MACRA and Quality Measures and How They Impact the FEC

As I’m sure you are aware by now, CMS and private payers are converting from a true Fee for Service reimbursement platform to a Quality Based reimbursement model. This process will take place under the Medicare Access and CHIP Reauthorization Act (MACRA) and will transition over a number of years, starting with tracking and reporting certain elements CMS feels will demonstrate “Quality” in 2017 to a series of reimbursement bonuses and reductions starting in 2019 - 2022. Private payers are also already transitioning to this model as well and several large carriers are requiring reporting of certain Clinical Quality Measures (CQM).

HOPD and independent owner operators under a Micro Hospital model currently seeing CMS patients need to be prepared now as tracking and reporting begins this year. Independent operators not currently seeing CMS patients may question the relevance to them. Several factors including competition, decreasing reimbursement, transition to a Micro Hospital or UC model in the future, and private payer transition to a Quality Based reimbursement model may force CMS participation in the near future. Preparation now will prevent delay and revenue loss for your practice. The potential financial impact is significant for the FEC as starting in 2019 there is a potential +4% / -4% bonus/penalty escalating to +9% / -9% in 2022.

MACRA repeals the SGR Formula and sets up two alternative payment programs; MIPS and APM. MIPS is most applicable to the FEC environment and will create a composite score for each practice based upon reporting in 4 performance categories; Resource Use Measures to Reduce Cost, Clinical Practice Improvement Activities, Clinical Quality Measures (PQRS), and Advancing Care Information (EHR Meaningful Use). The composite score will be used to compare your practice to other similar practices and determine if you qualify for a bonus or penalty. Providers can report by one of 3 mechanisms to meet 2017 requirements and avoid 2019 penalties; report single metric for any time period, report more than one metric for full 90 days, or report all data in all categories for full 90 days. 

The CQM required for reporting are a combination of the PQRS, Value-based Payment Modifier (VBPM), and Meaningful Use of EHR initiatives into one program. Practices seeing over 100 CMS patients per year or generating >$30,000 annual CMS revenue are eligible for participation. Practices are required to report 6 CQM across 3 of 6 Quality Domains, including one Outcome Measure. There are currently 13 PQRS CQM applicable to EM that may be utilized and ACEP has created a Qualified Clinical Data Registry (QCDR), CEDR, to aid in tracking and reporting and has added an additional approved 31 CQM to expand the list of relevant EM CQM. Capturing your CQM can be done through your EHR vendor and, if you participate in the ACEP CEDR, transferred directly to CEDR who will manage the reporting for your practice.
Information on applicable CQM, Quality Domains, and reporting requirements can be found at MARCA and CEDR. 

Preparation now is the key to a successful transition to avoid potential revenue loss for your practice and discussion with your EHR vendor, Billing Company, CMS, and CEDR (if you elect to participate) is critical.

David Ernst, MD, FACEP
FEC Section Councillor