patient relation management

MACRA Basics: MIPS vs APM - What You Need to Know About the New Rules

CareSkore

Header - MACRA MIPS vs APM (1)

What is MACRA?

The MACRA (Medicare Access and CHIP Reauthorization Act) is the new healthcare reform poised to replace all of the different “patchwork programs” for physicians who receive Medicare payments. As part of the shift towards value-based programs proposed by CMS (Centers for Medicare & Medicaid Services), it’s purpose is to set up a new framework that rewards physicians, not on the amount, but the quality of care they provide. As a provider, you have two different options for how you want to get reimbursed: MIPS (Merit-based Incentive Payment System) and APMs (Advanced Payment Model).

 

What is MIPS?

MIPS determines your reimbursement rates by the quality of care. Payment adjustments under MIPS are based on the MIPS Composite Score, which comprises of 4 key areas:

  • Quality (Formerly Physician Quality Reporting System or PQRS)
  • Advancing Care Information (Meaningful Use)
  • Clinical Practice Improvement Activities
  • Resource Use

If your score is above the threshold, you’ll receive a positive payment adjustment. But if you’re below, you’ll have a negative payment adjustment for the following year. Scores will be compared to both year-over-year improvements and other providers.

 

Benefits of Merit-Based Payments

High performers under MIPS receive a positive payment adjustment for up to 3x the adjustment factor, but physicians still have to report on quality measures to make sure standards are being upheld. Providers can maintain a higher score by simply improving patients’ outcomes through care coordination and ensuring patients have easy electronic access to their health information. Many are already using technology to increase patient engagement. By communicating with their patients in real-time, providers can better serve patients who have a higher risks of complication and readmission to the hospital. Through patient engagement and communications, providers receive credit for helping patients through personalized reminders to take their medicines, monitor their performance, and keeping them healthy throughout the continuum of care. Tying clinical practice improvement activities such as improving patient safety, population health, and long-term outcomes together, ultimately makes your practice much more efficient.

 

What is APM?

Aside from MIPS, the other payment track is an Advanced Payment Model or APM. Currently, patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) use this model. CMS, however, anticipates that more individual providers will qualify for this option. APMs will provide a 5% lump sum bonus based on the prior year’s payment beginning in 2019 over a 6 year time period.

To be eligible for APM, participants must:

  • Have serious quality measures comparable to MIPS
  • Use EHR (Electronic Health Record) technology
  • Bear “more than a nominal financial risk” similar to an ACO or PCMH

Physicians who choose an APM have an opportunity to earn more, but run the risk of paying Medicare back if they don’t meet savings goals. Understanding these risks and determining if they outweigh the potential benefits is a decision that providers will have to make individually or with their practice management team.

 

How to Choose the Best Payment Model

Which path do you take? You and your partners can weighout both payment models under the MACRA, but first, you’ll want to get the facts to make an informed decision.

Know yourself - Dig through the quality data. Are you a high performer? Find out why or why not. Know your current quality metrics and create a plan to improve.

Know your patient population - Do you know you take on patients that have multiple health problems or things you can’t control? That could be a factor in your reimbursement rates.

Under MIPS, there are over 90 activities you can choose from to demonstrate how you’re improving your clinical practice. These tactics can give you credit for helping patients overcome challenges like making sure they’re taking their medicine or adhering to a rehab program.

 

How Meaningful is Meaningful Use Technology

Another thing to consider is your meaningful use technology. Now, you’ll be measured on how well patients are making use of their electronic health information. Is it actually providing value? The intent is that providers and patients are actually sharing information and making prevention and high-quality care more accessible to patients.

 

Start Planning Now

The good news is that the current payment programs requiring reporting on quality metrics will be absorbed into the MACRA. Physician practices have until 2019 to choose their payment track, however, it’s never too early to understand your options and have a general idea of what makes the most sense for your practice. In the meantime, you should honestly evaluate your quality metrics and how you’re meeting meaningful use. Take the time to look for ways to improve and implement tactics that can help your patients now.

 

Sources:

NPRM - Quality Payment Program Fact Sheet

CMS Quality Reporting Programs

Medicare Access and CHIP Reauthorization Act (MACRA) Preview Module

Quality Payment Program - CMS

Quality Payment Program - MIPS and APM

MIPS or APM: Which is better for your practice?

