Quality Reimbursement: CMS’s Move Away From
Traditional Fee-For-Service Reimbursement and the Impact
on Physician Practices
Exploratory Paper
Steve Smith, MBA, FACMPE
August 3, 2017
This paper is being submitted in partial fulfillment of the requirements of Fellowship in
the American College of Medical Practice Executives
Quality Reimbursement: CMS’s Move Away From Traditional Fee-For-Service Reimbursement
and the Impact on Physician Practices
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Introduction
Reimbursement, and the maximization of that reimbursement, is a constant concern for Physician
Practice Executives and the organization they work for. Traditionally, executives have focused
on metrics such as efficiency, coding, and utilization management in order to maximize their
Medicare and Medicaid revenue. However, through the process of healthcare reform, the Centers
for Medicare and Medicaid Services (CMS) has introduced multiple new payment models (some
of which are voluntary and some of which are mandatory) which, if a physician practice
participates in, provides additional rewards when the practice meets or exceeds defined metrics.
Practices should, however, note that these new models also present downside risk for those
practices which do not meet stated performance metrics. Executives must therefore perform
detailed analysis to determine which programs the practice will participate in, as well as what
metrics need to be met for the practice to be successful under those programs. This exploratory
paper will examine three new payment models introduced by CMS since 2013: Comprehensive
Care for Joint Replacement (CJR), Comprehensive Primary Care Plus (CPC+), and the Medicare
Access & CHIP Reauthorization Act of 2015 (MACRA).
This paper will provide a brief background of three recent CMS value-based reimbursement
programs as well as the impact of those programs on the operations and financial success of
practices. The CMS Innovation Center website as well as articles and program fact sheets will be
utilized to communicate program requirements and opportunities in an effort to make these
complex programs more understandable for practice administrators and leadership. Best practices
and next steps will also be provided to guide practice leadership in their program implementation.
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Background
Healthcare organizations find themselves in an ever-changing industry. In the recent past there
have been many initiatives focused on areas such as privacy, security, and access to care, just to
name a few. The next major change seems to be a movement towards quality services at a
decreased cost. The Centers for Medicare & Medicaid Services (CMS) has implemented the
“CMS Quality Strategy 2016,” which includes the following three aims:
• Better Care: Improve the overall quality of care by making healthcare more person-
centered, reliable, accessible, and safe.
• Healthier People, Healthier Communities: Improve the Health of Americans by
supporting proven interventions to address behavioral, social, and environmental
determinants of health, and deliver higher-quality care.
• Smarter Spending: Reduce the cost of quality healthcare for individuals, families,
employers, government and communities.
In an effort to fulfill these aims, CMS has also defined the following six priorities in the quality
strategy:
• Make care safer by reducing harm caused in the delivery of care.
• Strengthen person and family engagement as partners in their care.
• Promote effective communication and coordination of care.
• Promote effective prevention and treatment of chronic disease.
• Work with communities to promote best practices of healthy living.
• Make care affordable.
Although the above aims and priorities were published in the “CMS Quality Strategy 2016”
document, The Department of Health and Human Services (HHS) indicated desires to change
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from a volume-based to a value-based reimbursement system in a press release dated January 26,
2015. In that release HHS Secretary Sylvia M. Burwell announced “a goal of tying 30 percent of
traditional, or fee-for-service, Medicare payments to quality or value through alternative payment
models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by
the end of 2016, and tying 50 percent of payments to these models by the end of 2018.” (Better)
The release would later state “HHS also set a goal of tying 85 percent of all traditional Medicare
payments to quality or value by 2016 and 90 percent by 2018 through programs such as the
Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs.”
Such a change in reimbursement methodology will require that Practice Managers gain a better
understanding of alternative payment models, specific model requirements, and the potential
financial impact (positive or negative) the practice will face under model participation. This
paper will examine three such alternative payment models and the potential impact to
reimbursement of each: Comprehensive Care for Joint Replacement (CJR), Comprehensive
Primary Care Plus (CPC+), and the Medicare Access & CHIP Reauthorization Act of 2015
(MACRA).
Comprehensive Care for Joint Replacement (CJR)
Background
According to CMS, “Hip and knee replacements are the most common impatient surgery for
Medicare beneficiaries and can require lengthy recover and rehabilitation periods. In 2014, there
were more than 400,000 procedures, costing more than $7 billion for the hospitalizations alone.
Despite the high volume of these surgeries, quality and costs of care for these hip and knee
replacement surgeries still vary greatly among providers.” (Comprehensive Care) For these
reasons CMS published the final CJR rule on November 16, 2015, which identified 67
Metropolitan Statistical Areas (MSAs) in which hospitals paid under the Inpatient Prospective
Quality Reimbursement: CMS’s Move Away From Traditional Fee-For-Service Reimbursement
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Payment System (IPPS) were required to participate in the model. A listing of the MSAs
participating in the model can be found in Appendix A.
Model Overview
Pricing and Payment
The CJR model holds participant hospitals responsible for the total costs of the episode of care for
90 days following discharge for those patients assigned MS-DRG 469 (Major joint replacement
or reattachment of lower extremity with major complications or comorbidities) or MS-DRG 470
(Major joint replacement or reattachment of lower extremity without major complications or
comorbidities). Each participating hospital is assigned a separate episode target price for each
MS-DRG which “generally will include a discount over expected episode spending and
incorporate a blend of historical hospital-specific spending and regional spending for LEJR
episodes, with the regional component of the blend increasing over time.” (Comprehensive Care
for Joint Replacement Model Provider and Technical Fact Sheet)
Those participating hospitals that achieve Medicare spending below the target price are eligible to
earn up to 5% of the target price in the first and second performance years. In year three of the
program those hospitals are eligible for 10% of the target price and in years four and five the
hospitals are eligible for 20%. However, if the participant hospital exceeds the aggregate
spending limit, that hospital is required to repay the difference to Medicare up to a specified
repayment limit beginning in performance year two. Those limits are 5% in performance year
two, 10% in year three, and 20% in years four and five.
Quality and Pay-For-Performance Methodology
It should come as no surprise to any healthcare professional that a decrease in cost, although
important to CMS, is not the only consideration made by CMS when determining success under
this model. Hospitals will be required to display a minimum level of episode quality before they
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are eligible to receive any reconciliation payments. To determine that minimum quality level,
CMS has adopted a composite quality score methodology. The composite score will be a
representation of performance and improvement of two quality measures: (1) THA/TKA
Complications Measure (NQF #1550) and (2) the HCAHPS patient experience survey measure
(NQF #0166). (Comprehensive Care for Joint Replacement Model Provider and Technical Fact
Sheet)
In addition to the composite score, CMS will take into consideration the hospital’s ability to avoid
expensive and harmful events such as readmissions, and hospital-acquired infections. Events
such as these have historically shown an increase not only in episode spending, but also quality
outcomes and patient satisfaction. Because this model aims to decrease cost and increase quality,
those hospitals with such events may find their reconciliation payments decreased, or eliminated
altogether. Conversely, those hospitals which achieve higher levels of quality and patient
satisfaction may see higher levels of incentive payments.
It should be noted, however, that CMS will provide hospitals with tools to help them improve
care coordination. These tools will be available to all hospitals included in selected MSAs and
include (Comprehensive Care for Joint Replacement Model Provider and Technical Fact Sheet):
1. Providing hospitals with relevant spending and utilization data.
2. Waiving certain Medicare requirements to encourage flexibility in the delivery of care.
3. Facilitating the sharing of best practices between participant hospitals through a learning
and diffusion program.
Beneficiary Benefits and Protections
While the focus in terms of financial and quality outcomes is primarily set on the anchor hospital,
CMS has been proactive in ensuring Medicare beneficiaries are not denied their rights as a patient
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under this model. For example, any patient who received an LEJR service in an MSA has the
right to choose the services provided as well as the provider of those services. And those choices
are not limited to the acute care setting. Although the anchor hospital may set up a narrow
network of post-acute providers where they prefer to have patients sent for post-acute care,
patients ultimately have the right to choose where they receive those services, regardless of
whether or not the facility of choice is included in the narrow network. In addition, patients have
the right to notify a Quality Improvement Organization (QIO) or CMS in the event they received
poor care.
