Success Strategies in MIPS and APMs:
Two Frontline Perspectives
Featuring Scott Hines, M.D., and Aric Sharp, M.H.A., CMPE, FACHE
Educating medical group physicians and clinicians as
soon as possible about MACRA, MIPS, APMs, and their
implications is crucial to the future of countless health
systems across the country. Crystal Run Healthcare and
UnityPoint Health share their unique pathways and
strategies for success under MACRA.
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Editor’s note: This article is from the AMGA Solutions Library, which highlights member best practices
and other strategies for successful medical group operations in a concise format highlighting key takeaways
from conferences, regional meetings, and webinars.
Content was originally presented in a webinar on July
21, 2016.
The current timetable to prepare for the Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) and its two physician payment tracks—the
Merit-based Incentive Payment System (MIPS) and
Advanced Alternative Payment Models (APMs)—is
remarkably short. Unless some last-minute changes are
enacted, both the MIPS and Advanced APM tracks are
set to officially begin in payment year 2019, meaning a
group will be measured on their performance beginning
on January 1 of 2017. Educating medical group physicians and clinicians as soon as possible about MACRA,
MIPS, APMs, and their implications is crucial to the
future of countless health systems across the country.
Scott Hines, M.D., chief quality officer, Crystal
Run Healthcare, and Aric Sharp, M.H.A., CMPE,
FACHE, VP accountable care, UnityPoint Health,
presented an AMGA webinar entitled “Strategies for
Success in MIPS and APMs: A Front-Line Perspective.”
Sharing each organization’s own unique pathways, Dr.
Hines and Mr. Sharp discussed strategies for success
under MACRA.
On the Matter of MIPS
Taking the lead on the first half of the digital
discussion, Dr. Hines explained that when Crystal Run
was looking toward the future and attempting to navigate through MACRA to better understand MIPS and
APMs, one of the first things the group did was simply
analyze the pros and cons of each pathway.
“In thinking through MIPS it could be a fairly
palatable short-term strategy,” says Hines. “Probably
not a long-term strategy. Over time, groups are going to
progress and be able to report and be successful under
this program. But as far as the short-term is concerned,
it may be a decent strategy.”
Dr. Hines detailed the more negative aspects of
MIPS as well, such as the fact that it is relatively complicated and carries a heavy administrative burden,
and that its true “rules of engagement” will not be
known until weeks before reporting begins, and that
its performance is ultimately difficult to gauge compared to others.
Looking at MIPS, there are four primary components, each weighted with a percentage to an
organization’s first year performance score. The largest
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portion of the score ties into Quality, accounting for
50% of a clinician’s performance score, followed by
25% for Advancing Care Information, 15% for Clinical Practice Improvement Activities, and 10% for Cost.
“The approach that we took was to dissect each
one of these components and try to determine how we
were doing under each of the domains, where we were
doing well, where we should continue to do the work
we’re doing, and where we feel we can improve,” said
Dr. Hines. Beginning with how Crystal Run maximizes
its clinical quality, Dr. Hines showcased Crystal Run’s
methodology via a flowchart (Figure 1) highlighted
by the organization’s use of a Continuous Quality
Improvement Cycle and a Variation Reduction Cycle.
In its Continuous Quality Improvement Cycle,
Crystal Run relies on an ongoing performance evaluation where clinicians identify areas for improvement,
identify the barriers to reach that improvement, and are
able to redesign their process. This allows Crystal Run
to measure the impact of their change and whether or
not it was successful. Meanwhile, the Variation Reduction Cycle is specifically geared toward establishing best
practices guidelines in order to eliminate unnecessary,
duplicative care from the clinic.
Turning toward the Advancing Care Information
domain—which essentially replaces Meaningful Use—
Dr. Hines acknowledged its complexity. “They have it
set up so that there is a base score, which accounts for
up to 50 points for certain basic capabilities. And then
there’s a performance score on top of that for more
advanced capabilities of up to 80 points. And then you
can get additional bonus points for even more advanced
capabilities. And if you earn 100 points or more, you
get the full 25% for this measure.”
Reporting for the scores include objectives and
measures such as protecting patient health information, electronic prescribing, providing patients their
electronic records, the coordination of care through
patient engagement, having some form of health
information exchange, and having a public health and
clinical data registry. “We’re already doing much of
this,” says Hines. “We have a web portal, but we’ve
been a lot more aggressive about encouraging folks to
use it. We even have our phone team and patient service
representatives enrolling patients when they call for
appointments to drive those numbers up—not just for
MIPS or Meaningful Use, but because it actually is a
huge time-saver for our providers to communicate with
our patients electronically.”
