Starting on Jan. 1, 2017, CMS began implementing its Quality Payment Program (QPP), a titanic shift away from the traditional fee-for-service mechanism and toward a system to reward high quality and low cost. In 2015, CMS announced a goal of 50% of all Medicare payments would be paid through alternative payment models by the end of 2018.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provides for small (0.5%) annual updates for the Medicare Physician Payment Schedule through 2019. MACRA sunsets payment adjustments at the end of 2018 under the current system, including physician quality reporting (PQRS), meaningful use (MU) and the value-based payment modifier (VBPM). The replacement, QPP, includes two parts: a new merit-based incentive payment system (MIPS) and advanced alternative payment models (APMs).

Reporting under QPP in 2017 will affect physician payments in 2019 in one of three ways: 1) Failures mean a 4% reduction to all Medicare Part B (regular Medicare) payments in 2019. 2) Success means up to a 4% increase in Part B payments in 2019 (and the potential for a bonus, too). 3) Neutral means neither a penalty nor a bonus.

In subsequent years, the penalty for failure and bonus for success increases. (Medicare Advantage [Part C] is not part of QPP although those contractors may be working in a parallel fashion to lower cost and improve quality.)

The advanced APMs’ part of QPP can take a number of forms. Of interest to ophthalmologists are Medicare Shared Savings programs and next-generation Accountable Care Organization models. Most ophthalmologists and optometrists will be subject to MIPS rather than APMs, so MIPS is the focus of this article.

Who is subject to MIPS?

In 2017, the eligible providers include physicians, physician assistants, nurse practitioners, and CRNAs; the list may broaden in the future. Clinicians who will not be subject to MIPS are: physicians in the first year of Medicare Part B; low-volume clinicians who fall below a threshold of 100 Medicare patients or $30,000 of billed charges; certain participants of Advanced APMs. Unless you are a new provider in your first year, or see few Medicare beneficiaries (e.g., pediatric ophthalmology), you have to contend with MIPS if you aren’t among the approximately 100,000 clinicians in an APM.

How it works

There are four parts to MIPS: quality performance standards, advancing care information, clinical practice improvement activities and resource use. Each part is assigned points, a score is calculated for each part and a composite score is determined for the clinician or group. The composite score is analogous to the concept of grade point average in school, using several courses with different credit hours and different grades. Each category is weighted differently. MIPS scoring shifts over time — quality reporting will play a smaller role in later years, while resource use will play a larger role.

There is considerable overlap with prior PQRS, MU and VBPM programs, but it is not identical:

• Quality – replaces PQRS

• Advancing Care Information (ACI) – replaces MU

• Clinical Practice Improvement Activities (CPIA) – there is no precursor

• Resource Use – replaces VBPM

Figure 1 is an example of a small practice (15 clinicians or fewer). Each measure and each category is assigned a possible number of points – a goal (a). A score is calculated for each measure and category based on achieved points (b) divided by possible points, resulting in a percentage (c). The composite score is calculated by multiplying the score in each category by the weight (d) then adding them up (e). Clinicians who achieve a composite score of 70 or higher will be eligible for an exceptional performance bonus in 2019, although we don’t know at this time how much that might be.

MIPS categories

Next, let’s look at each of the four categories.

1. Quality performance standards. In this category, you report a minimum of six measures which are similar to those in PQRS. One of the six must be an outcome measure. The threshold is 50% of all Medicare Part B patients. Based on performance, 1 to 10 points are assigned to each measure.

Scoring depends on the size of the group. Practices of 15 clinicians or fewer can receive a possible 60 points. Larger groups (16 clinicians or more) can receive a possible 70 points. All groups can receive a 10% bonus — six points for small groups and seven points for large groups.

Of the available quality measures, some likely choices for an ophthalmologist or optometrist include those addressing glaucoma, AMD, diabetes and cataract. The full list of measures can be found in Table A of the Final Rule (page 519 of the document). Note that the “POAG reduction of IOP” measure is the only outcome measure reportable by claims; all others require a registry or direct EHR reporting.