Interaction with Other Models and Programs
It should be noted that there may be instances where either patients who receive LEJR services or
the anchor hospital itself may be covered by or participate in other CMS models. In these
instances the patients who receive LEJR services will still be counted in the reconciliation for the
anchor hospital. However, the successful treatment and care for these patients will likely result in
positive outcomes in those other models. For example, if a hospital participates in the Shared
Savings Program and treats a CJR patient with low cost and high quality outcomes, the hospital
may be eligible for increased reimbursement under both models.
Provider organizations can also benefit from being a participant in CJR under the new Medicare
Access and CHIP Reauthorization Act of 2015 (MACRA). Track 1 of the CJR model has been
selected by CMS as an Advanced Alternative Payment Model (APM) under MACRA legislation.
Provider groups who participate in this track will be exempt from reporting Merit-Based
Incentive Payment System (MIPS) data to CMS and will be eligible for a 5% lump sum bonus on
an annual basis from 2019 through 2022.
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Best Practices for Success Under CJR
Alignment with Post-Acute Providers
By holding the participant hospital responsible for the entire episode of care, CMS requires
participant hospitals to think much differently about patient care after discharge. Participant
hospitals can no longer simply find a post-acute facility such as a Skilled Nursing Facility (SNF)
or Inpatient Rehabilitation Facility (IRF) with a bed available for the patient. Instead, participant
hospitals have begun to develop narrow networks of post-acute facilities to allow for greater
collaboration, care coordination, and hopefully, reduced episode costs.
However, creating and maintaining these narrow networks is not an easy task for the participant
hospitals, primarily because of the differences in reimbursement methodology. Take for example
a SNF facility, which is paid a daily rate by CMS. Historically, SNFs had the ability to maximize
revenue by keeping patients in their building for the maximum number of days allowed by CMS
and ensuring all of the patients concerns were thoroughly addressed prior to discharge. Under
CJR, however, an anchor hospital would like to have CJR patients discharged as quickly as
possible, while still medically appropriate, in an effort to reduce costs.
So how might an anchor hospital convince the SNF that discharging the patient sooner is a good
thing? Inclusion in the anchor hospital’s narrow network. But inclusion in that network takes
more than simply agreeing to do so. Facilities in a narrow network have to understand the cost
constraints the anchor hospital is subject to and agree to change the way they have historically
cared for patients. Some of those changes could include decreased lengths of stay, ER diversion
protocols, increased communication with the anchor hospital, and continual meetings between the
two entities to discuss areas of success and possible improvement under the regulation. While all
of these will undoubtedly require time and resources, being included in the hospital’s narrow
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network will likely result in increased referrals, which may help to offset the decreased revenue
due to decreased lengths of stay.
If informal alignment through the narrow network is not enough to change past behaviors, the
CJR regulations also allow facilities to engage with each other through gainsharing agreements.
These agreements allow for a more formal alignment, where both facilities share the risks and
opportunities under the regulation. When both entities have a financial stake in the performance
of the anchor hospital under CJR, the willingness and desire to change past care standards is more
easily achieved.
Data Analytics
The ability to collect, analyze, and act on collected data is imperative to the success under a
program such as CJR. Anchor hospitals need to have an understanding of not only their historical
performance for these types of procedures, but also the performance of post-acute providers in
their market. Unfortunately the latter of the two has traditionally not been tracked by some as it
has not been a primary concern. However, since hospitals are now being held accountable for the
costs of post-acute providers, information such as average length of stay, readmission rates (either
to the anchor hospital or other facilities), and quality scores must now be benchmarked. And only
those who are the top performers should be considered for inclusion in the narrow network
formed by the anchor hospital.
Unfortunately, as mentioned above, some of this data is not readily available. Information
regarding quality ratings, penalties, etc., can be found on the Nursing Home Compare website,
but information related to lengths of stay and readmissions may be harder to determine. For this
reason some hospitals have engaged with third-party providers who have access to historical
Medicare claims data. Through data mining these third-party providers are able to provide
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dashboard reports on post-acute providers. This data can then be used to develop scorecards,
which can help in the development of potential narrow network members.
Similar data mining can be implemented to track the hospital’s own historical performance.
Vendors can help the anchor hospital by determining the 90-day episode applicable for each
patient encounter that would have qualified under the CJR model, and benchmarking those
episodes against the target prices established by CMS. These benchmarks can then be used to
determine areas of care which need improvement, care pathways that may need to be modified,
and areas of success that may be able to be used as a guide for future episodes.
Comprehensive Primary Care Plus (CPC+)
Background
CMS launched the initial Comprehensive Primary Care initiative in 2012, which was aimed at
testing a new payment model for the delivery of comprehensive primary care. Under the CPC
model, CMS and other payers provided participating practices with monthly care management
fees on a per member basis. Practices were also eligible to share in savings achieved through the
more comprehensive services offered. After the completion of the CPC initiative, and because of
the successes achieved under that model, CMS announced the implementation of Comprehensive
Primary Care Plus (CPC+).
Round one of the (CPC+) initiative began on January 1, 2017 with a goal to “enable primary care
practices to care for their patients the way they think will deliver the best outcomes and to pay
them for achieving results and improving care.” (Comprehensive Primary Care Plus (CPC+)
Round 1 Practice Participants Fact Sheet) In order to be considered for participation, CMS
identified regions in the United States where there was interest from both commercial payers and
practices. Once the regions for round one were announced, practices within those regions were
allowed to submit an application for participation with CMS. That application had to indicate
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why the practice would be successful under the program, demographic data regarding the
practice, and how any funds received by CMS under the model would be utilized. CMS then
reviewed the applications and ultimately selected a total of 2,893 practices in round one of the
program (1,378 practices in Track 1 and 1,515 practices in Track 2). The regions included in
Track 1 of CPC+ can be found in Appendix B.
CMS has announced a second round of CPC+ applications which will begin in February 2017.
The initial application will be for payers in up to 10 additional regions and new payers in the 14
regions included in Round 1. Based on the responses received, CMS will then begin accepting
practice applications in the summer of 2017. However, CMS has decided that no new practices
from Round 1 regions will be accepted for Round 2.
Model Overview
CMS has designed CPC+ with two different tracks. Those practices accepted to Track 1 will
have the goal of building capabilities to deliver more comprehensive primary care to their
patients. Track 2 practices, however, have already built these capabilities and instead will focus
on assessment, risk stratification, and management of more complex patients.
Regardless of the track selected, practices involved in CPC+ will be required to deliver a more
comprehensive level of care that should lead to increased health in the population served by the
practice. In an effort to help practices achieve that goal and to make it more financially feasible,
CMS will issue payments to the practices on a monthly basis. Practices will be required to
account for the use of those funds so CMS can verify funds were truly used to enhance primary
care services and not simply retained by the practice.
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Program Track Requirements
Depending on the track each practice was selected to, there are differing operational requirements
that must be fulfilled under CPC+. In a CPC+ Care Transformation Brief, CMS identified five
CPC+ Primary Care Functions which practices in both tracks will utilize to transform care
delivery:
1. Access and Continuity – Ensuring that patients have timely access to engage the team
will enhance that relationship and increase the likelihood that the patient will get the right
care at the right time, potentially avoiding costly urgent and emergent care.
2. Care Management – Practices will identify high-risk, high-need patients in two ways: (1)
systematically risk stratify their empaneled population to identify the high risk patients
most likely to benefit from targeted, proactive, relationship-based (longitudinal) care
management; and (2) identify patients based on event triggers (e.g., transition of care
setting; new diagnosis of major illness) for episodic (short-term) care management
regardless of risk status. Practices will provide both longitudinal care and episodic care
management, targeting the care management to best improve outcomes for these
identified patients.
3. Comprehensive and Coordinated Care – Adds both breadth and depth to the delivery of
primary care services, builds on the element of relationship that is at the heart of effective
primary care, and is associated with lower overall utilization and costs, less fragmented
care, and better health outcomes.
4. Patient and Caregiver Engagement – Practices will organize a Patient and Family
Advisory Council (PFAC) to help them understand the perspective of patients and
caregivers on the organization and delivery of care, as well as its ongoing transformation
through CPC+.
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5. Data-Driven Population Health Management – Using team-based care, practices will
proactively offer timely and appropriate preventive care, and evidence-based
management of chronic conditions. Practices will improve population health through the
use of evidence-based protocols in team-based care and identification of care gaps at the
population level, as well as measure and act on the quality of care at both the practice and
panel level.
