From The Editor

My Dad’s definition of “mixed emotions” was seeing your mother-in-law drive off a cliff in your new car. A new Quality Payment Program (QPP) for practitioners takes effect this January, and I have mixed emotions about it. The final rule written by the U.S. Department of Health & Human Services is more than 2,000 pages long and has all the clarity of the tax code. It’s also fair to say that despite the hope of creating a patient-centered system focused on quality of care, the Centers for Medicare & Medicaid Services (CMS) has turned physician’s quality reporting into the equivalent of a GED for dropouts that anyone can pass. Frankly, the quality reporting process measures almost nothing about whether physicians actually provide quality patient care. On the other hand, consider a doctor in my building who sees wound care patients in his office. He performed 15 cellular product applications on one patient’s foot ulcer before referring him to me. (I controlled his bacterial bioburden and got him offloaded, and he healed.) I have lost count of the number of patients I’ve seen who have received thousands of dollars of advanced therapeutics without being provided the basics. When we pay for volume of services, disconnected from outcome or appropriateness, we waste resources and we do not get optimal patient care. We needed a different system. What we got was the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

To shift providers away from the fee-for-service model and onto a value-based payment system, they will participate in one of two reimbursement tracks: the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs). Providers can opt out of the MIPS track if they participate in an APM such as an accountable care organization or patient-centered medical home. In MIPS, providers pay will be based on success in four performance categories: quality, resource use, clinical practice improvement, and advancing care information (based on the Meaningful Use of electronic health records). On the MIPS track, physicians can earn plus or minus 4% of their Medicare Part B reimbursement in 2019. Bonuses or penalties lag two years behind the reporting year. The adjustment potential grows to 9% in 2022. CMS will exempt physician practices with less than $30,000 in Medicare charges or fewer than 100 unique Medicare patients per year. An analysis by the American Medical Association estimates 30% of physicians will be exempt from participation under this threshold. Nevertheless, CMS believes more than 93% of Medicare Part B charges will still be subject to the incentive framework, and predicts 87% of solo practitioners and nearly 70% of those in practices with 2-9 providers will receive a negative adjustment in 2019. In other words, most practitioners are going to take a financial hit with MACRA. Some flexibility was included in the final rule in hopes of helping small practices avoid penalties. The law gives physicians the option of minimal reporting, 90-day reporting, or full-year reporting.

Many practitioners have told me they were confident these new rules didn’t apply to them because they’re in private practice, because they were a podiatrist, or because their “congressman was going to fix it.” (By the way, MACRA was passed with bipartisan support and it will not go away under a new administration). You will be participating in the QPP in 2017 if you bill Medicare more than $30,000 per year and provide care for more than 100 Medicare patients annually. You must also be a physician (medical doctor, doctor of osteopathic medicine, doctor of podiatric medicine), physician assistant, nurse practitioner, clinical nurse specialist, or a certified registered nurse anesthetist. You do get to pick your pace for participation in the QPP. If you’re ready, you can begin collecting your performance data with an effective date of Jan. 1. You can also choose to start anytime between Jan. 1 and Oct. 2, 2017. Whenever you choose to start, you’ll need to send in your performance data by March 31, 2018. Depending on the data you submit, your 2019 Medicare payments will be adjusted up, down, or not at all. 

Pick Your MIPS Pace

If you choose the MIPS path of the QPP, there are three options:

1. Not participating in the QPP: If you don’t send any 2017 data, you will receive a -4% payment adjustment.
2. Test: If you submit a minimum amount of 2017 data to Medicare (eg, one quality measure or one improvement activity for any point in 2017), you can avoid a downward payment adjustment.
3. Partial: If you submit 90 days of 2017 data to Medicare, you may earn a neutral or positive payment adjustment.
4. Full: If you submit a full year of 2017 data to Medicare, you may earn a positive payment adjustment. 

Summary of Reporting for MIPS 2017  

• 6 Quality measures (bonus points for measures gathered and reported via a qualified clinical data registry [QCDR])
  • Including an outcome measure
• 5 Advancing Care Information (ACI) measures (bonus points for reporting to a registry)

1. Protect patient health (security risk analysis)
2. Electronic prescribing
3. Provide patient access to portal
4. Send a summary of care
5. Request a copy of care

• 4 Clinical practice improvement activities (bonus points for using a QCDR).

The cost category will be calculated in 2017, but will not be used to determine payment adjustment. In 2018, CMS will start using the cost category to determine payment adjustment. You might have noticed that a registry or QCDR is mentioned in each of the three categories of MIPS. That’s why every recognized specialty has a QCDR. Here’s the bottom line: You can do nothing and lose money. You can make some limited effort to participate and avoid a penalty, or you can engage with a registry, get serious about reporting, and possibly get a bonus. The U.S. Wound Registry (USWR) has quality measures and clinical practice improvement activities that are relevant to wound care practitioners, and it qualifies as a specialty registry for ACI. 

Sooner or later you will have to figure this out. The practitioners who figure this out can obtain as much as a 27% bonus. If more wound care practitioners get on board with reporting, there will be fewer practitioners paying penalties — and that reduces the pool for bonus money. It occurs to me I should not try so hard to get more practitioners engaged with the USWR, but I can’t help myself. I’d just like to see everyone win. 

Caroline E. Fife, MD, FAAFP, CWS, FUHM, is chief medical officer at Intellicure Inc.; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders.