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2018 QPP Proposed Rule: What it Means for MIPS & Quantifying the Impact on Specialty Practices – MACRA Monday

Posted on June 26, 2017 I Written By

The following is a guest blog post by Justin Barnes, Board Advisor at iHealth Innovations. This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

The Centers for Medicare and Medicaid Services (CMS) recently released a Proposed Rule highlighting recommended updates to the 2018 reporting period of the Quality Payment Program (QPP). Like flexibilities extended in 2017, the proposal seeks to further reduce reporting burdens on small practices and rural providers in the program’s second-year reporting period.

Merit-based Incentive Payment System (MIPS) reporting track updates include:

  • Increased low-volume exemption thresholds (<200 patients or <$90,000 in payments)
  • New virtual group options for solo practitioners and groups with 10 or fewer Eligible Clinicians
  • Extending “pick your pace” flexibilities into 2018
  • Postponing introduction of the Cost category to MIPS composite scores
  • Factoring MIPS performance improvements into quality scores
  • Permissions for facility-based providers to report through the facility where they do most of their work instead of the practice
  • Permitting the use of 2014 CEHRT in 2018 reporting

The Rule introduces new MIPS bonus point opportunities for:

  • The use of 2015 CEHRT
  • The care of complex patients

Recommendations also extend small practice relief including:

  • Up to 5 bonus points for practices with 15 or fewer Eligible Clinicians
  • Hardship exemption for Advancing Care Information category measures
  • Additional points on Quality measures that don’t meet completeness requirements

Comments on the Proposed Rule are due by August 21, 2017. Physicians have until October 2, 2017, to begin collecting performance data for the inaugural 2017 MIPS reporting period.

Calculating MIPS: The Financial Impact on Specialty Practices

Results from a crowdsourced survey fielded by Black Book Research among nearly 9,000 physician practices from February through April of 2017 reveal that 94 percent of physician participants were unaware or unsure of how to predict their 2017 MIPS performance scores. Seventy-seven percent of practices with three or more clinicians reported intentions to purchase MIPS compliance technology solutions by the fourth quarter of this year, largely driven by an inability to independently determine earning potential under MACRA.

Orthopedics, cardiology and radiology are among the highest incentivized specialties under MIPS. To help specialty practices quantify the fiscal impact MIPS poses, we evaluated average Medicare earnings by specialty to establish the MIPS calculations below. These estimates are based on bare minimum earnings and losses that could be greater for practices with larger Medicare patient populations and/or more physicians. (Calculations are strictly illustrative estimates.)

Cardiology Practices
Estimated average payment adjustment for a 5-clinician cardiology practice in 2019 alone: $43,601
Number of cardiology-specific QPP measures: 20

Orthopedics Practices
Estimated average payment adjustment for a 6-clinician orthopedics practice in 2019 alone: $34,603
Number of orthopedics-specific QPP measures: 21

Radiology Practices
Estimated average payment adjustment for a 6-clinician radiology practice in 2019 alone: $30,117
Number of radiology-specific QPP measures: 22

Note: The above projections assume the full incentive and penalty will be paid out as outlined in the MACRA law. However, the positive and negative payment adjustments will be scaled so the program is budget neutral. This means that the positive payment adjustments will have to be offset by penalties.

Navigating the Transition to MIPS
As clinicians prepare for reporting under MIPS, establishing specialty-specific expertise on financial, clinical and technical objectives can help practices thrive rather than just survive.

Tips as you for prepare for MIPS:

  • Know your reporting options and pick your path.
  • Choose measures that play to the strengths of your specific specialty practice. Review your current billing codes and Quality and Resource Use Report to help determine these areas.
  • Do a technology asset inventory to make sure you can track the required CQMs.
  • Customize your EHR for track your selected measures or ID an outsource vendor to assist.
  • Work towards minimum reporting requirements to avoid a penalty with a stretch goal to report on the full required measures to maximize positive adjustment earnings potential.

Additional resources:
QPP website
An overview and support documentation is available at the CMS QPP website here.

MIPS EDU Program
A new “Quality Payment Program in 2017: Pick Your Pace Web-Based Training” course with Continuing Education Credit is available through the Learning Management System. Learn more here.