In order to demonstrate a practices ability to fulfill those Primary Care Functions, CMS has
issued guidance to practices which indicates the minimum requirements for each function. As
mentioned previously, the requirements for those practices selected for Track 2 are more complex
and build on the requirements of Track 1. Below is an outline of the requirements of each track:
Track 1 Track 2
Access and Continuity
1.1 Achieve and maintain at least 95% empanelment to practitioner and/or care teams
1.4 Regularly offer at least one alternative to traditional office visits to increase access to care team and clinicians in a way that best meets the needs of the population, such as e-visits, phone visits, group visits, home visits, alternate location visits (e.g., senior centers and assisted living centers), and/or expanded hours in early mornings, evenings, and weekends
1.2 Ensure patients have 24/7 access to a care team practitioner with real-time access to the EHR
1.3 Organize care by practice-identified teams responsible for a specific, identifiable panel of patients to optimize continuity
Track 1 Track 2
Care Management
2.1 Risk-stratify all empaneled patients 2.1 Use a two-step risk stratification process for all empaneled patients: Step 1 - Based on defined diagnoses, claims, or another algorithm (i.e., not care team intuition Step 2 - adds the care team's perception of risk to adjust the risk-stratification of patients, as needed
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2.2 Provide targeted, proactive, relationship-based (longitudinal) care management to all patients identified as at increased risk, based on a defined risk stratification process and who are likely to benefit from intensive care management
2.6 Use a plan of care centered on patient's actions and support needs in management of chronic conditions for patients receiving longitudinal care management
2.3 Provide short-term (episodic) care management along with medication reconciliation to a high and increasing percentage of empaneled patients who have an ED visit or hospital admission/discharge/transfer and who are likely to benefit from care management
2.4 Ensure patients with ED visits receive a follow up interaction within 3 days of discharge
2.5 Contact at least 75% of patients who were hospitalized in target hospital(s) within 2 business days
Track 1 Track 2
Comprehensiveness and Coordination
3.1 Systematically identify high-volume and/or high-cost specialists serving the patient population using CMS/other payer's data
3.3 Enact collaborative care agreements with at least two groups of specialists identified based on analysis of CMS/other payer reports
3.2 Identify hospitals and EDs responsible for the majority of patients' hospitalizations and ED visits, and assess and improve timeliness of notification and information transfer using CMS/other payer's data
3.4 Choose and implement at least one option from a menu of options for integrating behavioral health into care
3.5 Systematically assess patients' psychosocial needs using evidence-based tools
3.6 Conduct an inventory of resources and supports to meet patients' psychosocial needs
3.7 Characterize important needs of sub-populations of high-risk patients and identify a practice capability to develop that will meet those needs, and can be tracked over time.
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Track 1 Track 2
Patient and Caregiver
Engagement
4.1 Convene a PFAC at least once in PY2017, and integrate recommendations into care, as appropriate
4.1 Convene a PFAC in at least two quarters in PY2017 and integrate recommendations into care, as appropriate
4.2 Assess practice capability and plan for support of patients' self-management
4.2 Implement self-management support for at least 3 high risk conditions
Track 1 Track 2
Planned Care and Population Health
5.1
Use feedback reports provided by CMS/other payers at least quarterly on at least 2 utilization measures at the practice-level and practice data on at least 3 electronic clinical quality measures (derived from the EHR) at both practice- and panel-level to inform strategies to improve population health management
5.2 Conduct care team meetings at least weekly to review practice- and panel-level data from payers and internal monitoring and use this data to guide testing of tactics to improve care and achieve practice goals in CPC+
Program Track Payment Models
CMS acknowledged in the Comprehensive Primary Care program that practices who agreed to
the level of required practice and care redesign would require resources and funds to successfully
implement that redesign. In an effort to help practices meet these needs, CMS implemented Care
Management Fees (CMFs). Based on the success of the CPC program, CMS has determined it
will continue to pay practices CMFs under CPC+.
CMS and commercial payers will issue monthly CMF payments on a prospective basis to both
Track 1 and Track 2 practices. The use of these funds, however, must be used to support staffing
and training necessary to meet the model requirements according to practice needs. Patient-
specific CMF payment will be based on the risk tier identified by CMS, which will be based on
the Hierarchical Condition Categories utilized by the practice. The risk-tier payments for each
track established by CMS are:
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Risk Tier Attribution Criteria Track 1 Track 2
Tier 1 1st quartile HCC $6 $9
Tier 2 2nd quartile HCC $8 $11
Tier 3 3rd quartile HCC $16 $19
Tier 4 4th quartile HCC for Track 1; 75-89% HCC for Track 2
$30 $33
Complex (Track 2 only)
Top 10% HCC OR Dementia
N/A $100
Average PBPM
$15 $28
In addition to the CMF payments, CMS has also implemented Comprehensive Primary Care
Payments (CPCPs), which are intended to “promote flexibility in how practices deliver care that
is traditionally provided face-to-face, and requires practices to increase the depth and breadth of
primary care they deliver.” (Comprehensive Primary Care Plus (CPC+) Fact Sheet) While Track
1 practices are not eligible for these payments and will continue to receive traditional fee-for-
service payments under the CPC+ model, Track 2 practices will receive a combination of fee-for-
service and CPCP. Practices are permitted to elect what percentage of fee-for-service and CPCP
payments they would like to establish for each performance year. The following is a summary of
the options available to practices by performance year:
2017 2018 2019 2020 2021
CPCP%/FFS% Options Available to Practices, By Performance Year
10%/90%
25%/75% 25%/75%
40%/60% 40%/60% 40%/60% 40%/60% 40%/60%
65%/35% 65%/35% 65%/35% 65%/35% 65%/35%
In an effort to ensure the quality of care is also considered under the CPC+ model, performance-
based incentive payments have also been introduced. These payments will be issued based on
performance on patient experience, clinical quality, and utilization measures. Track 1
participants will receive a payment of $2.50 per beneficiary per month and Track 2 participants
will receive $4 per beneficiary per month. It should be noted that although these payments will
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be paid to practices at the beginning of the performance year, CMS may recoup all or a portion of
those payments if quality and utilization thresholds are not met. This risk caused many practices
to carefully consider whether or not they should participate in the model, using their past
performance as a guide.
Practice Analysis Required Prior to Participation
While the desire to expand on primary care capabilities and financial incentives were very
attractive to many practices in Round 1 of CPC+, those practices had to undertake a careful
analysis to determine if they would be able to succeed under the model. Failure to properly
utilize prospective payments and/or meet quality and utilization targets presents a significant risk
for practices. Practices considering taking part in Round 2 of CPC+ will need to do similar
analyses in order to determine if the new payment model will be beneficial for their practice.
Regional Requirements
The first piece of analysis for practices was fairly simplistic. Practices had to determine if their
region was included in the CPC+ program, and if so, what commercial payers were also going to
participate in the model. Then, what amount of the practices payer mix was accounted for by the
combination of Medicare and commercial payers. For practices in regions such as Arkansas or
Oregon, where there were a significant number of commercial payers committed to the model,
there may have been significant upside opportunity to improve their practice capabilities with the
use of prospective payments. For practices in the Greater Kansas City region, however, there was
only one commercial payer selected to participate. Practices in that region were required to do a
thorough analysis to determine if the volumes accounted for by Medicare and Blue Cross Blue
Shield of Kansas City would provide enough of an upside opportunity to participate.
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EHR Capabilities
EHR capability was another area where practices had to undertake an extensive analysis.
Because practices are required to use Certified EHR Technology (CEHRT) under the model, they
had to not only verify their systems were considered CEHRT, but also determine what, if any,
upgrades or add-ons to existing systems would be required and what the associated costs may be.
Practices were also required to provide a Memorandum of Understanding (MOU) from the Health
IT vendor as a part of their application to the CPC+ program. If practices determined their
systems were not considered CEHRT, or the cost of necessary upgrades were too great, those
practices likely did not apply for the program, or their application was denied by CMS.
