MACRA & MIPS: Why Aggressive Physicians have a tremendous opportunity to benefit

MACRA-MIPS-Physician-Advice-Ophthalmology

MACRA & MIPS: Why Aggressive Physicians have a tremendous opportunity to benefit

During the recent Radiological Society of North America conference at McCormick Place in Chicago, a session titled, “Will MACRA and MIPS Kill Your Practice?” pretty much summed up the consensus feelings of most physicians. But as usual, with chaos and disruption of the status quo, an opportunity is present for the prepared and willing. And now, given the flexibility of the program, it’s hard to formulate a good reason why providers would not elect to participate in the new payment program in 2017. More importantly, as long as providers participate at some level, they can avoid reimbursement penalties in 2019.

Under MACRA’s Merit-based Incentive Payment System (MIPS), providers can submit as little as one quality measure improvement activity for any time period in 2017 and avoid a financial penalty.


Medicare Part B eligible providers are currently being measured annually in four performance categories to derive a MIPS score between 0 and 100. That score will determine positive, neutral, or negative future adjustments to each provider’s annual Medicare reimbursement. These point values will be shifted in 2018 and beyond, but clinicians’ 2017 performance in just two of these categories, ACI and Quality, will comprise 85% of their maximum potential score.


The more data submitted the more potential to earn a payment incentive. Data entered for 2017 for quality (60% of a physician’s overall score), advancing care information (25%) and clinical improvement activities (15%) will affect 2019 reimbursement under the program. Not submitting any data will result in a 4% payment penalty two years from now. There are three options under MIPS to avoid punishment: 1) submit minimal data and avoid penalties; 2) submit 90 days of data, have the opportunity for small upside; or 3) submit a full year of data, and have the opportunity of a potential bonus for high performance. Hidden in the details, however, is that future penalties dramatically increase both monetarily and will also damage a provider’s reputation.


The Centers for Medicare & Medicaid Services (CMS) will set a performance threshold score each year. In 2017, the performance threshold is 3. In 2018, and beyond, CMS will use the mean or median of eligible clinicians’ MIPS scores from a prior period. There is an incentive to be a high performer. Clinicians or groups that achieve a MIPS performance score of 70 or higher, can earn an additional higher positive adjustment up to an estimated 2.4%, funded from a separate pool of $500 million. Critically, all MIPS payment adjustments will impact clinicians on a two year lag, meaning that MIPS performance in 2017 will influence clinician payment in 2019.


Obviously, each specialty in medicine will be more effected than others, but all face the potential penalties if they receive Medicare reimbursement. In Ocular Surgery News U.S. Edition, January 10, 2017 Richard L. Lindstrom, MD points out how lucrative and penalizing this program can be for an Ophthalmologist. “The exciting opportunity and challenge for well-managed practices is to get into the highly rewarded group. Let’s say in 2022 in your locality, average surgeon reimbursement for cataract surgery is $640 per eye. The ophthalmologist with a maximum penalty would be reimbursed $582 per eye, and depending on the rewards available to distribute, the best performer with the highest MIPS score could get paid as much as $812. That is a $230 per cataract surgery difference, or for a practice that does 500 cataracts a year, $115,000.”


He also calculates “for the ophthalmologist earning $500,000 in Medicare revenue, the worst performer to best performer gap is $180,000 per year.” This means that the providers who are not participating will lose $180,000 or more per year in Medicare reimbursement, which is a significant penalty that all practices can’t afford. In addition in 2019, all providers face a range of payment adjustments, starting with potential penalties of -4% and bonuses as high as 12%. By proper planning now, there is no reason not to become a top performer and get the highest bonus, including the additional 2.4% from the separate pool.


While financial incentives for the program can be big, more importantly the Medicare Quality Payment Program lets the CMS publish each physician’s annual score (as well as scores for all participating physicians) on its Physician Compare website. Furthermore, it will also share that data with other third-party ratings sites including HealthGrades, Yelp and Google. That means patients and others will see physicians’ scores online, likely without the context included. So a low score, either due to poor performance or just simply doing the bare minimum to meet quality metric requirements will essentially look the same. The score also follows physicians who switch organizations–becoming, a part of that physician’s permanent file. While a poor score will be a negative mark, a top score has huge potential. This now becomes a new and easy marketing opportunity for those first adopters, especially those with electronic health records that are already pulling out the needed data. Many advisors suggest that physicians make their data work for them by selecting the measurement of activities that they already do and want for their patients. This can make the process relatively painless for the provider and office staff.


The four MIPS performance categories for the 2017 performance year are: Resource Use (to be scored in 2018), Clinical Practice Improvement Activities (CPIA), Advancing Care Information (ACI), and Quality (PQRS/VBM). For Ophthalmology, Cataract surgery is a natural and easy measure for most practices. There are six Cataract related quality measures on the QPP (Quality Payment Program), but it is easy to search and filter to find the measures that meet your needs or specialty.


The window for participation is closing sooner than you think, so now is the time to plan and execute how your practice can become highly rewarded with each provider gaining the coveted 100 MIPS score. Many EMR systems can easily pull out the necessary information to automatically forward the required data to CMS, and if not find out why. Remember, this is a great opportunity for the prepared. Don’t be left behind!


Recently, EyeMD EMR Healthcare Systems and Testimonial Tree have partnered to equip ophthalmology professionals with a new tool to more efficiently capture patient feedback, and also provide patients an easy way to share that feedback with their friends and family. In addition, Testimonial Tree service can be used as a Clinical Practice Improvement Activity (CPIA) for the Merit Based Incentive Payment System (MIPS) recently adopted by law. Testimonial Tree simplifies the collection of patient feedback, online reviews and testimonials. The platform helps physicians gain control of their online reputation and visibility on search engines and social media networks.


With there being several pieces to MIPS – some EMR’s like EyeMD automatically tracks those measures for Quality Measures and Advancing Care Information, Testimonial Tree falls into MIPS on the Improvement Activity category, which is not tracked with success rates. For the Improvement Activities, the practices are required to attest by confirming what measure they participated in. In the case of an audit, the provider will need to prove that they signed up for a service, and show proof that the surveys were sent and proof of what the practice has done in response to negative surveys. Historically, an enrollment confirmation (email) showing date of enrollment, and screenshots of sample surveys/responses would suffice for audit purposes.

Satisfaction-Survey-MIPS-DoctorsAs EyeMD EMR Healthcare Systems President Abdiel Marin affirms, “While we have many clients using our electronic medical record software to support their clinical operations, we believe the solution from Testimonial Tree will not only help enrich the potential for new patients, but also be helpful in enhancing existing patient relationships.” This integration essentially allows providers to easily (and automatically) send requests for feedback/surveys to patients after appointments at relevant points of care. It enables providers to quickly garner feedback from patients in a process that is fast, inexpensive, effective and automated. It also allows patients the opportunity to easily share the positive feedback with their friends and social media acquaintances through Facebook, LinkedIn, and other review sites.

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David Spellberg

David Spellberg MD, MBA, FACS is a career physician, surgeon, and entrepreneur with professional experience in Corporate Development, M & A Advisory, and Healthcare and Medical Technology.

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