Moving toward improved care through information

MACRA Payment: APM vs MIPS

 

MACRA Basics: The Method Behind MIPS Scoring

Mark Aquino

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When the sustainable growth rate (SGR) formula was set in stone in 1997, its sole intent was to better control the cost of healthcare payments to physicians. Payments towards clinicians were and still are predicated on volume of services, not value. If the overall physician costs were greater than Medicare expenditure targets, then physician payments were reduced.

Enter in MACRA, otherwise known as The Medicare and CHIP Reauthorization Act and we’re on our way to repeal the SGR formula and create an entirely new system that physicians must follow.

 

Old to the New

As the torch bearer in this shift towards value-based care, MACRA is proposing two payment systems that eligible physicians can choose to operate under; MIPS, or Merit-based Incentive Payment System and APM, also known as the Advanced Payment Model. The goal of MIPS is to provide physicians with the flexibility to choose activities and measure those most meaningful to their practice. With the introduction of Clinical Improvement Activities, a new performance category that physicians will be scored on, MIPS will consolidate the three categories that physicians already measured by; Quality, Resource Use, and Meaningful Use of Technology, forming the MIPS Composite Score as a result. The MIPS Composite Performance Score takes into account the weight across each performance category, performance factors, group performance, availability and applicability of measures, and special circumstances of nontraditional practices (practices located in rural areas and non-patient).

 

Are You Eligible?

First order of business: how do you know if you’re eligible to operate under the MIPS program? MIPS-eligible clinicians in the first and second year of the program include:

  • Physicians
  • PAs
  • NPs
  • Clinical nurse specialists
  • Certified registered nurse anesthetists

After the third year, the eligibility funnel expands, adding:

  • Physical or occupational therapists
  • Speech-language pathologists
  • Audiologists
  • Nurse midwives
  • Clinical social workers
  • Clinical psychologists
  • Dietitians
  • Nutritional professionals

You’re exempt from MIPS if you are:

  • In your first year of Medicare participation
  • Eligible for APM and qualify for bonus payment
  • Below the low volume threshold (Medicare billing charges less than equal to $10,000 and provides care for 100 or fewer Medicare patients in one year).
  • A hospital or facility

As you prepare your practice for MACRA, it’s critical to keep these four performance categories in mind, how they’re calculated, and how they tie-in together to form the MIPS composite score.

 

The Big Four

1. Quality

The quality performance category replaces the Physician Quality Reporting System, or PQRS, accounting for 50 percent of the MIPS composite score. Under the quality performance category, there will be six measures that doctors can choose to report on that best reflects their practice. In addition, doctors must also report on 1 high priority measure; outcome, appropriate use, patient safety, efficiency, care coordination or patient experience, and 1 cross-cutting measure.

Composite Score Weight: 50% in 2019

Maximum Possible Points: 80 to 90 points

Calculation and Scoring: Each measure equates to 1-10 points in comparison to historical reports. If a measure is not reported, score equals 0. Additional bonus points are awarded for patient experience, patient safety, care coordination, and EHR reporting.

 

2. Advancing Care Information

In the Advancing Care Information category, formerly known as Meaningful Use, clinicians are rewarded based on their performance of measures most favorable to them, reporting on key measures on interoperability and the exchange of information. The six objectives required to measure, as proposed by CMS include Protection of Patient Health Information, Patient Electronic Access, Coordination of Care Through Patient Engagement, Electronic Prescribing, Health Information Exchange, and Public Health and Clinical Data Registry Reporting.

Composite Score Weight: 25% in 2019

Maximum Possible Points: 100

Calculation and Scoring: A base score of 50 points is granted if the provider reports one or more use cases across each available measure. For each measure, up to 10 additional points are possible.

 

3. Clinical Practice Improvement Activities

Of over 90 activities to choose from, clinicians have the choice to measure activities best suitable for their practice. Those participating under medical homes earn full credit while APM participants earn half. Activity categories include Expanded Practice Access, Beneficiary Engagement, Achieving Health Equity, Population Management, Patient Safety and Practice Assessment, Emergency Preparedness and Response, Care Coordination, Participation in an APM, Integrated Behavioral, and Mental Health.

Composite Score Weight: 15% in 2019

Maximum Possible Points: 60

Calculation and Scoring: Each of the 90 activities is worth 10 points and “high-value activities” are given double the weight.

 

4. Resource Use

For clinicians and physicians, the score for the Resource Use or Cost category is based on claims and volume sufficiency. For this category, doctors need not report anything as CMS does the calculations. Clinicians that provide high-quality care for their patients achieve better performance, thus resulting in a higher score through being the most efficient in resource use.