Practice Capabilities
Perhaps the most complex required analysis is how the organization operated prior to CPC+ and
the determination of whether or not systems, staff (both clinical and non-clinical), and processes
could be changed to comply with the requirements of the model. From an IT perspective,
practices not only needed to determine if upgrades could be done to their systems to comply with
the model, and the cost of those upgrades, but also how the system may be used. For example,
one of the requirements of the model is that Track 2 practices is to offer at least one alternative to
traditional office visits to increase access to care team and clinicians in a way that best meets the
needs of the population. But if the practice did not currently have this technology in place and
operational, a careful consideration of costs and timing related to purchasing, installation, and
implementation would have been required. And without a better understanding of how to
appropriately and effectively use the technology, the practice may risk failing to meet the
requirement.
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Another area requiring significant analysis is the service offerings of the practice. One of the
primary goals of CPC+ is to expand the scope of services offered in the primary care setting.
This includes services such as extended office hours, remote visits, and possibly even the
integration of behavioral health, depending on the Track the practice is in. And while the
additional funds offered by CMS in the form of proactive payments can help with some of the
staffing costs associated with these additional services, there is one aspect which may be harder to
determine…the staff’s willingness to accept and operate under the new model. Clinical staff may
not be interested in holding weekly care team meetings, remote visits, or the implementation of
behavioral health. Non-clinical staff may take issue with the extended office hours and the need
to create additional reports to comply with the new practice model. Practice Managers interested
in pursuing Round 2 of CPC+ will need to take these things into consideration and determine if
the practice is positioned for participation.
The final key area of review for practices is the payment model itself. While there is certainly
interest in finding additional revenue for the practice, the care management fees must be utilized
to enhance the practice’s’ capabilities and the applicable expenses must be reported to CMS on an
annual basis. And these funds cannot be used for the purchase or upgrade of HIT. Instead,
practices are permitted to use the funds for wages for new or existing staff, care delivery tools, or
training and travel related to CPC+ educational events. So there needs to be careful analysis done
to ensure not only how much the practice can anticipate in funds, but also how those funds will be
spent.
There also needs to be careful analysis done when determining which track of CPC+ the practice
hopes to participate in. Track 1 still reimburses practices under the traditional fee-for-service
methodology, while Track 2 includes tiered options for fee-for-service and Comprehensive
Primary Care Payments. Because of the potential impacts to practice revenue, management must
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have a solid understanding of not only which revenue model is best for the practice, but also what
tier the practice should elect if selected for Track 2.
Overall the CPC+ model can allow forward-thinking, well equipped practices a means by which
the practice can continue to evolve and add additional services for patients. However, practice
managers need to carefully analyze not only the financial implications of the model, but also the
service offerings and reporting requirements. Failure to accurately report data to CMS or
substandard quality outcomes may lead to the practice having to pay back proactive payments to
CMS, some of which may have already been spent in expanding the practice’s capabilities and
offerings. Practices considering applying for inclusion in CPC+ when the application period
opens will need to begin their analysis today in order to make the best possible decision regarding
participation.
MACRA Implications
Another aspect of CPC+ that may make the model appealing to practices is CMS’s designation of
the CPC+ model as an Advanced Alternative Payment Model (APM). As is the case with CJR,
practices taking part in CPC+ will be exempt from reporting Merit-Based Incentive Payment
System (MIPS) data to CMS and will be eligible for a 5% lump sum bonus on an annual basis
from 2019 through 2022. This lump sum payment will be made to the practice in addition to
payments received under the CPC+ model, which could make CPC+ a very attractive option for
practices that are able to successfully complete the operational requirements of the model.
Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)
For the past 13 years, practice managers have been waiting for a new reimbursement
methodology to replace the Sustainable Growth Rate (SGR) formula. Each year practices were
informed of a need to fix the SGR and to do so would require large cuts to the physician fee
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schedule. But each time those needed cuts were announced, Congress issued a “patch” which
allowed the physician fee schedule to remain relatively unchanged, sometimes with a slight
increase. When the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) was
passed, CMS not only addressed the issues with the SGR, but also continued the shift toward
value-based Medicare reimbursement.
Background
With the replacement of the SGR formula, CMS signaled a desire to move away from the
traditional fee-for-service reimbursement methodology to one that paid clinicians based on
quality and value, instead of simply volume. The MACRA regulation, also referred to as the
Quality Payment Program (QPP), also aimed to simplify physician reporting requirements, which
previously had to be done under three different programs: The Physician Quality Reporting
System (PQRS), The Value-Based Modifier (VBM), and Meaningful Use (MU).
CMS further clarified the goals of MACRA in a document titled “Strategic Objectives for the
Quality Payment Program.” In that document CMS outlined six primary objectives:
1. Improve beneficiary outcomes and engage patients through patient-centered Advanced
APM and Merit-based Incentive Payment System (MIPS) policies.
2. Enhance Clinician experience through flexible and transparent program design and
interactions with easy-to-use program tools.
3. Increase the availability and adoption of robust Advanced APMS.
4. Promote program understanding and maximize participation through customized
communication, education, outreach, and support that meet the needs of the diversity of
physician practices and patients, especially the unique needs of small practices.
5. Improve data and information sharing to provide accurate, timely, and actionable
feedback to clinicians and other stakeholders.
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6. Ensure operational excellence in program implementation and ongoing development.
The first performance year for MACRA is calendar year 2017 and any applicable changes to
provider reimbursement based on 2017 performance will be made in 2019. This two year
lookback period will continue throughout the program. However, the 2017 performance year will
be different from later years as providers are being given the opportunity to “pick your pace”
regarding how much data is reported to CMS. This is being done to allow providers to begin
operating under the new legislation with as little risk as possible to future provider payments.
Any provider or provider group that submits at least some 2017 data to Medicare (e.g., one
quality measure for one day in 2017) will have a neutral adjustment to its Medicare Part B
payments in 2019. 2018, however, will be a full performance year, where providers are required
to report all required data to CMS, with any applicable changes to Medicare Part B payments
taking place in 2020.
Model Overview
The MACRA legislation created two new tracks for Medicare Part B reimbursement: The Merit-
Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).
The MIPS track most closely resembles traditional fee-for-service reimbursement, but
adjustments to provider payments will be based on the successful reporting of four categories:
Quality, Resource Use, Advancing Care Information, and Clinical Practice Improvement
Activities. The APM track, however allows practices to achieve higher levels of reimbursement
while assuming some risk related to patient outcomes. Providers in the APM track are also
exempt from MIPS reporting.
MIPS Track
As stated above, the MIPS track most resembles traditional fee-for-service reimbursement
methodology, and aspects of the track will feel very familiar to practice managers and providers.
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However, instead of provider fee schedules being impacted in a uniform manner across a region,
the increases or decreases to Medicare Part B reimbursement will now be based on the quality
and value of care, as well as increased capabilities of the practice.
At the end of each performance year practices will submit MIPS reporting data to CMS for
analysis and comparison to other practices throughout the country. And because MACRA is a
budget neutral program, those practices who have a decrease applied to their Medicare Part B
payments will effectively fund the increased to those practices who perform well. This is most
significant in the 2017 performance year. As mentioned above, if practices are allowed to submit
just one piece of data in order to avoid negative payment adjustments, the available funds for
payment increases will be limited in 2019. However, if practices fail to be fully capable of
reporting MIPS measures in 2018, and therefore receive a maximum possible negative payment
adjustment, there is a potential for many practices across the county to receive the maximum
possible positive payment adjustments. The table below from CMS illustrates the maximum
possible positive or negative adjustments per year, under the MACRA rule:
The MACRA legislation also applied MIPS reporting requirements to more than just physician
providers. In the 2017 and 2018 performance years, the following provider types were
determined to be eligible: Physicians (MD/DO and DMD/DDS), Physician Assistants, Nurse
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Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists. In 2019 it
is possible the following provider types will be added to the list of eligible clinicians (although
final determination will be announced by CMS at a later date): Physical Therapists, Occupational
Therapists, Speech-Language Pathologists, Audiologists, Nurse Midwives, Clinical social
Workers, Clinical Psychologists, Nutritionists, and Dieticians.
However, it should be noted that there are instances where providers will be exempt from MIPS
reporting. The first group of providers exempt from MIPS reporting are those providers who
participate in APMs. Because the APMs themselves implement guidelines similar to MIPS
measures, CMS will not require data submission for both CMS and the APM.
