Quality Reimbursement: CMS’s Move Away From Traditional ... · reimbursement of each:...

Quality Reimbursement: CMS’s Move Away From

Traditional Fee-For-Service Reimbursement and the Impact

on Physician Practices

Exploratory Paper

Steve Smith, MBA, FACMPE

August 3, 2017

This paper is being submitted in partial fulfillment of the requirements of Fellowship in

the American College of Medical Practice Executives

Quality Reimbursement: CMS’s Move Away From Traditional Fee-For-Service Reimbursement

and the Impact on Physician Practices

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Introduction

Reimbursement, and the maximization of that reimbursement, is a constant concern for Physician

Practice Executives and the organization they work for. Traditionally, executives have focused

on metrics such as efficiency, coding, and utilization management in order to maximize their

Medicare and Medicaid revenue. However, through the process of healthcare reform, the Centers

for Medicare and Medicaid Services (CMS) has introduced multiple new payment models (some

of which are voluntary and some of which are mandatory) which, if a physician practice

participates in, provides additional rewards when the practice meets or exceeds defined metrics.

Practices should, however, note that these new models also present downside risk for those

practices which do not meet stated performance metrics. Executives must therefore perform

detailed analysis to determine which programs the practice will participate in, as well as what

metrics need to be met for the practice to be successful under those programs. This exploratory

paper will examine three new payment models introduced by CMS since 2013: Comprehensive

Care for Joint Replacement (CJR), Comprehensive Primary Care Plus (CPC+), and the Medicare

Access & CHIP Reauthorization Act of 2015 (MACRA).

This paper will provide a brief background of three recent CMS value-based reimbursement

programs as well as the impact of those programs on the operations and financial success of

practices. The CMS Innovation Center website as well as articles and program fact sheets will be

utilized to communicate program requirements and opportunities in an effort to make these

complex programs more understandable for practice administrators and leadership. Best practices

and next steps will also be provided to guide practice leadership in their program implementation.



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Background

Healthcare organizations find themselves in an ever-changing industry. In the recent past there

have been many initiatives focused on areas such as privacy, security, and access to care, just to

name a few. The next major change seems to be a movement towards quality services at a

decreased cost. The Centers for Medicare & Medicaid Services (CMS) has implemented the

“CMS Quality Strategy 2016,” which includes the following three aims:

• Better Care: Improve the overall quality of care by making healthcare more person-

centered, reliable, accessible, and safe.

• Healthier People, Healthier Communities: Improve the Health of Americans by

supporting proven interventions to address behavioral, social, and environmental

determinants of health, and deliver higher-quality care.

• Smarter Spending: Reduce the cost of quality healthcare for individuals, families,

employers, government and communities.

In an effort to fulfill these aims, CMS has also defined the following six priorities in the quality

strategy:

• Make care safer by reducing harm caused in the delivery of care.

• Strengthen person and family engagement as partners in their care.

• Promote effective communication and coordination of care.

• Promote effective prevention and treatment of chronic disease.

• Work with communities to promote best practices of healthy living.

• Make care affordable.

Although the above aims and priorities were published in the “CMS Quality Strategy 2016”

document, The Department of Health and Human Services (HHS) indicated desires to change



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from a volume-based to a value-based reimbursement system in a press release dated January 26,

2015. In that release HHS Secretary Sylvia M. Burwell announced “a goal of tying 30 percent of

traditional, or fee-for-service, Medicare payments to quality or value through alternative payment

models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by

the end of 2016, and tying 50 percent of payments to these models by the end of 2018.” (Better)

The release would later state “HHS also set a goal of tying 85 percent of all traditional Medicare

payments to quality or value by 2016 and 90 percent by 2018 through programs such as the

Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs.”

Such a change in reimbursement methodology will require that Practice Managers gain a better

understanding of alternative payment models, specific model requirements, and the potential

financial impact (positive or negative) the practice will face under model participation. This

paper will examine three such alternative payment models and the potential impact to

reimbursement of each: Comprehensive Care for Joint Replacement (CJR), Comprehensive

Primary Care Plus (CPC+), and the Medicare Access & CHIP Reauthorization Act of 2015

(MACRA).

