Sizable regulations enforced upon physician groups are holding practice executives to a glowing screen late nights and through the weekend. Practices are dedicating substantial hours and personnel to determine which value-based initiatives to focus on in the coming years in order to remain profitable.
One thing that remains true is that physicians who bill Medicare more than $30,000 in Part B and provide care for more than 100 Medicare patients a year are subject to the Quality Payment Program (QPP) of MIPS or APMs under CMS’s MACRA reimbursement regulations. Several details including practice structure, size, and reporting capabilities, will determine the category under MACRA in which it applies.
So why is it that only 1 in 4 providers are ready for MACRA regulations?1 For starters, hundreds of pages of policy documents and numerous reports and legislation is complex. That's why we weeded through the minutia to provide several functions of automated referral management that produce quantifiable ROI for large physician groups participating in MIPS.
We Break MACRA Down Into four Groups of Medicare Reimbursements
MIPS-only - Non-PCMH, Not in an ACO
MIPS APMs - Track 1 ACOs, PCMH
Advanced APMS with at-risk ACO shared savings - Track 1+, 2, and 3 ACOs, Next Generation ACOs
CPC+ - Track 1 and 2 of Comprehensive Primary Care
Each category of MACRA financially awards practices that are integrating and coordinating with a network of accountable specialists to improve quality and administer patient-centered care. In this post, we map referral management’s quantitative impact on the MIPS-only category of MACRA.
Practices participating in MIPS-only, can receive up to a 9% payment adjustment from CMS reimbursement for 2020 performance and beyond.
An additional 10% exceptional performance bonus is awarded to the top 25% MIPS performers who score 70 or above out of 100.2
MIPS-only practices must select and report:
Up to six quality measurements - 60% of MIPS scores (50% in 2018 w/ Cost as 10% of score)
Five required ACI measures - 25% of MIPS scores (submit up to 9 measures for additional credit)
Up to four Improvement Activities - 15% of MIPS scores
Blockit supports practices in six MIPS Quality Measures:
Closing the Referral Loop: Receipt of Specialist Report - CMS50v5
Age Appropriate Screening Colonoscopy
Cervical Cancer Screening - CMS124v5
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care - CMS142v5
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation
CAHPS for MIPS Clinician
Closing the Referral Loop
Cancer Screenings and Diabetic Exams
In addition to scoring high in Closing the Referral Loop, practices use blockit to track and increase adherence on colorectal and cervical cancer screenings, as well as diabetic eye and foot exams. In fact, patient adherence rates are as high as 85% for practices using blockit — compared to the industry average of 50%.3
With blockit, practices get real-time decline data from their connected specialists by referral status, priority, ICD-10, and diagnosis to manage declines of CQMs
CAHPS for MIPS Clinician
By integrating primary and specialty care, blockit helps providers to receive exceptional CAHPS survey scores in:
Getting timely care, appointments, and information
blockit can auto-send TOCs to specialists with each referral, schedule the appointment, monitors how quickly an appointment is scheduled, when an appointment is complete, and when a consult report is returned.
Providers Communicate, Share Decision Making Between Visits
Providers share clinical information and last office notes and collaborate electronically on through blockit with their EMR, which logs correspondence in real-time
Patient's Rating of Provider
Continuity of care on blockit improves patient satisfaction scores5
Access to Specialists
Primary care connects electronically on blockit to seamlessly transition directly to a majority of medical specialties and subspecialties
Specialists administer higher quality care when they receive timely communication regarding referrals and consultations6
Meeting ACI (Formerly Meaningful Use)
Furthermore, two out of the five required measures of Advancing Care Information (ACI) are supported by the electronic connectivity of primary and specialty care. These two measures also qualify as Performance Measures, which increase overall score.
Practices using blockit can automatically deliver an electronic transition of care (TOC) with every referral. Demographic information populates through our leading integration from the providers EMR along with ensuring patient insurance edibility with receiving provider.
MIPS Improvement Activities
Automated referral management supports practices in completing five Improvement Activities that contribute to 15% of the MIPS score. Reporting five activities gives a practice 50 total points out of 60 possible points (13% out of 15%). To receive maximum credit, a practice must only select one additional activity.6 Practices participating in PCMH receive full credit.
A Harmonized Healthcare Ecosystem Lead to Significant Improvements
Blockit integrates practices to establish formalized lines of communication, information sharing and seamless transitions in care
Implementation of documentation improvements for practice/process improvements*
With blockit, metrics are available to track patients from scheduled appointment to returned consult report
Implementation of use of specialist reports back to referring clinician, location, visit types, insurance and more to close referral loop*
Electronic return of consult report from specialist with real-time reporting and log of communication and all clinical documentation within existing EMR.
Care coordination agreements that promote improvements in patient tracking across settings
Primary care collaborates with a high-percentage (85%) of patients following through.
Practice improvements for bilateral exchange of patient information*
* Eligible for ACI Performance Bonus
EXAMPLE: MIPS bonuses attributable to automated referral management
To quantify the opportunity for MIPS bonuses as a result of integrated referral networks, begin with $87,865, the average PCP reimbursement from CMS in 2014.2
Then, multiply that average reimbursement by 14%
MIPS bonus - 4% for 2017
Exceptional performer bonus - additional reporting measures from automated referral management places practice into high-performing percentile - 10%
Next, estimate that, at the least, 50% of a practice’s MIPS Composite Performance Score (CPS) is facilitated by referral management—given the measures outlined in this section
Lastly, multiply that by 50% to get a MIPS reimbursement estimate
Each physician could attribute $6,150.55 in MIPS bonuses to automated referral management for performance prior to 2020. A practice of 25 physicians would receive $153,763.75 in 2019 for 2017 performance.
1) HealthCare Dive | Survey: Nearly 75% of providers are not ready for MACRA or need help, http://www.healthcaredive.com/news/survey-nearly-75-of-providers-are-not-ready-for-macra-or-need-help/439315/
2) US Federal Register | Vol - 81 No. 214, published Nov 4, 2016 - Page 26274. https://www.gpo.gov/fdsys/pkg/FR-2016-05-09/html/2016-10032.html
3) Archives of Internal Medicine, Trends in Physician Referrals in the United States, 1999-2009 | http://www.ncbi.nlm.nih.gov/pubmed/22271124
4) The Milbank Quarterly http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145
5) Archives of Internal Medicine / JAMA Internal Medicine http://archinte.jamanetwork.com/article.aspx?articleid=226367
6) CMS Quality Payment Program (QPP) | https://qpp.cms.gov/measures/ia