Those providers who are in their first year of Medicare Part B participation are also exempt from
MIPS reporting. CMS understands that these providers, being new to healthcare reimbursement,
may need time to get used to billing and coding requirements. These providers can still submit
MIPS data to CMS, but their reimbursement will not be impacted. They will, however, receive
feedback from CMS which can help them better prepare for years in which they are required to
submit data and receive adjustments to payments.
Finally, those providers who fall below a low volume threshold will not be required to submit
data under MIPS. CMS has established the low volume threshold of either $30,000 in allowed
Medicare Part B charges or 100 separately identifiable Medicare beneficiaries. Individuals or
groups who fall below either of those thresholds, as identified by CMS through claims
submissions in the previous calendar year, will be exempt from MIPS reporting. This
determination will be made each year by CMS and providers will be notified of exemption in
December of each year.
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As mentioned above, practices will be assigned a composite score based on the data they submit
to CMS each year. How the composite score is determined will vary by year, with the Quality
category making up the highest percentage of the composite score for the 2017 performance year.
Specifically, CMS has established the following category weights for the first three performance
years:
In order to receive the highest possible composite score in each year, practices will need to report
the following information by performance category.
Quality
The quality category accounts for 60% of the composite score for performance year 2017 and
replaces PQRS and the quality component of the Value-Based Modifier Program. Because of the
heavy weighting during the first two performance years, many practices are very carefully
15% 15% 15%
25% 25% 25%
10%
30%
60%50%
30%
2017 2018 2019
Category Weighting
Quality
Resource Use
Advancing Care Information (ACI)
Clinical Practice Improvement Activities (CPIA)
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considering how this category is reported. In order to receive full credit for the category,
practices must report at least 6 measures, with each measure assigned a grate of between 1 and 10
points. At least one of the reported measures must be an outcome measure, although if an
outcome measure is not available for a practice it can report another high quality measure instead.
Practices can also earn bonus points by reporting additional outcome measures or high quality
measures that fit the way the practice operates or by submitting measures with end-to-end
electronic reporting.
CMS has identified more than 200 measures available for practices to select from and over 80%
of those measures have been tailored for specialists. These specialized measures resulted in CMS
developing Specialty Measure Sets, which are groups of quality measures that have been selected
for individual specialties (e.g., radiology, cardiology, etc.). Practices who elect to report on all
measures of a specialty set will receive full credit for the number of measures reported, regardless
of the number of measures in that specialty set. For example, if a specialty set contained only 4
measures, a practice that submitted all four of those measures would be eligible for full credit
under the quality category, although the stated minimum number of measures has been set at 6.
Conversely, if a specialty set contains 8 measures and a practice submits all 8 of those measures
to CMS, only the 6 highest scoring measures will be used when computing the composite score
for the practice. While this may not benefit a multi-specialty group, groups who are able to
submit data for a specific specialty set may see the flexibility and tailored measures as a way to
make reporting easier and more valuable.
In order to assist practices in determining which measures will be reported, CMS has created a
measure selection tool (https://qpp.cms.gov/measures/quality). The tool will allow practices to
filter measures based on keywords, priority level, data submission method (claims, registries,
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EHR, etc.), and specialty measure sets. Practices have the ability to export all measures or a
filtered list of measures in .csv format for additional analysis of each individual measure.
Resource Use (Cost)
The Resource Use category replaces the cost component of the Value-Based Modifier Program.
Although this category will not be considered as a part of the practice’s composite score for the
2017 performance year, CMS will provide feedback to practices throughout the year to prepare
for future performance years. Scores will be based on Medicare Part B claims adjudication so
there is no reporting required for the practices. CMS will base the practice score on total per
capita cost and Medicare spending per beneficiary. There will also be over 40 episode-specific
measures to account for reimbursement differences among specialties. Practices should carefully
review the reports provided by CMS during 2017 to identify areas of improvement for future
performance periods.
Advancing Care Information
The Advancing Care Information category replaces the former Medicare Meaningful Use
program and will account for 25% of the 2017 composite score. Perhaps the greatest advantage
of this new category is that it moves away from the “all or nothing” scoring methodology in place
under Meaningful Use and implements a benchmarked scoring system where practices can
achieve partial credit and still receive some awards if unable to achieve a score of 100%.
There are five required measures under this category, which account for 50% of the category’s
total score. The positive news for practices is that these categories are very similar to the
requirements previously in place under Meaningful Use: security risk analysis, provide patient
access, send summaries of care, participate in electronic prescribing, and request and accept
summaries of care. Practices can earn the remaining 50% of the category score through actions
such as patient education, coordination of care through patient engagement, and clinical
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information reconciliation. Bonus points can also be earned for participating in public health and
clinical data registry reporting and the use of Certified Electronic Health Record Technology
(CEHRT) to complete certain improvement activities. As with the Quality category, CMS has
published the available Advancing Care Information measures to its website and those measures
can be filtered and exported for further review.
It should be noted, however that some practices may not be required to submit data for the
Advancing Care Information category. Practices or providers who fall into one of the following
categories will have the Advancing Care Information category reweighted to 0% and the Quality
category will be reweighted to 85%:
1. Practices or providers who submit fewer than 100 patient facing encounters, as
determined by CMS after analyzing annual claims adjudication.
2. Practices or providers who are awarded a hardship exemption by CMS.
3. Practices or providers who perform at least 75% of professional services in a hospital
environment (either inpatient, outpatient, or emergency department), as determined by
CMS after analyzing annual claims adjudication.
4. Non-physician providers will receive exemptions for the 2017 performance period.
Just as with Quality metrics, practices are able to view and download the various Advancing Care
Information metrics through a quality selection tool (https://qpp.cms.gov/mips/advancing-care-
information). Practices will need to review this information as soon as possible to begin forming
or finalizing their reporting strategy.
Clinical Practice Improvement Activities
The Clinical Practice Improvement Activities category will account for 15% of the 2017
performance period composite score and activities have been determined by CMS to be either
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“high-weighted” or “medium-weighted” measures. Practices will be required to attest to the
completion of up to four improvement activities for a minimum of 90 days and like Quality and
Advancing Care Information, measures can be exported for this category from the CMS website
for additional analysis.
CMS has acknowledged that this category may be difficult for some practices, or that some
practices are already implementing these types of activities into their practice. For that reason,
CMS has announced preferential scoring methodologies for the following groups of practices:
1. Groups with fewer than 15 providers will only be required to attest to the completion of
two activities for a minimum of 90 days.
2. Groups in a geographical area identified as rural or a health professional shortage area
will only be required to attest to the completion of two activities for a minimum of 90
days.
3. Practices that have been certified by CMS as a patient centered medical home will
automatically receive full credit for this category.
4. Participants in APMs who do not have enough volume of either patients or revenue
flowing through that APM are still required to submit data under MIPS. However, these
practices will receive full credit for this category.
Again, practices are able to view the available metrics as well as download metric-specific
information at the Quality Payment Program website (https://qpp.cms.gov/mips/improvement-
activities) and should do so as soon as possible in order to finalize a reporting strategy.
APM Tracks
APMs allow practices the opportunity to earn additional revenue while assuming some risk as it
relates to patient outcomes. Practices who participate in an APM, and have enough volume of
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either patients or revenue flowing through that APM, can earn a lump-sum payment of 5% of
Medicare Part B allowable charges for participating in that model. In addition, the practice will
be permitted to earn rewards under the APM model itself. For practices who have already
implemented many of the activities listed under the MIPS track, moving to the APM track may be
a viable opportunity, but careful consideration must be made prior to changing to that
reimbursement track.
Perhaps the greatest barrier to APM participation at this time (CMS estimates only about 7% of
practices will quality for APM status in the 2017 performance year) is the limited number of
models available. In order to qualify as an APM, the model must meet the following
requirements:
1. Be CMS Innovation Center models, Shared Savings Program Tracks, or certain federal
demonstration programs.
2. Require participants to use certified EHR technology.
3. Base payments for services on quality measures comparable to those in MIPS.
4. Be a Medical Home Model expanded under Innovation Center authority or require
participants to bear more than nominal financial risk for losses.
