant impact on a clinic's inclusion in these new narrow network products that insurers are shifting towards. It can impact the ability to win new commercial contracts with commercial insurers, recruit providers, and patient retention could also become an issue. I think, as you think about participation in the program and how quickly you start moving forward, it's really important to think about the broader potential impact.

Another thing to think about is that the performance threshold is going to be reset each year. In 2017, the performance threshold is pretty low. In fact, you only have to report one thing to hit the performance threshold. But each year it's going to continue to move up and get a little bit harder. That's why it's really important to really be doing something this year and doing participating at the highest level as you possibly can, because the race is on and it's on now. Those that choose to delay are going to fall behind. It's going to be harder to get out of negative territory in future years. But those that are moving in the right direction, 2017 can really be the year that you get a first mover advantage. That can translate into some tremendous upside opportunity in future years. 

Preparing for MIPS

Ginny Mahaney: Let's talk about now some of the things you can do to prepare for MIPS. At a high level, before we dive into each performance category, let's talk about some things you want to think about just at a high level. First of all, evaluate which option, MIPS or an APM or an advanced APM, is most available to you and feasible to take on. If you're participating in an APM, is it an advanced APM? Controlling cost and quality is a team sport. If you participate in an APM at all that's working together to achieve common goals, you can expect to perform much better than if you go it alone.

Second, if you're going to fall under MIPS, how will you report? You have the option to report as an individual, as a group under a single tax ID number, or as a MIPS APM such as MSSP Track One. Again, controlling cost and quality is a team sport. But you want to be part of a good team that's working well together as a team, because the team score is going to be your individual score. If you choose to report as a group, that group score will be your individual score. If everyone is aligned and working together towards achieving the same goals, you'll be far better off than going it alone.

Third, it's important to know your current state. MU and PQRS are the building blocks of advancing care information and quality. How are you doing in those programs? What are the gaps? Look at your QRUR. Look at your reports and see how you're doing, how you've been doing historically.

Then, lastly, make sure you're optimizing your top-line revenue, because that can help to neutralize downside risk. There are a lot of ways to do that. There are a lot of different preventative programs you can participate in. Try to think about the ones that are going to have the added benefit of helping you improve your MIPS performance. Programs like the Annual Wellness Visit, Transitional Care Management, and Chronic Care Management, those programs are all geared towards helping people keep people well and out of the hospital. Those are good programs to consider because they're also going to help improve your MIPS score. 

MIPS Composite Score: Quality 

Ginny Mahaney: Let's take a little bit deeper of a dive into each category of the MIPS composite score. The first category is quality. As I mentioned, in year one, that's 60 percent of the score, but it decreases as cost comes into the equation. You need to choose six measures, so it's less than PQRS. One of those has to be an outcomes measure, a specialty-specific measure, or a subspecialty-specific measure. In order to perform well under the quality category, choosing the right measures is critical. Again, review your quality and resource use report. Understand how you're performing relative to your peers.

You're also going to want to pull some recent sample data and compare it to the deck files from CMS so you can identify which measures you have the highest probability of doing well on compared to the rest of the country. For example, in 2015 the national mean for a PQRS Measure 53, the pharmacologic therapy for persistent asthma, was 95.48 percent. If you're consistently doing fairly well at a 92 percent, say, that's still not a measure you want to choose because you're going to fall below the median.

Another area you want to focus on is staying on top of your polychronic patients between visits. Quality measures are all about ensuring patients get the right care at the right time. A large percentage of measures, if you read through them and you've been doing PQRS you know this already, they're geared towards chronic conditions and prevention. Staying on top of your polychronic patients between office visits, you could do a better job on your targeted quality measures and especially the outcomes measures. Also, treat acute conditions early to avoid hospitalization. 


MIPS Composite Score: Cost 

Ginny Mahaney: Cost, as I mentioned, is zero percent of the score initially, but it increases to 10 percent next year and then 30 percent. This is the category that everyone has the least experience in and without doubt will be the category that differentiates those that get bonuses. It's the one that takes the longest amount of time to improve in. Those that focus on this in 2017 are very likely to develop a competitive advantage in future years. I would really encourage you to think about cost this year and not wait until next year when it's 10 percent of your score to start the process.

Cost is based on 10 episode-based measures. They'll be calculated based on per-capita cost for all attributed beneficiaries and a Medicare spending per beneficiary measure. To perform well in this category, think about who your most important referral partners are, how you can do a better job working collaboratively with them. Who are your high-value providers, those that provide high-quality care at the lowest cost? There's a high variability in cost between providers, and that increased cost is going to have a negative impact on your cost performance. You really got to pay attention to that. The key point is that in order to fair well you really have to be thinking outside of the four walls of a single practice.

