Questions on MACRA Everyone Wants to Know

Dr. Birnholz:

MACRA is one of the hottest buzz words in clinical medicine and health policy today, but in a fast-changing legislative landscape, questions arise on the current and future directions for MACRA, as well as best practices for all of us going forward.  So, we’ve gathered some of the top questions everyone wants to know, and we’re going to address them here. 

This is Inside Medicare’s New Payment System on ReachMD and I’m Dr. Matt Birnholz.  Joining me are Ashley McGlone, Washington Council for the AMA and Laura Hoffman, who is the AMA’s Assistant Director of Federal Affairs.  Ashley and Laura, welcome to the program.

Ms. Hoffman:

Good to be here.

Ms. McGlone:

Thanks.

Dr. Birnholz:

Great to have you both.  So Laura, let me position the first question to you.  Perhaps one of the biggest FAQs that has come around recently, and that’s that the new administration and Congress are moving to repeal the Affordable Care Act, or ACA, and replace it with something different.  So, obviously, a big question hangs over the healthcare community now as to whether the same is going to happen with MACRA.  I guess the question of position with you is, is MACRA here to stay?

Ms. Hoffman:

Yes.  We have heard this question a lot.  Unlike the ACA, however, MACRA passed through Congress with almost unanimous bipartisan support.  So, it’s really seen by those in Congress as separate from the ACA altogether.  We do not think that it will be subject to overhaul and rather we’re focusing our efforts to work with the new administration and with Congress to address any concerns that we see moving forward.

Dr. Birnholz:

Ashley, let me turn to you, because this is another big question that has to do with timing, and that is that if MACRA begins in 2017, how come we’re hearing about PQRS, MU, VBM reports and appeals for this year?

Ms. McGlone:

While MACRA reporting could have started as early as January 1, 2017, the MACRA incentives and penalties won’t impact physician payment until 2019.  So, in other words, CMS is continuing its policy of using a 2-year look-back period before awarding any of the penalties and incentives under MACRA.  So, physician Medicare payment in 2017 is still going to be impacted by 2015 performance in the pre-MACRA programs including PQRS, Meaningful Use, and the Value-Based Payment Modifier.  And, similarly, 2018 payment is going to be impacted by PQRS, Meaningful Use, and Value-Based Payment Modifier performance in 2016. 

Dr. Birnholz:

And Ashley, let me continue with you because participation in best practices are sort of the next logical leap, as far as the common FAQ here.  So, the first big question:  What is the advantage of participating as a group versus individual?

Ms. McGlone:

There are advantages to each approach that will change based on the composition of your practice.  So, for example, in general, if you decide to report as a group, every NPI within a group’s tax identification number is going to have to report on the same measures and will receive the same score.  In addition, within the Quality category, for example, if you choose to report as a group, it’s going to be the group as a whole that’s going to meet the measure threshold requirements, not each individual physician.  So, this may be beneficial to some practices and not beneficial to others.  As for the Improvement Activities category, a group is going to receive credit even if only one of the group’s physicians completes an Improvement Activity.  So, in other words, every physician in the group does not need to perform an Improvement Activity in order for the group to receive credit in that category.  And then, finally, keep in mind that if you plan on participating in MIPS as a group, instead of as an individual, the use of an EHR is going to affect your group’s overall score and reporting capabilities.    So, for example, if some physicians in the group don’t have an EHR, they’re not going to be able to contribute to the group’s ACI score, which could negatively affect the group’s overall score.   So, really, it depends; you have to look at the composition of your group to see if it’s going to be an advantage or a disadvantage for you to participate as a group versus an individual. 

Dr. Birnholz:

And Laura, Ashley made reference to MIPS, and so, the question that comes up is on the technology end.  Does one need an electronic health record, or EHR, to participate in MIPS? 

Ms. Hoffman:

A lot of folks are worried about that.  If they don’t have an EHR they think that they will be blocked out of the program.  So, the good news is that you can still participate in MIPS if you don’t have an EHR.  That said, using Federally Certified Electronic Health Record technology, which is commonly known as CEHRT, will help you to maximum the number of points that you need to do well in your overall MIPS composite score.  You want to remember, too, that the Advancing Care Information, the ACI component of MIPS that Ashley referenced, counts for 25% of your total MIPS score.  And participation in that component does require the use of CEHRT.  So, while the other MIPS components such as quality, cost, and improvement activities do not expressly require the use of CEHRT, using an EHR may enable more reporting flexibility and can provide the opportunity for additional bonus points.