CMS has published the following list of Advanced APMs and as additional models are approved
they will be published to https://qpp.cms.gov/learn/apms:
1. Comprehensive ESRD Care (CEC) – Two-Sided Risk
2. Comprehensive Primary Care Plus (CPC+)
3. Next Generation ACO Model
4. Shared Savings Program – Track 2
5. Shared Savings Program – Track 3
6. Oncology Care Model (OCM) – Two-Sided Risk
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7. Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1 – CEHRT)
As mentioned above, simply participating in one of the APM models is not enough to be eligible
for MIPS exemption and the 5% lump-sum bonus. Practices who elect to participate in the APM
track must have certain volumes of either patients or revenue flowing through that APM.
Otherwise, the practice will be responsible for reporting data under MIPS, although preferential
scoring will be available. The following chart obtained from CMS Quality Payment Program
Fact Sheet outlines the required volume levels established by CMS for each performance year:
Because practices will have to have some risk under these models, careful consideration must be
given not only to patient and revenue volumes, but also the possibility of the practice being
successful under the selected model. Failure to produce quality outcomes may result in a loss of
revenue under the APM and the 5% lump-sum bonus received from CMS may or may not be
enough to offset that revenue decrease.
Requirements for Success Under MACRA
While the MACRA legislation is a major change and can be intimidating for some practices, there
are some steps that can be taken now to help practices succeed in both the short and long-term
under the legislation. However, these actions should be taken now so that needed systems and
processes can be put in place prior to the first full performance year of 2018.
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Understand Financial Risk and Opportunity
Perhaps one of the most important thing to understand about the MACRA legislation is the
financial risk or opportunity faced by the practice. As discussed previously, each performance
year carries a maximum positive or negative adjustment to provider reimbursement. Practices
must be able to determine what those individual percentages mean to a practice, both in each
individual year as well as throughout the life of the program.
In order to complete this analysis, the practice needs to first identify its historical amount of
Medicare Part B allowable charges. For example, if a practice were to determine its average
allowable charges per year was $750,000, the graph below shows the potential risk and
opportunity for revenue in each payment year:
While financial risk and opportunity of only $30,000 and $37,500 in 2019 and 2020 respectively
may not seem significant, the practice must realize that by 2022 that figure will increase to
$67,500 annually, resulting in a total risk or opportunity of $390,000 between 2019 and 2025.
Practices should also keep in mind that these figures assume no additional Medicare patient
volume, no additional providers being added to the practice, and does not take into consideration
$(30,000.00)$(37,500.00)
$(52,500.00)
$(67,500.00) $(67,500.00) $(67,500.00) $(67,500.00)
$30,000.00 $37,500.00
$52,500.00
$67,500.00 $67,500.00 $67,500.00 $67,500.00
$(80,000.00)
$(60,000.00)
$(40,000.00)
$(20,000.00)
$-
$20,000.00
$40,000.00
$60,000.00
$80,000.00
2019 2020 2021 2022 2023 2024 2025
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the addition of provider types required to submit data under MIPS beginning in 2019. All of
these factors could greatly increase the possible risks and opportunities for future reimbursement.
The financial risks and opportunities, while they may seem small at the beginning of the program,
have the potential to grow very large in future years, so practices must be sure to implement plans
to ensure long-term success and risk mitigation.
Determine 2017 Reporting Option
When determining how information will be reported to CMS, practices need to determine not
only if they will report data as individuals or as a group, but also what means they will use to
actually submit their data. Both group and individual reporting have their advantages and
challenges and practices will need to carefully analyze each to determine which option is best for
their organization.
Individual or Group Reporting
Reporting under MACRA, whether as a group or an individual, is based on the combination of
NPI and Tax ID. If reporting is done at the individual provider level, each NPI will be tied to a
single Tax ID. Group reporting, however, will have multiple NPIs sharing a common Tax ID.
One aspect that must be reviewed by the practice is payment adjustments. If the practices
determines to submit data for each individual provider, then each individual provider will have
his or her payments adjusted based on their individual performance. If the group were to choose
to submit data as a group, then each provider within that group would receive the same payment
adjustment based on the group’s performance. Practice leadership will need to determine if some
providers will accept having their payment adjustments at least partially determined by their
partners. If this will cause any friction within the group, reporting as individuals may be a better
option.
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Another area of review is how the practice is currently reporting to PQRS, Value-Based Modifier,
and Meaningful Use programs, if they are at all. Reporting as individuals can certainly require
more time and resources than reporting as a group. However, if those resources are already in
place because of past reporting, reporting as individuals may not be overly cumbersome.
However, for those who have always reported data as a group, or have not reported to previous
programs, it may be more simplistic to report as a group.
Practices will also need to take into consideration whether or not they have certain providers who
may fall below the previously mentioned low volume thresholds, and if the practice wants to take
advantage of those exemptions. When reporting as a group, the group’s volume will be taken into
consideration when determining volumes. So in the case of a practice with three providers, if
each saw only 75 Medicare patients in the year, each individual would qualify for low volume
exemption. However, if the practice submitted data as a group, the patient volume would be the
combined number of 225 and the practice would be required to submit MIPS data.
Data Submission Methods
Practices are permitted to submit MIPS data to CMS in a variety of ways including Qualified
Clinical Data Registries, Qualified Registries, and through their Electronic Health Record (EHR).
The following chart identifies how each MIPS category can be submitted to CMS:
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Submission Methods Quality Cost
Clinical
Practice
Improvement
Activities
Advancing
Care
Information
Qualified Clinical Data
Registry X X X
Qualified Registry X X X
Electronic Health Record X X X
Administrative Claims (No
Submission Required) X X
CMS Web Interface
(Groups of 25 or More) X X X
CAHPS for MIPS Survey X
Attestation X X
For some practices, contracting with either a Qualified Clinical Data Registry or Qualified
Registry may be desired so they have a partner in the data submission process who can help
verify all required data is present prior to submission to CMS. Although there is a cost to using
these services, some practices have determined that cost to be low enough to not offset the
benefits of having a partner. Other practices may determine that submitting data through their
EHR is beneficial since there are available bonus points under MIPS for doing so. Practices
interested in EHR reporting will need to work closely with their vendor to ensure that vendor is
capable of doing such reporting, and also identifying any applicable system upgrades and the cost
of those upgrades.
Ultimately, the goal for a practice should be efficiency in data submission. The ideal submission
methodology would be one that can submit data to CMS for all needed categories so the practice
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doesn’t have to maintain and track submission under multiple systems. The costs of either a
third-party registry or any IT costs should also be taken into consideration when selecting a
submission method.
Assess Performance Under Previous Programs
Because MACRA replaces the PQRS, Value-Based Modifier, and Meaningful Use programs,
many of the aspects of those programs are present in the MACRA legislation. For those practices
who submitted data under, and performed well, under those past programs, much of the
infrastructure and processes needed for success may already be present. For example, many of
the measures previously available under PQRS are still available under the Quality category of
MIPS. So there may be little time or resources needed for those practices who have already
reported that data in the past. Conversely, those practices who have never reported data may
require additional time and/or resources.
For those practices that either did not submit data or submitted data, but failed to achieve high
scores under previous programs, MIPS may provide an opportunity to improve performance.
Preferential scoring for small practices, a wide variety of available measures, and multiple data
submission methods should provide much more flexibility than existed in the previous programs.
Complete a MACRA Participation Plan
A MACRA Participation Plan is simply the documented plan established by a practice for success
under the new legislation. While the plan itself may be complex, it is by no means set in stone
and may need to be edited as practices determine new opportunities for success.
Perhaps the most important aspect of the plan is the development of a Steering Committee which
can analyze program options, select appropriate measures, oversee data submission, and review
composite scores for areas of improvement. Traditionally these committees are made up of
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senior administrative leadership, clinician leadership, IT leadership, and representatives from the
organization’s department responsible for quality. Other individuals or teams can certainly be
involved as well, but these groups or individuals will make up the core of the committee.
When selecting measures, the group will need to ensure clinical leadership has a solid
understanding of documentation requirements and what will be required of clinicians. If the
committee simply tells clinicians the measures they will be expected to document and report,
those clinicians may or may not engage with the plan. However, allowing the clinicians to at
least have a say in what measures are selected and how they need to be documented, there is a
greater chance of engagement and success.
Once the committee has developed the measures to be reported, subcommittees can then be
created to specialize in the four MIPS categories. Those subcommittees will then be responsible
for the implementation, tracking, and reporting progress or needed resources back to the steering
committee. Ideally the subcommittees will meet at least twice per month in the early months of
plan implementation and those meetings can become less frequent over time as the plan is
implemented and running smoothly. Steering Committee meetings should be held at least
monthly and include a review of the MACRA Participation Plan as a standing agenda item.