Second, leverage referral management technology so that you can make sure patients are being referred to those high-value providers. You can coordinate care with them more effectively and you can maintain visibility into your patients' status as they navigate across the community of care. If you don't know where patients are and what's happening, you won't be able to manage the cost of their care. Staying on top of polychronic patients is also very important in the cost category. 93 percent on Medicare spend is on polychronic patients. Staying on top of the polychronics is equally important to cost as it is to quality. One thing you can consider is Medicare's CCM program as a good mechanism to stay on top of these patients. That will help you head off health issues before they escalate into an ER visit or a hospitalization. Again, treating those acute conditions early to help avoid hospitalizations will be important. 


MIPS Composite Score: Improvement Activities

Ginny Mahaney: Clinical practice improvement is, again, 15 percent of the score. You need to complete up to four improvement activities. If your pace of participation is the partial year or a full year, it has to be for at least 90 days. There are two types of measures. Some of those are 20 points, so you would need just two. Some of those are 10 points, so you would need to complete four. It's important to note that PCMH gets full credit in this category and APMs will get at least partial credit as well.

What can you do in this category to perform well? First thing, certainly, if you're not a PCMH, think about moving in that direction. You can get credit, full credit, as long as you're certified as a PCMH by October 1st, because remember you just have to report for 90 days even if you're reporting for the full year for MIPS. This category just requires 90 days of data. If you're part of an APM, compare the activities that are required as part of your specific APM to the improvement activity measures. Those measures are in Table H if you have a copy of the final Rule. Just do a search for Table H to get that list, or you can find it on the CMS website.

CMS will score those activities in the same manner that they're otherwise scored for MIPS-eligible clinicians. If you don't receive the max score, you can also submit additional improvement activities to get there. Choosing the right measures is also important in this category. Look at what activities you're already doing that you can get credit for. Also think about how you can double dip. Which measures will also have the biggest impact on cost? There's some measures that qualify for a bonus in the advancing care information category. Look at those as well and choose wisely. 


MIPS Composite Score: Advancing Care Information

Ginny Mahaney:  Advancing care information. This is the category that was previously Meaningful Use. It's 25 percent of your score. The overall score in this category, and I find this a little bit confusing so I'm going to try to break this down and make it as simple as I can. There are two scores that make up your total score. There's the base score and there's a performance score. The base score includes five measures. Those are based on Meaningful Use three. You have to report a yes or a numerator of one for all five of those base measures in order to get a score greater than zero in this category overall. Your base score can make up up to 50 percent of your overall score in this category.

The performance score can actually account for up to 90 percent of your score. But, again, you get a zero in the entire category if you don't at least have a yes or a one for all of the five base measures. You can also get bonuses for reporting to registries and, as I mentioned on the last slide, for certified EHR improvement activities.

I'll mention two other quick points that I think would be important to know. 2017 is the first year that EHR, QCBRs, and qualified registries are able to submit what was previously the EHR Incentive Program Objectives, which is now the advancing care information category. It's also the first time that that data can be reported through the CMS web interface. Then, secondly, under the EHR Incentive Program, EPs that were part of a group could attest together but they were assessed as individuals. Now, under MIPS, when you report as a group you're going to be assessed as a group.

In this category, for 2017, you need to have at least a 2014 certified EHR. In 2018, you have to have your 2015 edition to submit for this category. Make sure you're moving in that direction toward the 2015 edition so you're ready January 1 of 2018. Then, secondly, make sure you achieve a yes or a one in the numerator for those five base measures, because, again, if you don't you're going to get a zero overall in this category. The NU thresholds don't apply. You only need a one in the numerator. But if you don't report that, a one or a zero, you get a zero overall.

Next I'm going to hand it over to Autumn. She's going to talk a little bit more about how to choose your measures and then implement those into your workflow.

Steps for Implementing MIPS

Autumn Bell: Thank you, Ginny. What I want to do today, because one looming question still really remains, is what are some of the ways that I go about implementing this into my practice? We're going to focus on the MIPS track. The most common question that we get at NueMD is, are you guys MACRA or MIPS compliant or certified? The short answer is yes. But, does this answer really help you? Unfortunately, it does not. It will require some work on your end. Let's go ahead and walk through this little by little.