Composite Score Weight: 10% in 2019

Maximum Possible Points: Average score of resources measures that can be attributed.

Calculation and Scoring: 1-10 points based on performance benchmarks.

 

What’s Ahead

As the final MACRA ruling is just a few months away, physicians—and hospitals—must prepare themselves by understanding the implications of MACRA—both MIPS and APM—and have actionable information on what they can do to address the proposed payment systems. While MACRA—if passed—goes into effect in 2019, both 2017 and 2018 performance and payments will be accounted for.  you can, not only improve your processes and workflows but more importantly, enhance how you serve your patients better in the continuum of care.

Are you looking to learn more about MACRA? Join us as we cover how to directly approach the new payment systems in our upcoming webinar, MACRA: Addressing the Transition, this Thursday, August 11th at 11AM PDT.

 

References:

CMS Quality Payment Program NPRM

CMS The Medicare, The Merit-Based Incentive Payment System: MIPS Scoring Methodology Overview

 

Where EHRs Fall Short: 3 Reasons Doctors Need Personalized Population Management

Mark Aquino

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Look into the center of a hospital’s information technology stack, and you’re bound to find electronic health record systems (EHRs) to be the cream of the crop, costing healthcare providers tens to hundreds of millions of dollars for implementation and use. As the core system of record within a healthcare organization, when it comes to providing the 360-degree view on any given patient or patient population, EHRs fall short on giving the complete picture.

 

The State of Electronic Health Record Systems

It’s no doubt that EHRs are critical to a hospital or health practice. An EHRs’ core capability rests on being able to store significant amounts of patient data records and is used across multiple functions—care quality, finance, and operations—within a health organization. Whether it’s capturing notes on patient encounters, insurance claim information, or data on historical visits, you name it—EHRs are effective in that regard. This, however, is what EHRs were designed to do, and nothing more; to operate as silos of unstructured data.

Storing data and interpreting data are two independent undertakings. It’s important for doctors to be able to distinguish between the two without overspending on time and resources. In order to capture the complete picture on a patient population, clinical and financial departments need a dedicated system that allows for seamless interpretation of patient data, predictability, and personalized patient communication at will. Keep an eye out for the following when looking into a population management solution:

 

 1. Predicting no-shows and patient risks

Tracking historical patient data is fundamental. But what about predicting and planning for the future? As healthcare providers continue to amass increasingly large amounts of patient data from socioeconomic to demographic inputs, not leveraging that data is an opportunity missed. Where EHRs lack, a Personalized Population Management™ can make up in value, as EHRs were not designed to predict future occurrences from their stored data. Doctors need a solution that not only enables them to manage no-show and cancellation rates but addresses dire questions like, Which patients within my population are at-risk? What are the leading factors for my patients’ risks? How can I improve the health of my patient population?

 

 2. The need to engage patients

Doctors and physicians want to spend more time doing what they do best: caring for their patients, not trying to make sense of high volumes of unstructured data. When relying on EHRs for patient engagement, physicians and nurse practitioners can face barriers; meeting personalized demands, usability issues, unnecessary workload. What doctors and physicians seek is a tool that not only gives back lost time from using EHRs but a tool that enables bi-directional patient communication even when patients leave the premise. This calls for a communication medium to be put in place dedicated to engaging patients and helping doctors get what patients need when they need it.

 

 3. Meeting regulatory reporting requirements

One thing is true. It’s becoming much more difficult for doctors to focus on their population. While the rise of the health IT landscape was meant to automate certain tasks, the reality is it’s taking up more and more of a doctor’s time. With new reporting and payment regulations underway, doctors must have a solution fixated to handling this department. EHRs alone aren’t enough and extracting data from these systems can be a daunting task. Orchestrated in alignment, however, EHRs and predictive analytics make a formidable pair. Together as the bread-and-butter of the health IT stack, EHRs and predictive analytics empower healthcare providers to capture data, interpret it for actionable insights—regardless of complexity or magnitude—and help providers with their patients in the continuum of care.

 

Personalized Population Management does not replace an EHR. Rather, Personalized Population Management complements a robust EHR system. In this new era of healthcare, predictability tied with communication and reporting gives doctors the ability to ultimately improve their financial and clinical outcomes and focus on what matters most, the patient.

 

The Medicare Access and CHIP Reauthorization Act (MACRA) is underway to completely change how healthcare providers approach medicare payments. Are you ready? Join us as we discuss how to approach MACRA in our upcoming webinar, MACRA: Addressing the Transition.

