Healthmonix Advisor

As you report your MIPS data, it can feel like a lot of work with little ROI for the last two years. But wait. Sometimes we need to step back and evaluate the bigger picture. While we often focus on "getting the job done", there are changes in the healthcare economy that are occurring that are strategic.

For years, we’ve heard that the Merit-based Incentive Payment System (MIPS) will provide a noticeable incentive for participants in this Medicare FFS program. And for years, there have been reasons why that has not occurred. First, CMS wanted to ‘start slow’ with the MIPS program in 2017 and 2018, so the caps on penalties and incentives were small. Then the potential penalties and incentives were raised, but the threshold for qualifying for an incentive remained low. This, coupled with the program’s budget neutrality meant there was not much revenue to distribute to high performers. Then COVID-19 negated much of the program for the last two years. So here we are, in year five, and we see that the program, for the first time, will have a significant downside and upside potential.

The long-awaited CY 2021 Medicare Physician Fee Schedule Final Rule update is now here. Despite the disruptions of the Public Health Emergency COVID-19, participation in performance year 2019 was strong. Thus the 2021 Final Rule moved forward with finalizing a number of proposed changes, including a higher performance threshold for performance year 2021, anticipated changes in weight to the Quality and Cost performance categories of the Merit-based Incentive Payment System (MIPS), and the introduction of the APM Performance Pathway. Other expected initiatives, such as MIPS Value Pathways, the requirement for registries to build their own benchmarks for certain measures, and the sunsetting of the CMS Web Interface, have been pushed back to at least the 2022 performance year.

Starting in January, 920 primary care practices will embark on the one of the newest payment models from the Centers for Medicare & Medicaid Services (CMS) via the Primary Care First (PCF) Program.  The main criteria for participation in the program are:

• 70% or more of the practice’s collective billing must be for primary care services.
• Use of a 2015 Certified Electronic Health Record Technology (CEHRT) by the practice.
• At least 125 services provided for attributed Medicare beneficiaries.

Also, for the first year of the program, there is a limited geographical area for participation.

Between 2018 and 2019, 74 of Medicare’s 561 accountable care organizations (ACOs)—or 13%—left the program, according to research by Leavitt Partners. The same research also found that 26% of ACOs that reached the end of their three-year agreement opted to not renew it at the end of 2018.

A new CMS toolkit, released through the CMS ACO learning system, shows five innovative care coordination strategies that have helped Medicare ACOs find success through shared savings.

According to a recent announcement from the National Association of ACOs (NAACOs), CMS failed to adequately communicate significant changes to measure ACO-17, Preventive Care and Screening, Tobacco Use- Screening and Cessation Intervention, until after 2018 quality reporting had begun. NAACOs believes that CMS’s failure to communicate these changes will result in unintended consequences such as lowered or even eliminated shared savings rates for ACOs that consequently received a lower performance score or failed to meet quality standards.

When the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law, it created two distinct pathways for reporting: the Merit-Based Incentive Payment System (MIPS), and the Advanced Alternative Payment Model (Advanced APM). Under MIPS, Medicare Part B payments are tied directly to clinician performance based on Composite Performance Scores (CPS), whereas the Advanced APM track encourages groups of clinicians to take on greater risk (and reward) for cost and quality of care.

In this week’s blog, we’re taking a deep dive into Qualifying APM Participant (QP) and Partial QP Determinations, as laid out in the 2019 QPP final rule.

CMS estimates that between the 2013 and 2015 performance years, accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) saved $954 million. But according to a new analysis from Dobson DaVanzo & Associates, commissioned by the National Association of ACOs (NAACOS), they actually saved $1.84 billion—almost twice as much.

The analysis also found that MSSP delivered net savings of $541.7 million for 2013-2015 after accounting for shared savings bonuses; this is in contrast to the CMS benchmark calculation, which found that the organizations increased Medicare spending by $344.2 million.

The tracks of the Medicare ACO model vary greatly, but have been steadily gaining in prevalence since their launch in 2011. Despite the steady increase in ACO participation, most groups are staying at the Track 1 level. In fact, in 2018, 460 of the 649 ACOs existed at the Track 1 level.