The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaces the Medicare Sustainable Growth Rate (SGR), which was how CMS previously controlled the cost of Medicare payments to physicians. MACRA is aimed at strengthening Medicare access and improving physician payments, among other improvements.

Out of MACRA is the Quality Payment Program (QPP), which streamlines several pay-for-performance programs in the new Merit-based Incentive Payments System (MIPS) and provides incentive payments for participation in Advanced Alternative Payment Models (APMs). Payment adjustments start out at +/-4% in 2019 and increase up to +/-9% by 2022 and continue at that rate for several years after.

There are several factors that go into determining if a clinician is MIPS eligible in 2017. Primarily, any Medicare Part B clinician billing more than $30,000 a year and delivering care for more than 100 Medicare patients a year is eligible, with the exceptions being those clinicians that are newly enrolled in Medicare, below the volume threshold, or already participating in an Advanced APM.

MIPS essentially replaces the PQRS (Physician Quality Reporting System) and MU (Meaningful Use) criteria. Providers who, during at least 90 days, report 6 or more quality metrics (out of 271), document 4 or more practice improvement activities (out of 92), and fulfill at least 9 required measures for advancing care information (out of 15) may qualify for financial incentives and avoid penalties (e.g., 4% in 2017 for failure to provide at least 3 successive months of reporting).

In 2017, there are three MIPS performance categories: Quality, Improvement Activities, and Advancing Care Information. (Cost will be added as a fourth
category beginning in 2018.) For the majority of MIPS eligible clinicians, the percentage breakdowns are as follows:

  • Quality makes up 60% of the composite performance score
  • Advancing Care Information makes up 25%
  • Improvement Activities make up 15%

Controlling for Quality with Chronic Care Management (CCM) – bullets represent published MIPS metrics

CCM is an excellent stepping stone into MIPS. Both programs share Medicare’s goals for physician payment reform and value-based reimbursement models.
Plus, CCM and MIPS share many programmatic features, such as developing and following a comprehensive care plan, performing medication reconciliations, and managing transitions of care.

A Chronic Care Management (CCM) program fully supports the Quality metrics necessary to maximize incentives and minimize penalties under MIPS. The specific quality metrics supported will be practice and specialty dependent. Below are illustrative examples of MIPS metrics that can be met by having a CCM program:

  • Controlling high blood pressure (“Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period”)
  • Hypertension: Improvement in blood pressure (“Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.”)
      • Health coaches can access the patient’s diagnoses via the EMR/EHR and collect patient-generated blood pressure data via telephone, text messaging, and MD Revolution’s proprietary mobile and web applications. This information allows health coaches to monitor and report the percentage of patients whose blood pressure has either been under control or has improved while enrolled in the CCM program.
  • Body mass index screening (“Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2”)
      • Similar to blood pressure noted above, body mass screening can be easily performed via similar procedures
  • Preventive care and screening: Influenza immunization (“Percentage of patients aged 6 months and older seen for a visit between October 1 and
    March 31 who received an influenza  immunization OR who reported previous receipt of an influenza immunization”)

      • Health coaches document patient-reported information regarding influenza immunizations, and can access electronic health records to validate the information for MIPS reporting.
      • All reporting on influenza and other screenings will be predicated upon patients enrolling and participating in the CCM program. Accordingly, patient and provider engagement with CCM services will be central for success within MIPS.

Below are illustrative examples of MIPS metrics that can be met by leveraging our turnkey CCM solution, which will provide both the technology and service elements to ensure your patients get appropriate screening and documentation within the provider’s electronic health record.

  • Diabetes: Eye exam (“Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period”)
  • Diabetes: Hemoglobin A1C poor control (“Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period”)
  • Diabetes: Medical Attention for Nephropathy (“The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.”)
  • Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use (“Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use”)
  • Breast Cancer Screening (“Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.”)
  • Colorectal Cancer Screening (“Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.”)
  • Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (“Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified”)
  • Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (“Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen”)

Starting a CCM program – either in-house or through a partner – can help a practice create the proper infrastructure to ensure full compliance with MIPS.
That’s because CCM provides an opportunity to strengthen ties with patients, improve their outcomes, and in general, position the practice for bigger wins in the future.

Practice Improvements are fully enabled for MIPS through a CCM service

  • Chronic care and preventative care management for empaneled patients (“Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following: Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; plan of care for chronic conditions; and advance care planning; use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target; use pre-visit planning to optimize preventive care and team management of patients with chronic conditions; use panel support tools (registry functionality) to identify services due; use reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.”)
  • Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including the development of improvement plan.
      • Health coaches collect patient experience and satisfaction information via telephone. Centro Healthcare can also conduct random patient satisfaction surveys following monthly telephone encounters.
  • Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the certified EHR technology.
      • Health coaches discuss the prioritization of care plan goals with patients and/or caregivers via the telephone.
  • Engagement of patients through implementation of improvements in patient portal (“Access to an enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and includes interactive features allowing patients to enter health information and/or enables bidirectional communication about medication changes and adherence.”
      • MD Revolution’s online app is constantly evolving and improving. It contains clinically relevant education, provides an overview of patient-generated data, allows access to individual care plans, and enables secure digital communication to occur between patient and chronic care professional.

According to CIO magazine, “CCM provides poly-chronic patients with the level of care necessary to keep them well and minimize preventable utilization, which is critical under MACRA.
CCM also subsidizes the foundational technology and operational capabilities necessary to succeed under MACRA, such as interoperability across all care settings, asynchronous patient communication, and better care management methodologies.”

CCM fulfills the following measures aimed at Advancing Care Information:

  • Provide patient access (“At least one patient seen by the MIPS eligible clinician during the performance period is provided timely access to view online, download, and transmit to a third party their health information subject to the MIPS eligible clinician’s discretion to withhold certain information.”
      • MD Revolution’s online app allows patients to view and/or download their individual care plan. The patient only needs to log in to the app using an internet-enabled device. A health coach can guide the patient through the process.
  • View, download or transmit (“At least one patient seen by the MIPS eligible clinician during the performance period (or patient-authorized representative) views, downloads or transmits their health information to a third party during the performance period.”)
      • It is possible to track and document whether a patient has viewed or downloaded their care plan using the online app. A health coach can also send an electronic copy of the care plan to the patient via email upon request.
  • Patient-specific education (“The MIPS eligible clinician must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide access to those materials to at least one unique patient seen by the MIPS eligible clinician.”)
      • Health coaches send patients weekly health tips with educational information specific to the patient’s diagnoses via the online app or email.
  • Secure messaging (“For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative) during the performance period.”)
      • Health coaches can send at least one clinically relevant secure message each week to patients.
  • Patient-generated health data (“Patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for at least one unique patient seen by the MIPS eligible clinician during the performance period.”)
  • Health coaches collect patient-generated data via a telephone, text messaging, or the online app and document how much patient-generated data each patient submitted. Submitted data include blood pressure, blood glucose, weight, pain, stress, sleep, nutritional information, among others.

CCM satisfies and overlaps all four MIPS Performance Categories including Quality, Practice Improvement Activities, Advancing Care Information, and Cost (which will begin in 2018).
By starting a CCM program now, practices will be best prepared to achieve the maximum MIPS incentive payments this year, and beyond.


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