Pay for Performance: Understanding and Preparing for MIPS

As this year draws to a close and the healthcare ecosystem continues to adjust to the many changes that have been implemented in recent years, physicians will soon be adapting to a new chapter in the regulation of medicine. January marks the start of the Merit-based Incentive Payment System (MIPS), a framework that replaces the Medicare Sustainable Growth Rate (SGR) and rolls together various reward and punishment systems for reporting clinical quality measures.

While physicians may shudder at the prospect of accommodating yet another regulatory change, it is worth noting that the fundamental concept of MIPS perhaps signals that regulators have been listening to physicians’ feedback about the current systems. Instead of three or four different frameworks demanding our compliance, we will have a single system that aims for greater simplicity and user-friendliness.

Understanding how MIPS will impact physicians, their practices, and their ability to deliver care requires close scrutiny look at its details. The Centers for Medicare & Medicaid Services (CMS) will release its final rule on MIPS in November 2016. This will give physicians less than two months to prepare their practices and staff for MIPS—not an encouraging sign. Alas, it may be too optimistic to expect that the government has learned from its past mistakes and offer a cure-all for its tendencies toward micromanagement.

As we await the final rule, taking a deeper look at what we already know about MIPS may better prepare the physician community for its implementation.

A MIPS Breakdown

MIPS consists of four components, each weighted differently as part of a physician’s total score. Below is a simple breakdown and the relative weights assigned to each:

• Quality Performance: 50%
• Advancing Care Information (renamed from Meaningful Use): 25%
• Clinical Practice Improvement Activities (CPIA): 15%
• Resource Use: 10%

Quality performance. Quality Performance represents half of one’s overall score in the first year of MIPS. It replaces some elements of the Value-Based Modifier as well as Physician Quality Reporting System (PQRS), both of which will be phased out. Since the details haven’t been fully spelled out yet, it remains unclear whether neurologists will need to participate in aspects of medical care that are not directly related to neurological care, such as smoking reduction, weight reduction, glucose tolerance. In fact, only a limited number of neurological performance measures are available, which may be a problem for the specialty and will need to be addressed over time, but we will see exact details on which measures neurologists should be participating in when the final rule is released.

We also don’t know whether the new framework will allow groups to submit data or if individual physicians will be responsible for reporting. This could have a major impact for specialists who are part of a group, as group-based reporting allows specialists to avoid reporting measures on items unrelated to their specialty. It is quite possible under the new system that individual physicians will not receive credit for group reporting, which means specialists will need to learn the exact measures on which to report.

Given the current lack of measures in neurology, one possible route that the MIPS system may allow will be to adopt the American Academy of Neurology’s (AAN) registry, called Axon, to become a qualified data registry. This would allow participants to qualify under a system they already use. In these initial years, Axon will be available for a limited number of users as the system gradually grows. Axon will be able to track whether physicians are making necessary improvements as well as give them feedback about their outcomes, measures, and the counseling of patients.

There are other registries that may be available for individuals in certain subspecialties, but these may be limited and we’re not totally sure which registries would qualify. On the other hand, Axon is for general neurologists and would be a significant help for neurologists who use it. We anticipate that Axon will become a means through which physicians can participate in quality performance measures, and that it would eventually be available to all physicians. However, the process will take time, as not all Electronic Health Record (EHR) systems are currently compatible with it.

Advancing Care Information (Formerly “Meaningful Use”). Another major component is Advancing Care Information (ACI). This is simply a new term for “Meaningful Use,” the system of measures that CMS implemented several years ago that rewarded or penalized physicians based on use of an EHR. The program was designed with the goal of exchanging information amongst different electronic vendors, but the rules were written in such enormous detail that it drove many of users as well as vendors out of the market. Moreover, physicians that attempted to qualify for incentives were forced to become more attentive to details of the digital world and less attentive to details of the clinical world, which may explain why CMS’s estimated users were far lower than initially projected.

Importantly, ACI likely will tone down the strict Meaningful Use rules, particularly those rule in the more recent phases of the program. ACI will likely create goals that are more attainable and less demanding, which would be a step in the right direction. The current leadership at CMS appears to understand that the previous stringent demands forced many vendors and practitioners to walk away from the program. Thus, they now are attempting to arrive at a more pragmatic and realistic program in which 25 percent of an individual’s MIPS score will be based on less demanding criteria.

One key difference from Meaningful Use is that ACI may not hinge on a pass-fail system. Whereas physicians previously needed to complete many check boxes and faced the threat of Meaningful Use failure simply by missing one hurdle, partial credit now would be given to physicians who satisfy most measures. The more forgiving nature of ACI will be helpful particularly for physicians who are beholden to vendors that may not have achieved successful implementations of certain aspects of ACI. Since physicians are so dependent on their vendors, given the investment required to implement one, they would no longer run the risk of being penalized for the vendor’s shortcomings.

