Two years ago, The Medicare Access and CHIP Re-authorization Act of 2015 (MACRA) proposed to drive healthcare’s payment reforms for clinicians and other insurance services (government such as Medicare or commercial). It was intended to move from traditional fee-for-service payments to a new coordinated care model, though a little risk bearing. Following this, on May 9, 2016, the US Centers for Medicare and Medicaid Services (CMS) Quality Payment program published rules/rewards which would employ the key features of the act: ‘the Merit-based Incentive Payment System (MIPS), which would apply to eligible clinicians that Medicare pays under the Physician Fee Schedule (PFS), as well as the incentives for clinicians to participate in Advanced Alternative Payment Models (APMs).’
The MIPS Model:
The purpose of MIPS is to support independent practices and its payments thereby improving patient care, and to decrease provider burdens. The payments differ on the basis of the organization’s capability to augment people, processes and technology for collecting and reporting data as per the MIPS measures; along with enhancing the clinicians’ performance to match up to the MIPS measures. The MIPS model administers bonuses or penalties to physicians depending on their performance with respect to other physicians on the basis of predetermined set of quality and value measures. The bonuses and the penalties focus on the base fee-for-service rates and the annual payment updates. This program changes the way Medicare pays physicians and therefore, it is imperative for physicians to understand the challenges and opportunities it poses.
Oncologists’ Revenue Benefits?
Under the MIPS program, the oncologists will be reimbursed in a positive, neutral or negative adjustments based on an individual/group practice.
For better reimbursements, oncologists must ensure their practice is reporting for the PQRS system, Meaningful Use, Quality and Resource Use Report and Value-Based Payment Modifier as these scores will then be merged to a single MIPS score with Advanced Care Information (formerly Meaningful Use), Cost (formerly Value-Based Modifier Program), Improvement Activities and Quality (formerly PQRS). Physician services data of 2017 must be submitted to CMS in 2018. CMS will then evaluate and begin reimbursements in 2019. ‘The MIPS score, ranging from 0 to 100, will be determined from quality activity (50% of score), electronic health record (EHR) use (25%), cost of care (10%), and clinical practice–improvement activities (15%).’
Lower score will make oncologists receive a reduced fee schedule/negative payment adjustment of 4% in 2019, whereas a high score will see an increase by 4% in 2019; all moving up to +-9% in 2022 and beyond. The MIPS program further consists of 19 oncology reportable process and outcome measures, under which 6 must be reportable measures and 1 outcome measure; if more are reported, highest scores are taken. The practices must also report a minimum of 20 cases, with 50% of patients qualified for each measure.
Oncologists to increase revenues can also report further for bonus scores based on public health and clinical data registry. Clinical Practice Improvement Activities account for 15% of MIPS composite performance score, while attesting 4 improvement activities for a minimum of 90 days; i.e. any quality data that has been reported for at least 90 days in 2017 is eligible for payment adjustment in 2019. If there is no reporting, there will be a negative payment adjustment in 2019; if minimal submission, there will be only an avoidance of negative payments; if there is partial submission, the practice earns neutral or small positive payment; and finally, if practices submit a full data of 2017, they can earn a moderate positive payment adjustment. All this could include documented chemotherapy plans and current medication/medication reconciliation.
MACRA is a complete change from the status quo. The authorized reporting and reimbursement mechanism/program of MIPS for clinicians and physicians payments is certainly paving the way to becoming the game-changer at every stage of the healthcare system.
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