New Quality Reporting Program to Reward Value-Based Care

This is the second in a continuing series of articles on value-based payment.

The American health care system is moving from paying physicians for the volume of services they perform to paying for the value of the care they provide. This movement toward “value-based payment” has greatly accelerated in recent years to address the high level of Medicare spending and is furthered by advances in technology—especially the proliferation of electronic health records (EHRs) and payer-incentive programs to encourage more EHR adoption. The goal of this evolution is summed up in the so-called Triple Aim: improved patient care, better population health, and lower per capita cost of health care.

In the second of a series of articles in “Changing Practice/Changing Payment,” Psychiatric News focuses on a new quality program, known as the Merit-Based Incentive Payment System (MIPS), which was established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). APA submitted detailed comments on the MACRA proposed rule that the Centers for Medicare and Medicaid Services (CMS) issued on April 27. The final MACRA rule is expected in November.

Q: What is MIPS?

A: MIPS consolidates current Medicare quality programs (Physician Quality Reporting System, EHR Meaningful Use, and Value-Based Payment Modifier) and adds a new category for “clinical practice improvement.” MIPS also offers the first substantial rewards for achieving high-quality care.

MIPS reporting begins in January 2017, with payment adjustments starting in January 2019. Each “eligible clinician” or group will receive a “composite performance score” for performance in four categories—quality, resource use, use of certified electronic health records under “Advancing Care Information,” and clinical practice improvement activities—compared against the average of all MIPS clinicians. Those scoring above average receive a bonus, while those scoring below average receive a penalty. Scoring is somewhat flexible, but here are some general guidelines:

• Quality counts 30 percent (50 percent in 2019 and 45 percent in 2020), based largely on the Physician Quality Reporting System (PQRS).

• Resource use counts 30 percent (10 percent in 2019 and 15 percent in 2020), replacing the Value-Based Payment Modifier (VM). CMS will calculate this, with no reporting required.

• Advancing care information (ACI), which assesses the use of EHRs and replaces the Meaningful Use program, counts 25 percent.

• Clinical practice improvement activity (CPIA), the new category, counts 15 percent.

MIPS bonuses—and penalties—will be up to 4 percent in 2019, 5 percent in 2020, 7 percent in 2021, and 9 percent starting in 2022. Those payment adjustments are budget neutral. But there is an extra $500 million a year for bonuses of up to 10 percent for “exceptional” performers, from 2019 to 2024.

Q: What else do I need to know before the MIPS adjustments take effect in 2019?

A: In 2017 and 2018, Medicare payments to all psychiatrists (regardless of practice size) will be subject to value-based payment modifier bonuses or penalties. These currently range up to 4 percent.

Starting in 2018, all Medicare claims will include special codes to identify the care episode, patient condition, and physician’s relationship to the patient. These codes will link patients to clinicians for measuring resource use. APA is working with member experts to recommend appropriate psychiatric episodes of care.

MACRA sets a goal of achieving interoperability of EHRs by the end of 2018.

Q: What are the key features of the >MIPS program for psychiatrists?

A: Psychiatrists are exempt from MIPS reporting and payment adjustments for a particular year if (1) this is their first year of Medicare enrollment; (2) they meet the “low volume threshold” of no more than $10,000 in Medicare billings and 100 Medicare patients; (3) they qualify for the MACRA bonus for “advanced” alternative payment models (APMs); or (4) they meet the definition of a partial qualifying APM participant and choose not to report under MIPS.

Psychiatrists will no longer be required to report nine quality measures across three National Quality Strategy “domains.” They will have to report only six quality measures, including one cross-cutting measure and one outcome measure. If no outcome measure is available, they must report one measure related to appropriate use, patient safety, efficiency, patient experience, or care coordination.

APA will post a list of MIPS quality measures relevant to psychiatry after the final rule is issued. The new ACI program offers partial credit for using electronic health records; however, some psychiatrists may find the limited outcome measures in high-priority areas a significant barrier to meeting the scoring criteria.

CPIA options include “Integrated Behavioral and Mental Health” activities such as providing integrated care consistent with the collaborative care model.

Starting in 2018, psychiatrists in small practices (of up to 10 clinicians) may form “virtual groups” for joint MIPS reporting and assessment. The infrastructure is still being developed, and APA will keep members informed as more details become available.

MIPS may apply to clinical psychologists and clinical social workers starting with reporting in 2019 and payments in 2021.

MACRA includes $100 million for technical assistance to small and rural practices, plus those in health professional shortage areas, for MIPS reporting and transitioning to new models of care.

MIPS does not apply to Medicare Advantage payments or programs.

Q: Are there advantages for registry reporting?

A: MACRA preserves current reporting methods but also encourages reporting via qualified clinical data registries (QCDRs) by individuals and group practices. In addition to being less burdensome, registry reporting counts toward the ACI and CPIA categories, potentially leading to higher MIPS scores and bonuses. QCDR measures can also be directly approved by CMS, avoiding longer review by the National Quality Forum—the only organization designated by Congress to endorse quality measures. APA is now beginning to develop a mental health clinical quality data registry for use by psychiatrists in quality reporting.

Q: What is new for quality measures?

A: MIPS will continue most valid PQRS quality measures and add measures used by private payers and for different settings. MACRA includes $75 million in development funding of new measures. CMS has issued a final Quality Measure Development Plan to address measure gaps. (Information on the plan is available here.) APA submitted comments on the draft plan in February.

Q: How can APA help you prepare for MIPS?

A: We welcome your questions!

• MIPS Quality and Resource Use: Samantha Shugarman, [email protected]

• MIPS CPIA: Nevena Minor, [email protected]

• MIPS ACI/EHRs: Nathan Tatro, [email protected]

• MACRA APMs: Eileen Carlson, [email protected]

• Coding, reimbursement, and practice management questions: APA Practice Management Helpline, (800) 343-4671 ■