2. Advancing care information (ACI). In the first year, ACI makes up 25% of the composite MIPS score. This shows EHR’s importance within MIPS. If you do not have a certified EHR in place, then you cannot qualify for any points in this category. Assuming you have a certified EHR, the ACI scoring is made up of three parts: a base of 50 points, a performance score worth a possible 90 points; and 15 possible bonus points. To receive the base score of 50 points (it’s all or nothing, 50 or 0), clinicians must provide the numerator/denominator or yes/no for each of the five measures:

1. Security risk analysis

2. Electronic prescribing

3. Patient access

4. Summary of care

5. Request / accept patient care record.

In 2017, a passing grade for any quantitative measure within this category will be achieved with a numerator of 1. That’s a low bar.

The ACI performance objectives each have two or more measures. Some examples include the following:

1. Patient electronic access (e.g., patient-specific information)

2. Coordination of care (e.g., secure messaging)

3. Health information exchange (e.g., request/accept patient care record)

4. Public health & CDRR (e.g., clinical data registry).

Measures in the first three objectives earn a possible 10 points each; the five public health measures can each earn one bonus point; as a group, they can earn a maximum of five points. CMS says, “For the transition year [2017], we will award a bonus score for improvement activities that utilize certified electronic health record technology and for reporting to public health or clinical data registries” up to a maximum of 10 points. The CMS website includes a full list and discussion of the ACI measures.

The ACI category has a possible 155 points, but each area has its own maximum. No more than 50 points can come from your base score, no more than 90 points from the performance score, and 15 possible bonus points. If you achieve 100 points or more, you max out the ACI category. So, even though it is possible to garner 155 points, you can only count 100 of them. If you score less than 100 points, your ACI score decreases proportionally.

3. Clinical practice improvement activity (CPIA). This new category within MIPS has no predicate measure. CPIA requires reporting for at least 90 days during the reporting period’s first year (2017). There are 94 activities designated as either high-weighted activities (11) or medium-weighted activities (83). The CPIA category includes the following eight measures:

1. Expanded practice access

2. Population management

3. Care coordination

4. Beneficiary engagement

5. Patient safety and practice assessment

6. Achieving health equity

7. Emergency response and preparedness

8. Integrated behavioral and mental health.

The full list of measures can be found in Table H of the Final Rule (page 810 of the document). Three major factors affect reporting for CPIA: the size of your practice, whether you use EHR and whether you use a qualified clinical data registry.

Physicians must achieve a total of 40 points from improvement activities during a 90-day reporting period. High-weighted activities are worth 20 points; medium-weighted activities are worth 10 points. Providers may garner 40 points by any combination of high- and medium-weighted activities. Physicians in small groups of 15 or fewer are only required to complete one high-weighted or two medium-weighted activities for full credit. CMS doubles a small practice’s attainment of 20 points to reach the goal of 40 points. Large groups are not so favored. See the CMS website for an interactive CPIA tool.

4. Resource use (cost). The resource use or cost category of MIPS replaces the cost component of the VBPM. Performance in this category would be assessed, starting in 2018, using payments to all providers from traditional Medicare claims data. It requires no reporting by clinicians. MIPS-eligible clinicians would be scored based on resource use for Medicare patients only, and only for patients that are attributed to them. A beneficiary is attributed to the taxpayer identification number of the physician or group that “accounted for a larger share of allowed charges for primary care services for the beneficiary than primary care physicians of any other taxpayer identification number.” In this context, primary-care services are defined as CPT procedure codes 99201 through 99215 – the evaluation and management codes. Eye codes (920xx) are not primary-care services. In most instances, the beneficiary will be attributed to a PCP or GP and not an ophthalmologist or optometrist. Beneficiaries who receive no “primary care services” are not assigned to any clinician.

Conclusion

How do you get started? Here are your next steps:

• Identify eligible clinicians; determine if any are new or low volume.

• Choose individual or group participation in MIPS.

• Investigate advanced APMs.

• If you have not reported PQRS, now is the time to start; you need to practice.

• Consider implementing EHR if you have not already.

• Investigate clinical practice improvement activities.

• Consider a registry.

• Visit the CMS website and check out the CMS Enterprise Portal and Physician Compare.

• Start as soon as possible, but no later than October 2017, to report 90 consecutive days.

Professional societies are also providing training and resources, as are we.

While you can avoid a 2019 penalty with very little effort, you might make a bonus if you plan carefully and start early; you cannot avoid a penalty in 2019 if you do nothing. For additional information, visit the CMS website. OP