Comprehensive Care for Joint Replacement (CJR)

Background

According to CMS, “Hip and knee replacements are the most common impatient surgery for

Medicare beneficiaries and can require lengthy recover and rehabilitation periods. In 2014, there

were more than 400,000 procedures, costing more than $7 billion for the hospitalizations alone.

Despite the high volume of these surgeries, quality and costs of care for these hip and knee

replacement surgeries still vary greatly among providers.” (Comprehensive Care) For these

reasons CMS published the final CJR rule on November 16, 2015, which identified 67

Metropolitan Statistical Areas (MSAs) in which hospitals paid under the Inpatient Prospective



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Payment System (IPPS) were required to participate in the model. A listing of the MSAs

participating in the model can be found in Appendix A.

Model Overview

Pricing and Payment

The CJR model holds participant hospitals responsible for the total costs of the episode of care for

90 days following discharge for those patients assigned MS-DRG 469 (Major joint replacement

or reattachment of lower extremity with major complications or comorbidities) or MS-DRG 470

(Major joint replacement or reattachment of lower extremity without major complications or

comorbidities). Each participating hospital is assigned a separate episode target price for each

MS-DRG which “generally will include a discount over expected episode spending and

incorporate a blend of historical hospital-specific spending and regional spending for LEJR

episodes, with the regional component of the blend increasing over time.” (Comprehensive Care

for Joint Replacement Model Provider and Technical Fact Sheet)

Those participating hospitals that achieve Medicare spending below the target price are eligible to

earn up to 5% of the target price in the first and second performance years. In year three of the

program those hospitals are eligible for 10% of the target price and in years four and five the

hospitals are eligible for 20%. However, if the participant hospital exceeds the aggregate

spending limit, that hospital is required to repay the difference to Medicare up to a specified

repayment limit beginning in performance year two. Those limits are 5% in performance year

two, 10% in year three, and 20% in years four and five.

Quality and Pay-For-Performance Methodology

It should come as no surprise to any healthcare professional that a decrease in cost, although

important to CMS, is not the only consideration made by CMS when determining success under

this model. Hospitals will be required to display a minimum level of episode quality before they



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are eligible to receive any reconciliation payments. To determine that minimum quality level,

CMS has adopted a composite quality score methodology. The composite score will be a

representation of performance and improvement of two quality measures: (1) THA/TKA

Complications Measure (NQF #1550) and (2) the HCAHPS patient experience survey measure

(NQF #0166). (Comprehensive Care for Joint Replacement Model Provider and Technical Fact

Sheet)

In addition to the composite score, CMS will take into consideration the hospital’s ability to avoid

expensive and harmful events such as readmissions, and hospital-acquired infections. Events

such as these have historically shown an increase not only in episode spending, but also quality

outcomes and patient satisfaction. Because this model aims to decrease cost and increase quality,

those hospitals with such events may find their reconciliation payments decreased, or eliminated

altogether. Conversely, those hospitals which achieve higher levels of quality and patient

satisfaction may see higher levels of incentive payments.

It should be noted, however, that CMS will provide hospitals with tools to help them improve

care coordination. These tools will be available to all hospitals included in selected MSAs and

include (Comprehensive Care for Joint Replacement Model Provider and Technical Fact Sheet):

1. Providing hospitals with relevant spending and utilization data.

2. Waiving certain Medicare requirements to encourage flexibility in the delivery of care.

3. Facilitating the sharing of best practices between participant hospitals through a learning

and diffusion program.

Beneficiary Benefits and Protections

While the focus in terms of financial and quality outcomes is primarily set on the anchor hospital,

CMS has been proactive in ensuring Medicare beneficiaries are not denied their rights as a patient



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under this model. For example, any patient who received an LEJR service in an MSA has the

right to choose the services provided as well as the provider of those services. And those choices

are not limited to the acute care setting. Although the anchor hospital may set up a narrow

network of post-acute providers where they prefer to have patients sent for post-acute care,

patients ultimately have the right to choose where they receive those services, regardless of

whether or not the facility of choice is included in the narrow network. In addition, patients have

the right to notify a Quality Improvement Organization (QIO) or CMS in the event they received

poor care.

Interaction with Other Models and Programs

It should be noted that there may be instances where either patients who receive LEJR services or

the anchor hospital itself may be covered by or participate in other CMS models. In these

instances the patients who receive LEJR services will still be counted in the reconciliation for the

anchor hospital. However, the successful treatment and care for these patients will likely result in

positive outcomes in those other models. For example, if a hospital participates in the Shared

Savings Program and treats a CJR patient with low cost and high quality outcomes, the hospital

may be eligible for increased reimbursement under both models.