First thing, make sure you learn as much as possible, because it's going to be your responsibility to pick the measures and figure out how you are going to attest to these different measures. Like Ginny mentioned, make sure you evaluate your practice. See where you stand now. That will help you to figure out which measures you're going to choose. In that, you also need to know what you're reporting options are going to be, individual or group or through your EHR, through claims. Then make sure you're educating your staff. This is going to take some work incorporating this into your workflow. Your staff, you guys need to work as a group.

The next slide that we have is going to be very helpful to access this information. We're going to go through a lot of this information in this. This will help you refer back. When this is published, these will actually be linked to take you to the different areas that we'll talk about. For the MIPS reporting requirements, again, you need to decide if you want to do individual or group, and then learn about the reporting requirements for each category.

For improvement activities for the first year, all you have to do is designate a yes or a no response for the activities listed on the clinical practice improvement activities inventory. For quality, your data submissions can either be administrative claims, your claims, your EHR, registries, or if you're reporting as a group you have the CMS web interface. For cost, this does not require any data submission. CMS will actually calculate your score based on services delivered and the Medicare payments that were paid for these services. For advancing care information, like again Ginny said, you need to make sure you're using at least a 2014 ONC-certified EHR. Next year, you'll have to be using a 2015 certified edition.

Next is how to determine what measures you're going to attest to. First is cost. As it says here, you're not required to select any measures, as I had mentioned. Cost is not actually going to be factored into your MIPS score for the first year, but it will increase to that 10 percent. You have to learn about these now. One of the links that I gave to you is going to give you more information on how CMS is putting together these episode groups and the triggering codes that go along with them. When you get some time, go ahead and take the time to look over them and get familiar with them.

This is a great tool that you can use. Again, a link is provided for you to filter out improvement activities to help you decide which ones you would like to do. You're going to need to complete four out of about 92 provided improvement activities. You need to make sure that you really read about the activities, because they can vary from humanitarian volunteer work. It can be care coordination initiatives. There's ways that you can expand your access to your practice for your patients, like telehealth or expanding your hours, and to proactively managing chronic and preventative care. Once you select the measures, make sure you download your CSV file and keep it for your records.

For quality, again, there's a search tool provided for you. What you guys see on this slide, I use the filters to filter down by specialty. I use the general practice. Then I filter down that I'm going to submit via claim submission. When I did that, I thought about my patient population and I used an elderly population as my little test case. Over to the right you can see that there are six measures that I picked that will meet the requirements. It does have one outcome measure. It's very easy to use. Just make sure you pick one that you know that you can do well in. Again, be sure you download your CSV for your records.

One thing to remember with the quality as far as the reporting, if you report your measures via your EHR you have to report on 50 percent of all of your patients. But if you report the measures via claims, you have to report on 50 percent of the Medicare Part B patients. In 2018, the reported measures must have a minimum of 20 cases.

In advancing care information, as said earlier, you need to make sure you have an ONC-certified EHR. Without this, you run the risk of scoring zero in this category. We already saw an overview of the base score. These base measures are listed here, which will require your certified EHR. The security risk analysis is something that you will have to do within your own practice. The e-prescribing, you have to have at least one prescription that has been queried from a drug formulary and sent electronically. Then, the patient access. Make sure that your patients have access to a patient portal where they can retrieve their medical information.

Health information exchange is being able to send patient information between providers. This category in particular is going to be very important to know your HIPAA laws and how to protect yourself with that. That is where Jason, our HIPAA expert, is going to come in and teach you all about that. Jason, welcome aboard.


Jason Karn: Okay, great. MACRA and HIPAA. These two things tie together. As we saw before, we have the advancing care information. In order to qualify, in this category you have to have five key items. HIPAA does require a annual security risk analysis and also requires secure electronic information. These are items that are also pushed as part of MACRA. The reason that we see this overlap is that HHS is concerned that actually a lot of practices weren't following through with doing these risk analyses, making sure that HIPAA was really implemented.

HIPAA is much more detailed than what you're going to see in MACRA as far as security and protecting PHI. One of the reasons they put this in was really to reinforce the importance of this. As we talked about earlier, we're really going to be looking for a one or a yes on these items to make sure that you qualify. This is going to be a full 25 percent of your score going forward. These are things that you need to make sure you have in place and that you can document and show going forward.

We are going to talk more about this. This is more of a teaser for what we're going to talk about next week. Next week, we're going to talk more about what to do about HIPAA compliance, the steps that you need to take, how that's going to help you with your MACRA compliance, and those items. I'm going to open up the floor here to more questions, because I'm sure everybody has questions about more detail about MACRA and the different parts of it. Next week, just remember we'll be talking about HIPAA and doing those security risk analysis, also privacy analysis and those sorts of things.