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At a Crossroads? Which Reimbursement Pathway is Best Suited to Your Practice?

Aiden Spencer
CureMD

Paper or plastic? Debit or credit? Netflix or Amazon? These are the kind of choices we are asked to make everyday. They are not, though, the type of decisions that keep us up at night.

But it’s a different story for the MIPS-or-APM pick that doctors are facing. Many doctors are currently feeling some anxiety over the looming decision they’ll have to make regarding those two reimbursement models under the Medicare Access and CHIP Reauthorization Act (MACRA). Beginning in 2019, because of MACRA, physicians accepting Medicare Part B will be required to participate either in the Merit-Based Incentive Payment System (MIPS) or an alternative payment model (APM).

While 2019 seems far off, physicians are encouraged to become familiar with both payment models now so they may make an informed decision later.

Things to consider about MIPS

  • MIPS is weighted on performance. While MIPS is geared toward traditional fee-for-service payments, physicians will be judged on their performance in four categories: clinical quality; meaningful use of health information technology like EHRs and medical billing software; resource use; and practice improvement.
  • MIPS works on a sliding scale. In 2019, the annual payment update will be 0.5% plus-or-minus 4% based on a composite score on the four categories mentioned above. Between the years 2020 and 2025, the baseline update will be 0% with a 5% variance plus-or-minus based on a physician’s performance in 2020. There will be a 7% variance in 2021, and finally a 9% variance between 2022 and 2025. Beginning in 2026 the baseline update is expected to be 0.25% with a variance of 9%.
  • Top performers can expect a bonus under MIPS. The Department of Health and Human Services (HHS) will set an annual performance threshold for MIPS participants. Physicians who score in the top 25th percentile between the years 2019 and 2024 will qualify for a yearly performance bonus in the form of an adjustment of up to 10%. The maximum amount available during this time period is dependent on how physicians score relative to the threshold. MACRA is expected to set aside up to $500 million annually to pay top performers.
  • Thresholds will be set in advance. There is no guesswork with MIPS. Physicians will know the exact threshold they are required to meet for a positive performance adjustment. They will also be able to review their own data to set and meet performance goals.
  • Some Medicare penalties will go away. The goal of MIPS is to breathe new life into Medicare reporting by replacing the existing Physician Quality Reporting System, the EHR meaningful use program, and the Value-Based Payment Modifier. Medicare penalties that had been scheduled for 2019 for PQRS and MU (which could have totaled as much as 7%) will be canceled.

Things to consider about APMs

  • APMs redesigned for higher quality and lower costs. With APMs, physicians will be paid more (or differently) while they accept full accountability for controlling and reducing cost of care delivered.
  • APMs come with risk. Physicians who wish to participate in APMs such as accountable care organizations (ACOs) or advanced patient-centered medical homes will do so at their own financial risk.
  • APMs may earn more. APM participants will receive yearly baseline increases of 5% on fee-for-service payments between 2019 and 2024. Beyond this, payments will be governed by their own APMs guidelines. So, if their APM achieves cost savings, participants could very well receive higher payments.

How to choose the best pathway for your practice

Get input from staff

There is no one-size-fits-all process for determining which reimbursement path is best for your practice. There’s also no reason why you have to bear the brunt of this big financial decision yourself. Speak with your staff members to get their input on which model they think will work best for your organization.

Are you certain of the requirements?

MACRA applies to individual eligible professionals (EPs), groups of EPs, and even virtual groups. The first phase of MACRA (2019 and 2020) will include a broad set of MIPS-eligible clinicians, including physician assistants, nurse practitioners, and clinical nurse specialists. Come 2021 and beyond, the HHS secretary can—and most likely will—expand the list of EPs.

It’s important to note that not all providers are subject to MACRA. Hospitals and facilities are not affected. And MACRA does not apply to clinicians participating in their first year of Medicare and those with so few Part B beneficiaries as patients that they fall below volume threshold.

Are you currently participating in any programs?

If you are currently participating in any reimbursement programs, they may have a significant impact on the decision you make. For instance, if you already participate in Meaningful Use, the Physician Quality Reporting System, or the Value-based Modifier, your transition into MIPS will most likely put you ahead of the game because you will be scored against other EPs and reimbursed based on your performance in these three programs. Similarly, if you are currently participating in an ACO or patient-centered medical home, you are already well on your way to APM success. By taking advantage of the programs you are already participating in, you can reduce the learning curves associated with MACRA and maximize your reimbursements.

MIPS vs APM? Each program has its pros and cons. Which one is most advantageous will depend on the particular circumstances, capabilities, and past experiences of clinician or medical practice. It is a tougher choice than paper vs. plastic but if doctors ask themselves the right questions and weigh their options, they should be able to make the right choice.

Aiden Spencer is a health IT researcher and writer at CureMD who focuses on various topics related to the health IT industry. You can get in touch with him on Twitter: @AidenSpencer15

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