Provider organizations can also benefit from being a participant in CJR under the new Medicare

Access and CHIP Reauthorization Act of 2015 (MACRA). Track 1 of the CJR model has been

selected by CMS as an Advanced Alternative Payment Model (APM) under MACRA legislation.

Provider groups who participate in this track will be exempt from reporting Merit-Based

Incentive Payment System (MIPS) data to CMS and will be eligible for a 5% lump sum bonus on

an annual basis from 2019 through 2022.



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Best Practices for Success Under CJR

Alignment with Post-Acute Providers

By holding the participant hospital responsible for the entire episode of care, CMS requires

participant hospitals to think much differently about patient care after discharge. Participant

hospitals can no longer simply find a post-acute facility such as a Skilled Nursing Facility (SNF)

or Inpatient Rehabilitation Facility (IRF) with a bed available for the patient. Instead, participant

hospitals have begun to develop narrow networks of post-acute facilities to allow for greater

collaboration, care coordination, and hopefully, reduced episode costs.

However, creating and maintaining these narrow networks is not an easy task for the participant

hospitals, primarily because of the differences in reimbursement methodology. Take for example

a SNF facility, which is paid a daily rate by CMS. Historically, SNFs had the ability to maximize

revenue by keeping patients in their building for the maximum number of days allowed by CMS

and ensuring all of the patients concerns were thoroughly addressed prior to discharge. Under

CJR, however, an anchor hospital would like to have CJR patients discharged as quickly as

possible, while still medically appropriate, in an effort to reduce costs.

So how might an anchor hospital convince the SNF that discharging the patient sooner is a good

thing? Inclusion in the anchor hospital’s narrow network. But inclusion in that network takes

more than simply agreeing to do so. Facilities in a narrow network have to understand the cost

constraints the anchor hospital is subject to and agree to change the way they have historically

cared for patients. Some of those changes could include decreased lengths of stay, ER diversion

protocols, increased communication with the anchor hospital, and continual meetings between the

two entities to discuss areas of success and possible improvement under the regulation. While all

of these will undoubtedly require time and resources, being included in the hospital’s narrow



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network will likely result in increased referrals, which may help to offset the decreased revenue

due to decreased lengths of stay.

If informal alignment through the narrow network is not enough to change past behaviors, the

CJR regulations also allow facilities to engage with each other through gainsharing agreements.

These agreements allow for a more formal alignment, where both facilities share the risks and

opportunities under the regulation. When both entities have a financial stake in the performance

of the anchor hospital under CJR, the willingness and desire to change past care standards is more

easily achieved.

Data Analytics

The ability to collect, analyze, and act on collected data is imperative to the success under a

program such as CJR. Anchor hospitals need to have an understanding of not only their historical

performance for these types of procedures, but also the performance of post-acute providers in

their market. Unfortunately the latter of the two has traditionally not been tracked by some as it

has not been a primary concern. However, since hospitals are now being held accountable for the

costs of post-acute providers, information such as average length of stay, readmission rates (either

to the anchor hospital or other facilities), and quality scores must now be benchmarked. And only

those who are the top performers should be considered for inclusion in the narrow network

formed by the anchor hospital.

Unfortunately, as mentioned above, some of this data is not readily available. Information

regarding quality ratings, penalties, etc., can be found on the Nursing Home Compare website,

but information related to lengths of stay and readmissions may be harder to determine. For this

reason some hospitals have engaged with third-party providers who have access to historical

Medicare claims data. Through data mining these third-party providers are able to provide



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dashboard reports on post-acute providers. This data can then be used to develop scorecards,

which can help in the development of potential narrow network members.

Similar data mining can be implemented to track the hospital’s own historical performance.

Vendors can help the anchor hospital by determining the 90-day episode applicable for each

patient encounter that would have qualified under the CJR model, and benchmarking those

episodes against the target prices established by CMS. These benchmarks can then be used to

determine areas of care which need improvement, care pathways that may need to be modified,

and areas of success that may be able to be used as a guide for future episodes.