Practices should also be mindful of the fact that the creation of these committees, plans, and
standard meetings will take time to implement. And meeting stated objectives will be a long-term
process involving multiple departments. So the process of planning and committee development
should start as soon as possible to make sure processes and procedures are in place and familiar
prior to the first full performance year of 2018.
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Evaluate EHR Vendor Readiness
Many practices may choose to report MIPS data through their EHR system as a means to keep
costs low while achieving higher levels of efficiency. However, those practices must ensure their
EHR vendors are capable of reporting. And if the system is not capable, the vendor will need to
indicate whether or not plans exist to implement that capability and what the costs to implement
that capability is anticipated to be. If the vendor does not plan to implement that capability in the
short term, or if the costs are anticipated to be too high, practices may need to either select a new
EHR vendor or choose to submit their MIPS data to CMS in another way.
Review Internal Processes
Internal processes will need to be continually reviewed and evaluated by the organization to
ensure MACRA reporting and data collection is not overly cumbersome to either clinical or non-
clinical staff. And as with the creation of the MACRA Participation Plan, clinical leadership
should be involved in these discussions to ensure processes do not place a burden on patient care.
These reviews should initially take place as a part of the Steering Committee’s initial meeting and
each subcommittee should attempt to identify process improvements that apply to their committee
on a continued basis, especially in the initial months of the plan. This will be especially
important for those practices that are either new to reporting data, or are reporting data they have
not reported previously. Practices who already have processes in place may not need as intensive
of an initial review and analysis, but must be sure to continually evaluate the effectiveness and
efficiency of their processes.
Consider Participating in a Qualified APM
As stated previously there are benefits in participating in a Qualified APM, both financial and
operational. However, practices must be very cautious when selecting an APM to participate in.
Because Qualified APMs have to incorporate at least a minimal level of risk to a practice’s
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revenue, practice leadership must do their due diligence in identifying APM requirements,
analyzing practice capabilities, and determining patient volumes (both in terms of the number of
patients and revenue). Practices who fail to perform well under an APM model may have their
revenue reduced by more than what was at risk under the MIPS track. And if an insufficient
volume of patients or revenue flow through that APM, the practice will not receive the 5% lump-
sum bonus paid by CMS and will still have to report data under MIPS.
Ultimately, however, successful participation in a Qualified APM can present a significant
opportunity for practices to not only improve the practice’s operations, but also increase revenue.
Because CMS plans to continually announce new Qualified APM models, practices will need to
continually refer to the formal listing at https://qpp.cms.gov/learn/apms to identify and analyze
newly announced models.
Conclusion
The Centers for Medicare and Medicaid Services (CMS) has clearly communicated its desire to
move away from traditional fee-for-service reimbursement and towards value-based
reimbursement with the implementation of Comprehensive Care for Joint Replacement (CJR),
Comprehensive Primary Care Plus (CPC+), and The Medicare Access & CHIP Reauthorization
Act of 2015 (MACRA), as well as other payment initiatives. For success under these models,
practices will be required to continually analyze aspects of patient care such as cost, quality, and
service offerings to identify areas of improvement.
The Practice Manager may assume ultimate responsibility for success under these payment
models and to continually identify, analyze, and determine whether a reimbursement model is a
fit for the organization. However, in order to perform well that manager will require a team of
individuals dedicated to the practice’s success to assist him or her in selecting and operating
Quality Reimbursement: CMS’s Move Away From Traditional Fee-For-Service Reimbursement
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within value-based reimbursement. Clinical leadership will need to provide guidance regarding
efficient, quality patient care. IT leadership will need to work closely with vendors to determine
system capabilities and identify needed system changes or upgrades and the cost of those
upgrades. Data and finance leadership will need to analyze financial and outcomes data to
identify care pathways that lead to quality outcomes at low costs and also identify those pathways
that may need to be changed due to either quality or financial outcomes.
Ultimately it will be those organizations that dedicate themselves to these processes and analyses
that are positioned for long-term success in value-based reimbursement.
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Bibliography
Better, Smarter, Healthier: In Historic Announcement, HHS Sets Clear Goals and Timeline for
Shifting Medicare Reimbursements from Volume to Value
September 14, 2016. Retrieved from http://www.hhs.gov/about/news/2015/01/26/better-
smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-
shifting-medicare-reimbursements-from-volume-to-value.html#
Comprehensive Care for Joint Replacement Model
September 14, 2016. Retrieved from https://innovation.cms.gov/initiatives/cjr
Comprehensive Care for Joint Replacement Model Provider and Technical Fact Sheet
September 14, 2016. Retrieved from https://innovation.cms.gov/Files/fact-sheet/cjr-
providerfs-finalrule.pdf
Comprehensive Primary Care Plus
September 16, 2016. Retrieved from
https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus
Comprehensive Primary Care Plus Care Delivery Transformation Brief
October 15, 2016. Retrieved from https://innovation.cms.gov/Files/x/cpcplus-
caredeliverybrief.pdf
Comprehensive Primary Care Plus (CPC+) Round 1 Practice Participants Fact Sheet
September 16, 2016. Retrieved from https://innovation.cms.gov/Files/fact-sheet/cpcplus-
fs-rd1.pdf
MACRA Alternative Payment Models (APMs)
January 28, 2017. Retrieved from https://qpp.cms.gov/learn/apms
MIPS Quality Measure Selection Tool
January 28, 2016. Retrieved from https://qpp.cms.gov/measures/quality
Overview of the CMS Quality Strategy
September 14, 2016. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-
Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality-
Strategy-Overview.pdf
Quality Payment Program Fact Sheet
October 26, 2016. Retrieved from
https://qpp.cms.gov/docs/Quality_Payment_Program_Overview_Fact_Sheet.pdf
Strategic Objectives for the Quality Payment Program
January 3, 2016. Retrieved from https://qpp.cms.gov/docs/QPP_Key_Objectives.pdf
Quality Reimbursement: CMS’s Move Away From Traditional Fee-For-Service Reimbursement
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APPENDIX A – MSAs Included in CJR
MSA MSA Title Counties
14500 Boulder, CO Boulder County
16180 Carson City, NV Carson City
17860 Columbia, MO Boone County
19500 Decatur, IL Macon County
22420 Flint, MI Genesee County
23580 Gainesville, GA Hall County
24780 Greenville, NC Pitt County
26300 Hot Springs, AR Garland County
33700 Modesto, CA Stanislaus County
34940 Naples-Immokalee-Marco Island, FL Collier County
35300 New Haven-Milford, CT New Haven County
35980 Norwich-New London, CT New London County
39740 Reading, PA Berks County
40980 Saginaw, MI Saginaw County
42680 Sebastian-Vero Beach, FL Indian River County
46340 Tyler, TX Smith County
19740 Denver-Aurora-Lakewood, CO Adams County, Arapahoe County, Broomfield County, Clear Creek County, Denver County, Douglas County, Elbert County, Gilpin County, Jefferson County, Park County
10420 Akron, OH Portage County, Summit County
10740 Albuquerque, NM Bernalillo County, Sandoval County, Torrance County, Valencia County
11700 Asheville, NC Buncombe County, Haywood County, Henderson County, Madison County
12020 Athens-Clarke County, GA Clarke County, Madison County, Oconee County, Oglethorpe County