 

I Will Keep Them From Harm and Injustice (Part 2)

CareSkore

Part 2: Preventing No-Shows

 

Being stood up is never fun and it’s disrespectful in professional appointments. Unfortunately, it’s not a matter of if, but when patients will miss appointments. People will get stuck in traffic and priorities shifting throughout the day. No-shows will continue to occur, but there are ways to dramatically reduce patients from disappearing.

The problem with no-shows is that healthcare providers don’t get notice of a patient’s status. It could be because of time constraints, monetary constraints (e.g. insurance deductibles), or even physical constraints. The reasons behind patient no-shows may vary by individual needs.

Healthcare providers have attempted to reduce no-shows with a fee policy. One office placed “problem patients” on probation. Others simply absorb the lost time and income. While the onus ultimately rests upon the patient, doctors cannot provide proper care if the patients do not show up. It hurts a patient more than the physician.

In part two of our Population Health Management series, we explore the problem of no-shows, and how to prevent it from occurring.

 

Challenge #2: Preventing no-shows

No-shows are defined as intended appointments that are not canceled or rescheduled less than two hours before the designated time.

The worst part of patient no-shows is not knowing a patient’s condition. For doctors, this uncertainty is cause for concern because it elevates the risk of pain and suffering. Prolonging a diagnosis and treatment for a medical condition can be both physiologically and financially taxing.

Patient no-shows have been reported to be as low as 5.5% and as high as 30%. Higher rates were particularly apparent for academic practices.

No-show patients may seem harmless since it guises itself as a much-needed break for overworked physicians. But it severely hurts a hospital’s bottom line. Not only does the practice lose revenue, cost per patient increases as well as readmission rates, which may lead to hefty penalties.

 

Opportunity: Reducing Patient No-Shows

Understanding your patients is critical for reducing no-shows. It begins with observing your practice’s no-show rates. Only 63% of healthcare providers tracked missed appointments. The remaining practices are unaware of the severity of their no-show rates, and would be difficult to measure and improve on performance.

In one study, a 47% of patients are habitual no-show patients. The problem is that the 35% of the habitual no-show patients had close ties with the physicians. This makes no-show policies difficult to implement. In fact, 7% of the habitual no-shows are also 15% of the arrived visits. This makes patient management a complex and sensitive challenge.

Understanding the individual patient is as important as knowing the patient population. Each patient is unique and has different reasons for not attending an appointment. The likelihood of patient no-shows can be attributed to their clinical data, claims history, demographics, and socioeconomic status.

 

Recommendations: Nurture your Patients

There are many reasons why patients fail to appear without notice. There are ways healthcare providers can reduce no-show rates by focusing on actively engaging at-risk patients.

Traditional methods such as no-show fees, double bookings, or first come first serve practices, can marginally improve no-shows. However, these techniques can cause friction and are as unprofessional as a discount domestic airline.

To focus on the cause, rather than the symptom, healthcare providers should place more attention on long lead times. Doctor’s appointments are often made weeks in advance, which patients have to be diligent to reserve. As the appointment approaches, reminders are often necessary.

Suum cuique is the latin verb for “To each their own.” Everyone has a personal preference. Using a personalized approach encourages, rather than punishes, patients for showing up. And it’s showing results.

Patients are five times more likely to keep an appointment when they receive a call reminder. By receiving reminders, 17.3% of patients missed appointments, compared with 23.1% of patients who received no reminder call missed their appointments.

However, calling to remind each patient is laborious. Patient Relation Management technologies such as CareSkore, actively engages patients using Short Messaging Service (SMS). Texting a patient not only provides clear communication, it is automated, bidirectional, and asynchronous.

 

Automated

When an appointment is approaching messaging technologies can automatically send reminders to patients without using admin time.

 

BiDirectional

SMS technologies that leverage Artificial Intelligence (A.I.) like CareSkore engages patients in a natural conversation. Unlike push notifications, A.I. is bidirectional, which means the computer understands the language and responds accordingly.

 

Asynchronous

Unlike a phone call, text messages can be received and responded without needing the recipient to be actively engaged in real time.

 

The Patient Lifecycle

No-shows hurt both patients and caregivers. But there are ways to reduce the lost time. Nurturing patients throughout their lifecycle helps avoid no-shows. This does not require a large call center, but the careful implementation of intelligent software. Doctors are here to treat, but they are only as effective as the presence of a patient.