Despite improvements, ACI does not fix all of the problems of the Meaningful Use program. Practices are still required to train staff and physicians, as well as pay the cost of implementing hardware, upgrades, etc. Such expenses, requirements, and regulations perhaps reflect both the fundamental problem and inevitable reality of the regulation of healthcare.

Clinical Practice Improvement Activities. Many neurologists already complete Practice Improvement in Practice (PIP) activities as part of their board certification Maintenance of Certification (MOC) activities. The American Board of Psychiatry and Neurology (ABPN) requires PIP activities, which have been renamed as Part IV Improvement in Medical Practice. This includes a Clinical Module and a Feedback Module. One or the other is required for physicians who need periodically to recertify for ABPN. These involve collecting feedback from patients, peers, or others. The information is used to identify areas for practice improvement. As a follow-up, the physician or practice implements quality improvement, and later demonstrate effective change for the better.

Other Clinical Practice Improvement Activities are expected. These may include expanded practice access such as expanded hours, decreased appointment wait times, and expanded access to subspecialty services. Care coordination services include better communication with other health care providers, checking that the patient follows through with advised services, and easy access to phone and visits. Patient safety issues vary and are many across a practice. Practice assessments may be produced through a national organization’s survey process.

Resource Use. Although resource use represents the least important component of MIPS, it nonetheless may pose significant challenges for neurologists. Resource use is designed to curb the inappropriate use of resources in healthcare. For instance, the actions of a doctor who orders $5,000 worth of evaluations for a patient with a sore throat will qualify as an inappropriate use of resources. However, this system doesn’t currently account for context. By example, if you are a physician who sub-specializes in caring for multiple sclerosis (MS) patients, the use of expensive disease modifying therapies will require significant resources. The inherent risk is that you may be labeled as “resource intensive” and be considered an adverse outlier. In other words, it’s quite possible that the current system may punish physicians for taking the appropriate action in patient care.

The current version of the system may not be refined enough to make the differentiation between resource use that is truly appropriate or inappropriate. In fact, it may be refined poorly for those people who appropriately use resources to treat people with serious disease that need resources. Hopefully, with time this will be addressed to reflect the nuances of resource utilization.

MIPS Preparation Tips

As we await the final rule on and rollout of MIPS, it would be prudent for all physicians to become better familiarized with the current clinical measure reporting standards, since it is likely that many of them will carry over. Even though PQRS and the Value Based Modifier are phasing out, the central tenets of these systems will likely remain intact. This is why one of the best strategies for preparing for MIPS may be to learn more about the current structures.

Be prepared to rely only on your own reporting, as specialists might not be able to rely on general medicine group colleagues to satisfy all measures. Also, if you are a member of a small group, it would be wise to ensure that you are meeting current EHR standards, so that when the more relaxed measures of ACI takes effect you can rest assured that you are in compliance.

Perhaps most importantly, recognize that new rules will be unveiled in November, which means we will have a relatively limited window to adapt and prepare. Thus, somewhere during November and December it is critical to make an effort to learn the new quality performance standards, so that you can adapt your records and patient billing system and ensure a smooth submission beginning in January.

Future Trends in Healthcare Regulation

Within the broader realm of healthcare regulation, MIPS represents one of many chapters in an increasingly discouraging saga. Certainly, there are advantages and drawbacks to the new framework if we look at the details, but if we step back and look at the broader trend, we are seeing a healthcare system defined by increasing regulatory intrusion on patient care. Perhaps most unsettling about this trend is that the individuals responsible for writing the rules for how patients should be cared for often have no clinical experience and fail to understand the nuances of medicine. Meanwhile, physicians are spending more time on non-clinical activities as they find themselves buried in red tape.

While MIPS is undoubtedly flawed, it offers a modicum of hope that regulators have listened to physicians and responded to pushback. It remains to be seen if MIPS achieves its designed goals, nevertheless we have seen some steps of progress to show that CMS is willing to adapt. The current leadership is sympathetic to physicians and understand that middle level managers and others in the agency have made the lives of physicians, nurses, and other healthcare professionals too complex by adding too much non-clinical activity. Moreover, senior CMS management legitimately is trying to back off from that, despite the obvious challenges of attempting to steer such a massive operation.

All that said, however, the entire leadership of CMS will be turning over in January with the new Presidential administration. We don’t know whether the attitudes of the new staff will reflect current leadership and we will have to wait and hope that the new leadership will be as receptive to physicians’ feedback as this inevitably complex world of increased regulation in healthcare takes shape. n

Marc R. Nuwer, MD, PhD is a Professor of Neurology and Clinical Neurophysiology at UCLA. He is a past-president of the California Neurology Society and a former member of the American Academy of Neurology Board of Directors.