12420 Austin-Round Rock, TX Bastrop County, Caldwell County, Hays County, Travis County, Williamson County
13140 Beaumont-Port Arthur, TX Hardin County, Jefferson County, Newton County, Orange County
13900 Bismarck, ND Burleigh County, Morton County, Oliver County, Sioux County
15380 Buffalo-Cheektowaga-Niagara Falls, NY Erie County, Niagara County
16020 Cape Girardeau, MO-IL Alexander County, Bollinger County, Cape Girardeau County
16740 Charlotte-Concord-Gastonia, NC-SC Cabarrus County, Gaston County, Iredell County, Lincoln County, Mecklenburg County, Rowan County, Union County, Chester County, Lancaster County, York County
17140 Cincinnati, OH-KY-IN
Dearborn County, Ohio County, Union County, Boone County, Bracken County, Campbell County, Gallatin County, Grant County, Kenton County, Pendleton County, Brown County, Butler County, Clermont County, Hamilton County, Warren County
18580 Corpus Christi, TX Aransas County, Nueces County, San Patricio County
20020 Dothan, AL Geneva County, Henry County, Houston County
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20500 Durham-Chapel Hill, NC Chatham County, Durham County, Orange County, Person County
23540 Gainesville, FL Alachua County, Gilchrist County
25420 Harrisburg-Carlisle, PA Cumberland County, Dauphin County, Perry County
26900 Indianapolis-Carmel-Anderson, IN
Boone County, Brown County, Hamilton County, Hancock County, Hendricks County, Johnson County, Madison County, Marion County, Morgan County, Putnam County, Shelby County
28140 Kansas City, MO-KS
Johnson County, Leavenworth County, Linn County, Miami County, Wyandotte County, Bates County, Caldwell County, Cass County, Clay County, Clinton County, Jackson County, Lafayette County, Platte County, Ray County
22500 Florence, SC Darlington County, Florence County
28660 Killeen-Temple, TX Bell County, Coryell County, Lampasas County
30700 Lincoln, NE Lancaster County, Seward County
31080 Los Angeles-Long Beach-Anaheim, CA Orange County, Los Angeles County
31180 Lubbock, TX Crosby County, Lubbock County, Lynn County
31540 Madison, WI Columbia County, Dane County, Green County, Iowa County
32820 Memphis, TN-MS-AR Crittenden County, Benton County, DeSoto County, Marshall County, Tate County, Tunica County, Fayette County, Shelby County, Tipton County
33100 Miami-Fort Lauderdale-West Palm Beach, FL Broward County, Miami-Dade County, Palm Beach County
33340 Milwaukee-Waukesha-West Allis, WI Milwaukee County, Ozaukee County, Washington County, Waukesha County
33740 Monroe, LA Ouachita Parish, Union Parish
33860 Montgomery, AL Autauga County, Elmore County, Lowndes County, Montgomery County
34980 Nashville-Davidson--Murfreesboro--Franklin, TN
Cannon County, Cheatham County, Davidson County, Dickson County, Hickman County, Macon County, Maury County, Robertson County, Rutherford County, Smith County, Sumner County, Trousdale County, Williamson County, Wilson County
35380 New Orleans-Metairie, LA Jefferson Parish, Orleans Parish, Plaquemines Parish, St. Bernard Parish, St. Charles Parish, St. James Parish, St. John the Baptist Parish, St. Tammany Parish
35620 New York-Newark-Jersey City, NY-NJ-PA
Dutchess County, Bergen County, Bronx County, Essex County, Hudson County, Hunterdon County, Kings County, Middlesex County, Monmouth County, Morris County, Nassau County, New York County, Ocean County, Orange County, Passaic County, Pike County, Putnam County, Queens County, Richmond County, Rockland County, Somerset County, Suffolk County, Sussex County, Union County, Westchester County
36260 Ogden-Clearfield, UT Box Elder County, Davis County, Morgan County, Weber County
36420 Oklahoma City, OK Canadian County, Cleveland County, Grady County, Lincoln County, Logan County, McClain County, Oklahoma County
Quality Reimbursement: CMS’s Move Away From Traditional Fee-For-Service Reimbursement
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36740 Orlando-Kissimmee-Sanford, FL Lake County, Orange County, Osceola County, Seminole County
37860 Pensacola-Ferry Pass-Brent, FL Escambia County, Santa Rosa County
38300 Pittsburgh, PA Allegheny County, Armstrong County, Beaver County, Butler County, Fayette County, Washington County, Westmoreland County
38940 Port St. Lucie, FL Martin County, St. Lucie County
38900 Portland-Vancouver-Hillsboro, OR-WA Clackamas County, Columbia County, Multnomah County, Washington County, Yamhill County, Clark County, Skamania County
39340 Provo-Orem, UT Juab County, Utah County
41860 San Francisco-Oakland-Hayward, CA Alameda County, Contra Costa County, San Francisco County, San Mateo County, Marin County
42660 Seattle-Tacoma-Bellevue, WA King County, Snohomish County, Pierce County
43780 South Bend-Mishawaka, IN-MI St. Joseph County, Cass County
41180 St. Louis, MO-IL
Bond County, Calhoun County, Clinton County, Jersey County, Macoupin County, Madison County, Monroe County, St. Clair County, Franklin County, Jefferson County, Lincoln County, St. Charles County, St. Louis County, Warren County, St. Louis city
44420 Staunton-Waynesboro, VA Augusta County, Staunton city, Waynesboro city
45300 Tampa-St. Petersburg-Clearwater, FL Hernando County, Hillsborough County, Pasco County, Pinellas County
45780 Toledo, OH Fulton County, Lucas County, Wood County
45820 Topeka, KS Jackson County, Jefferson County, Osage County, Shawnee County, Wabaunsee County
46220 Tuscaloosa, AL Hale County, Pickens County, Tuscaloosa County
48620 Wichita, KS Butler County, Harvey County, Kingman County, Sedgwick County, Sumner County
Quality Reimbursement: CMS’s Move Away From Traditional Fee-For-Service Reimbursement
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APPENDIX B – Regions Included in CPC+
Region Participating Counties Provisional Payer Partners
Arkansas Statewide
Arkansas Blue Cross Blue Shield
Arkansas Superior Select, Inc.
Arkansas Health & Wellness Solutions
HealthSCOPE Benefits
Medicaid
QualChoice Health Plan Services, Inc.
Colorado Statewide
Anthem Blue Cross and Blue Shield
Colorado Choice Health Plans
Medicaid
Rocky Mountain Health Plans
UnitedHealthcare
Hawaii Statewide Hawaii Medical Service Association
Greater Kansas City
Johnson County, KS
Blue Cross Blue Shield of Kansas City
Wyandotte County, KS
Clay County, MO
Jackson County, MO
Platte County, MO
Michigan Statewide Blue Cross Blue Shield of Michigan
Priority Health
Montana Statewide
Blue Cross Blue Shield of Montana
Medicaid
PacificSource Health Plans
New Jersey Statewide
Amerigroup New Jersey
Horizon Blue Cross Blue Shield of New Jersey
UnitedHealthcare
North Hudson Capital Region (NY)
Albany County
Columbia County
Dutchess County
Greene County
Montgomery County
Orange County Empire Blue Cross Blue Shield
Rensselaer County Capital District Physicians' Health Plan (CDPHP)
Saratoga County MVP Health Plan, Inc.
Schenectady County
Schoharie County
Sullivan County
Ulster County
Warren County
Washington County
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Region Participating Counties Provisional Payer Partners
Ohio and Northern Kentucky
Aetna
Anthem Blue Cross and Blue Shield
AultCare
All counties in Ohio Buckeye Health Plan
Boone County, KY CareSource
Campbell County, KY Gateway Health Plan of Ohio, Inc.
Grant County, KY Medical Mutual of Ohio
Kenton County, KY Molina Healthcare of Ohio, Inc. Medicaid
Paramount Health Care
SummaCare, Inc.
UnitedHealthcare
Oklahoma Statewide
Advantage Medicare Plan (AMP)
CommunityCare
Blue Cross and Blue Shield of Oklahoma
Medicaid
UnitedHealthcare
Oregon Statewide
AllCare Health, Inc.
ATRIO Health Plans
CareOregon
Eastern Oregon Coordinated Care Organization (EOCCO)
FamilyCare Health
Oregon Health Authority (Medicaid)
Moda Health Plan
PacificSource
PrimaryHealth of Josephine County
Providence Health Plan (PHP
Providence Health Assurance (PHA)
Tuality Health Alliance (THA)
Umpqua Health
Western Oregon Advanced Health, LLC
Williamette Valley Community Health
Yamhill Community Care Organization, Inc.
Greater Philadelphia (PA)
Bucks County
Chester County Aetna
Delaware County Independence Blue Cross/Keystone Health Plan East
Montgomery County
Philadelphia County
Rhode Island Statewide
Blue Cross Blue Shield of Rhode Island
Medicaid
UnitedHealthcare
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Region Participating Counties Provisional Payer Partners
Tennessee Statewide
Amerigroup Tennessee
Medicaid
UnitedHealthcare
Volunteer State Health Plan, Inc.