Dr. Birnholz:

If you’re just tuning in, this is Inside Medicare’s New Payment System on ReachMD and I’m Dr. Matt Birnholz.  I’m speaking with Ashley McGlone and Laura Hoffman from the AMA, about frequently asked questions on MACRA.  Ashley, let me turn to you.  Let’s cover a question on reporting.  Are there advantages to reporting measures for more than 90 days?

Ms. McGlone:

Yes.  So, that’s a question that we’ve received a lot and there may be advantages.  By reporting for more than 90 days, a physician may be more likely to receive an incentive payment.  And what CMS says is that, for some physicians, having a longer time period to report data may be beneficial and may help physicians receive a larger incentive payment.  However, the bottom line is that it really all comes down to the actual data that the physician is reporting, whether that’s for 90 days or a full calendar year.

Dr. Birnholz:

Now Laura, swinging back to a common requirement question, and this gets back to the technology elements that we spoke about earlier, are Computerized Physician Order Entry or CPOE and Clinical Decision Support, or CDS, still required under ACI, as we’ve been talking about with Ashley?

Ms. Hoffman:

No, they aren’t.  After many years of AMA advocacy, CMS removed the CPOE and CDS measures from both the ACI component of MIPS and also the Meaningful Use Program.  CPOE and CDS functionality will still be included in the EHR, so that folks can use them if they would like to, but CMS no longer is going to require a certain number of orders, or that a physician enters those orders, or that physicians implement a certain number of CDS tools.  So, this means now that physician practices are free to develop policies around CPOE and CDS in ways that really blend with their workflows and help to improve patient care.

Dr. Birnholz:

Laura, let me stay with you.  How about another timing question and this time it will be around alerts.  I’m sure a number of physicians out there have been asking, when will CMS notify them to let them know if they qualify for the 2017 low-volume exemption?  What can you tell us about that?

Ms. Hoffman:

At the end of April, CMS began to send to letters to TINsto notify them whether the NPIs practicing in that particular TIN would meet the low-volume threshold in MIPS.  And, as a reminder, that threshold is $30,000 in allowed Medicare charges, or 100 unique Medicare patients, and that’s at either the group or individual level.  Falling below that threshold, so if you have less than $30,000 of allowed Medicare charges, or fewer than 100 unique Medicare patients, that means you’re exempt from needing to participate in the Quality Payment Program.  Now, physicians, what you should do, even if you think your TIN has received your letter, no matter what time of the year it is, you just want to make sure to check with your TIN to confirm whether you’ve met that low-volume threshold.  And, in addition, CMS has released a tool on their Quality Payment Program Portal which is available at www.QPP.CMS.gov where physicians can check their individual status by entering their NPI into the text box that pops up on the screen, and that will tell you, again, whether you’ve met that threshold and kind of walk you through some of the requirements for your participation in MIPS.  It is important to remember, though, that, again, if you are participating as a group, if your TIN decides to participate in that format, as opposed to you participating as an individual, your performance information will count towards your group’s score, even if individually you’re below that low-volume threshold.  So, check in with your TIN about whether you are below the threshold, and also confirm whether you’re reporting as a group, or whether you are free to participate as an individual.

Dr. Birnholz:

Ashley, I’m going to wrap up with you, because, sadly, we only have time for one more frequently-asked question.  So, what better than to come back to small practices, small groups?  How will funding be provided to small groups for quality reporting?

Ms. McGlone:

MACRA requires that direct technical assistance be provided to help MIPS physicians that are in small practices with 15 or fewer physicians, and also those that are located in rural areas, health-professional-shortage areas, and medically under-served areas; help them participate in the Quality Payment Program.   So, CMS currently has a fact sheet on the Quality Payment Program website which is QPP.CMS.gov, and the fact sheet lists the current technical assistance organizations and how they’re going to help physicians.  And so, this includes assisting physicians with selecting and reporting on appropriate measures and activities, engaging in continuous quality improvement, and optimizing their health information technology and evaluating their options for joining an Advanced Alternative Payment Model.

Dr. Birnholz:

Well, with that, I very much want to thank my guests, Ashley McGlone and Laura Hoffman, from the AMA.  We’ve been talking about Frequently Asked Questions on MACRA.  To access this interview and other related content, visit ReachMD.com, or download the ReachMD app.  I’m Dr. Matt Birnholz, as always inviting you to Be Part of the Knowledge.