Detailing the third domain—Clinical Practice
Improvement Activities—Hines discussed what
amounts to any quality improvement efforts that can
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FIGURE 1
MIPS—Maximize Clinical Quality
FIGURE 2
MIPS—Alternative Payment Models
increase the ability of the organization to coordinate
care. Says Hines, “Many of the things that are outlined
in the NCQA Patient Centered Medical Home Recognition process—they’re actually so closely aligned that the
legislation allows automatic full credit in this domain
for practices that are NCQA/PCMH recognized. So
our strategy here is to maintain our recognition for all
of our old sites and then to attain recognition for all of
our new primary care sites.”
For the last of the four domains—Resource
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Use— Hines says Crystal Run’s strategies are divided
into tactics designed to reduce internal resource
utilization or external utilization. Under the internal
utilization, it is focused on the organization’s aforementioned Variation Reduction Cycle, which serves
as a cost-control measure that seeks to standardize
care according to clinical guidelines and eliminate
waste among those not adhering to national or local
practice standards. “To put it very simply, it’s a threestep process,” says Hines. “First you need to analyze
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FIGURE 3
Robust Analytic Approach
T
S
the utilization and collect the data, which is ‘What
does it cost to take care of a patient per year with a
specific diagnosis.’ And then you want to compare that
utilization between your providers. And where you see
variation, analyze what the source is.”
Using Crystal Run’s care for diabetes as an
example, broken-down data showed a three-fold variation in the cost of care. Subsequent analyses illustrated
it had little to do with the patients being sicker, little to
do with the quality being better, but much to do with
the fact that best practice guidelines were not being
followed. Reviewing their best practice guidelines and
having its physicians work through these gaps in just
six months, Crystal Run saw a significant reduction in
overall charges for diabetes. Transferring the lessons
learned from the experience to other departments,
Crystal Run was able to reduce utilization by 14%—
translating to $4.2 million in savings.
Under external utilization, using claims data,
Crystal Run is able to look at inpatient utilization,
emergency room (ER) utilization, skilled nursing facility
(SNF) utilization, and acute rehab utilization, the top
four areas of spending in the Medicare Shared Savings
Program (MSSP). For inpatient and ER utilization,
Crystal Run performed a manual chart audit of 100
admissions, discovering that 60% of patients did not
call before going to the ER, 20% came from SNFs, and
20% came from the office. This data has led to plans
for a Call First Campaign exploring the possibility of
providing alternate forms of transportation to patients,
the establishment of a SNF care manager, as well as the
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hiring of an inpatient coordinator that can determine
whether services in the ER can be managed outside of
the hospital. Additionally, in order to help identify these
patients, Crystal Run now has access to the ADT (admission, discharge, transfer) feed from local hospitals for
ER visits and admissions, and provides daily and weekly
summaries to its care managers, providers, and nurses.
To reduce SNF length of stay, it has put out a
Request for Applications for preferred facilities that are
willing to work with the organization to safely transition patients to home, hired a SNF care manager, and
started the process of putting together a dashboard to
track and trend admissions. Lastly, looking at acute
rehab, Crystal Run now has a prehab program for
those who are undergoing elective joint replacements to
do rehab before surgery so that they may have a better
likelihood of going home sooner after the surgery. They
are also partnering with facilities that have lower utilization of acute rehab.
“In summary, I think it’s very important early on to
determine your appetite for risk,” says Hines. “It’s also
important to identify opportunities in all four domains
of MIPS. The biggest key is to not delay.”
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Another Alternative
O
Handing things over to Aric Sharp, the presentation turned to the pathway of APMs. “When it comes
to Alternative Payment Models, CMS has been pretty
clear in the proposed rule at what they deem to be
Alternative Payment Models and those that are eligible to be Advanced Alternative Payment Models,”
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says Sharp, presenting a slide (Figure 2) on what
models—Next Generation Model Accountable Care
Organization (ACO), MSSP Track 3, Comprehensive
End Stage Renal Disease Large Dialysis Organization,
MSSP Track 2, Comprehensive Primary Care Plus,
Oncology Care Model with two-sided risk, MSSP Track
1, Bundled Payments for Care Improvement—fit into
which category.