2017 CMS-Approved Qualified Clinical Data Registries
Additional specialty-specific measures are available via approved 2017 QCDRs to meet MIPS reporting requirements. Options for cardiology, radiology and orthopedic practices are included. Learn more here.

About the Author:
Justin Barnes is a nationally recognized business and policy advisor who serves as Chairman Emeritus of the HIMSS EHR Association as well as Co-Chairman of the Accountable Care Community of Practice. As Board Advisor with iHealth, Justin assists providers with optimizing revenue sources and transitioning to value-based payment and care delivery models. Justin has formally addressed Congress and the last three Presidential Administrations on more than twenty occasions on the topics of MACRA, value-based medicine, accountable care, interoperability, consumerism and more. He is also host of the weekly syndicated radio show “This Just In.” Justin can be found on Twitter at @HITAdvisor.

Specialty-Focused EHRs Re-Entering The Picture

Posted on June 6, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Over time, I’ve read a great deal on whether specialist clinicians should invest in EHRs designed for their area of practice or not. One school of thought seems to be that specialists can do just fine by buying broadly-based systems and implementing practice-specific templates, a move which also offers them a longer list of EHRs from which they can choose. Another, meanwhile, is that EHRs designed for use by all clinicians can undercut practice efficiency by forcing specialist workflow into a one-size-fits-all straightjacket.

But the arguments in favor of specialized EHRs seem to be taking hold of late. According to the latest data from Black Book, specialist surgical and medical practices have been switching over to specialty-driven EHRs in overwhelming numbers during the first half of this year. Its researchers found that during the first and second quarter of 2016, 86% of the 11,300 specialty practices it surveyed were in favor of switching from generalist to specialist EHRs.

According to the research firm, 93% of specialists surveyed felt that templates available in specialty EHRs offered a substantial benefit to patients who needed individualized documentation, especially in practices that see a high volume of predictable diagnoses.

If that’s the case, why did so many specialists start out with generalized EHRs?  Eighty-nine percent of respondents said that they bought the non-specialist EHR they had because they were focused on meeting Meaningful Use deadlines, which left them too little time to vet their original EHR vendor sufficiently.

Lately, however, specialist practices have decided that generic EHRs just aren’t workable, Black Book found. Nearly all respondents (92%) said that given their workflow needs, they could not afford to spend time need to shape all-purpose systems to their needs. When they switched over to purchasing a specialty-driven EHR, on the other hand, specialists found it much easier to support ultra-specific practice needs and generate revenue, Black Book reported.

That being said, specialists also switched from generalized EHRs to practice-specific systems for reasons other than clinical efficiency. Black Book found that 29% of specialists make the change because they felt their current, generic EHR was not achieving market success, raising the possibility that the vendor would not be able to support their growth and might not even be stable enough to trust.

Specialists may also be switching over because the systems serving their clinical niche have improved. Black Book researchers note that back in 2010, 80% of specialist physicians felt that specialized EHRs were not configurable or flexible enough to meet their needs. So it’s no surprise that they chose to go to with more robust multi-use and primary care systems, argues Black Book’s Doug Brown.

Now, however, specialized EHRs perform much better, it seems. In particular, improvements in implementations, updates, usability and customization have boosted satisfaction of specialist EHRs from 13% meeting or exceeding expectations in 2012 to 84% in the second quarter of 2016.

Still, practices that buy specialty EHRs do make some significant trade-offs, researchers said. Specifically, 88% of specialists said they were concerned about a lack of interoperability with other providers, particularly inpatient facilities. Respondents reported that specialty-specific EHRs aren’t fitting well within hospital network and regional health information exchanges, imposing a considerable disadvantage over large multispecialty EHRs.

And not surprisingly, investing in a replacement specialty EHR has proven to be a financial burden for specialist practices, Black Book concluded. Forty-eight percent of all specialty practices switching EHRs between June 2014 and April 2016 said that making such investment has put the practice in an unstable financial position, the research firm found.

My general sense from reading this research is that specialist practices have good reasons to replace their generalized EHR with a specialist EHR these days, as such products appear to have matured greatly in recent years. However, these practices had better be ready to deploy their new systems quickly and effectively, or the financial problems they’ll inherit will outweigh the benefits of the switchover.