The key, Sharp explains, is in determining whether
an organization meets the criteria of the more advanced
models. According to the CMS proposed rule, in order
to be an Advanced APM, providers must use certified
electronic health record technology, and the program
must include MIPS-comparable quality measure metrics
and must bear nominal downside risk. Also, a provider
group must have a minimum threshold of business running through the APM.
Being an Advanced APM comes with its share of
advantages. As Sharp points out, an Advanced APM is
excluded from any MIPS reporting and its associated
administrative burden. The APM Entity is also used
to determine Advanced APM eligibility. “What that
means is that there can actually be participants that
join your APM Entity in these efforts and kind of ride
on the coattails for a period of time as you collaborate
together to improve care,” says Sharp. “That can help
coordinate efforts in the market as you work together
to begin managing risk.”
In addition to these advantages, Sharp says individual participants may be shielded from risk, that choices
can be made about what entities within a network can
and should bear risk, and to what degree. Yet another
advantage is the 5% bonus that is provided to Qualifying APM Participants. This bonus is calculated on the
participant’s entire Part B business. Finally, Critical
Access Hospital providers are eligible.
For those looking to take the step toward the APM
model, Sharp outlined several capabilities needed for
success. Among the key “levers” described by Sharp:
the ability to accurately and compliantly code risk,
manage utilization, consolidate enough lives to spread
the risk, have the discipline to keep within a network
of aligned providers, and continuously improve quality.
Analytics’ role is even more important (Figure 3).
“If you don’t have robust analytics, you probably
are not ready to move down this path,” says Sharp.
Finally, there has to be some form of meaningful reinforcement to share savings and appropriate risk. “All
of this illustrates that this is not practice as usual,”
says Sharp. “This is not doing what we’ve done for
the last 10 to 20 years in medical group practice.
These are all new variables. They’re new dynamics.
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There’s a lot that goes into it, and it takes some understanding of how these capabilities work and how to
translate them into action.”
Choosing Wisely
Ultimately, Sharp argues the importance of putting
everything into context. “We are on a road here that
has a pretty long path,” he says. “We have to change
our care model, while also transforming our business
model. You can call that a path to risk or a path to
capitation—whatever label you want to put on it.
Changing your care model and business model by definition changes your operations inside and out. I think
that’s where MIPS and MACRA pushes all of us. It’s a
daunting challenge. It will be a very active time over the
next five years. We all will be faced with an inordinate
amount of change.”
From the Audience
Q: Are you having trouble with insurance companies
paying for the retinal camera scans?
Hines: Yes, we are looking at this more as a quality
improvement initiative and if there is fee-for-service
revenue that’s possible for that, all the better. But when
we made the decision to do this, the fact that diabetes
eye exam was in every one of the risk-based contracts
and quality incentive contracts, we felt we needed to do
everything we can to improve performance there and
that the majority of the ROI would be on that side of it.
Some insurers are paying without issues. Some insurers
are being a little more difficult, but we’re looking at it
more on the quality incentive side.
Q: How do you currently view the commercial sector
as a partner in risk-based arrangements, (e.g., are they
now or do you expect them soon to offer suitable
risk-based contracts, particularly with those financial
thresholds in the APM program)?
Sharp: I think that’s pretty mixed by part of the
country. What we’re experiencing is that the largest
commercial players in our geographic region are willing to enter into risk-bearing contracts. We’re moving
others in that direction pretty quickly. Now whether
those are great models I think remains to be seen. Will
they qualify under the all-payer option? We just don’t
know yet because we don’t know the criteria around
that exactly. If it follows what’s been laid out as nominal risk and thresholds, we’ll probably be okay, but I
suspect there will be some sort of attestation that the
insurance company has to do to CMS around that.
To back up for a minute and broaden the lens here,
the goals of MACRA, as we see them at an industry
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level, is to move from volume to value. The government
is really focused on shifting risk to providers over a
period of time both through MIPS and the APM model,
while maintaining beneficiary choice, managing a
budget, and streamlining quality programs. As a group
practice, that leaves us with some challenges, the first
of which is understanding our options, and ultimately
learning how to manage a population, take risk, and
manage it effectively around that population, and getting paid for the real value you’re providing.
Scott Hines, M.D., is chief quality officer at Crystal
Run Healthcare, and Aric Sharp, M.H.A., CMPE,
FACHE, is VP accountable care at UnityPoint Health.
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