Comprehensive Primary Care Plus (CPC+)

Background

CMS launched the initial Comprehensive Primary Care initiative in 2012, which was aimed at

testing a new payment model for the delivery of comprehensive primary care. Under the CPC

model, CMS and other payers provided participating practices with monthly care management

fees on a per member basis. Practices were also eligible to share in savings achieved through the

more comprehensive services offered. After the completion of the CPC initiative, and because of

the successes achieved under that model, CMS announced the implementation of Comprehensive

Primary Care Plus (CPC+).

Round one of the (CPC+) initiative began on January 1, 2017 with a goal to “enable primary care

practices to care for their patients the way they think will deliver the best outcomes and to pay

them for achieving results and improving care.” (Comprehensive Primary Care Plus (CPC+)

Round 1 Practice Participants Fact Sheet) In order to be considered for participation, CMS

identified regions in the United States where there was interest from both commercial payers and

practices. Once the regions for round one were announced, practices within those regions were

allowed to submit an application for participation with CMS. That application had to indicate



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why the practice would be successful under the program, demographic data regarding the

practice, and how any funds received by CMS under the model would be utilized. CMS then

reviewed the applications and ultimately selected a total of 2,893 practices in round one of the

program (1,378 practices in Track 1 and 1,515 practices in Track 2). The regions included in

Track 1 of CPC+ can be found in Appendix B.

CMS has announced a second round of CPC+ applications which will begin in February 2017.

The initial application will be for payers in up to 10 additional regions and new payers in the 14

regions included in Round 1. Based on the responses received, CMS will then begin accepting

practice applications in the summer of 2017. However, CMS has decided that no new practices

from Round 1 regions will be accepted for Round 2.

Model Overview

CMS has designed CPC+ with two different tracks. Those practices accepted to Track 1 will

have the goal of building capabilities to deliver more comprehensive primary care to their

patients. Track 2 practices, however, have already built these capabilities and instead will focus

on assessment, risk stratification, and management of more complex patients.

Regardless of the track selected, practices involved in CPC+ will be required to deliver a more

comprehensive level of care that should lead to increased health in the population served by the

practice. In an effort to help practices achieve that goal and to make it more financially feasible,

CMS will issue payments to the practices on a monthly basis. Practices will be required to

account for the use of those funds so CMS can verify funds were truly used to enhance primary

care services and not simply retained by the practice.



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Program Track Requirements

Depending on the track each practice was selected to, there are differing operational requirements

that must be fulfilled under CPC+. In a CPC+ Care Transformation Brief, CMS identified five

CPC+ Primary Care Functions which practices in both tracks will utilize to transform care

delivery:

1. Access and Continuity – Ensuring that patients have timely access to engage the team

will enhance that relationship and increase the likelihood that the patient will get the right

care at the right time, potentially avoiding costly urgent and emergent care.

2. Care Management – Practices will identify high-risk, high-need patients in two ways: (1)

systematically risk stratify their empaneled population to identify the high risk patients

most likely to benefit from targeted, proactive, relationship-based (longitudinal) care

management; and (2) identify patients based on event triggers (e.g., transition of care

setting; new diagnosis of major illness) for episodic (short-term) care management

regardless of risk status. Practices will provide both longitudinal care and episodic care

management, targeting the care management to best improve outcomes for these

identified patients.

3. Comprehensive and Coordinated Care – Adds both breadth and depth to the delivery of

primary care services, builds on the element of relationship that is at the heart of effective

primary care, and is associated with lower overall utilization and costs, less fragmented

care, and better health outcomes.

4. Patient and Caregiver Engagement – Practices will organize a Patient and Family

Advisory Council (PFAC) to help them understand the perspective of patients and

caregivers on the organization and delivery of care, as well as its ongoing transformation

through CPC+.



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5. Data-Driven Population Health Management – Using team-based care, practices will

proactively offer timely and appropriate preventive care, and evidence-based

management of chronic conditions. Practices will improve population health through the

use of evidence-based protocols in team-based care and identification of care gaps at the

population level, as well as measure and act on the quality of care at both the practice and

panel level.

In order to demonstrate a practices ability to fulfill those Primary Care Functions, CMS has

issued guidance to practices which indicates the minimum requirements for each function. As

mentioned previously, the requirements for those practices selected for Track 2 are more complex

and build on the requirements of Track 1. Below is an outline of the requirements of each track:

Track 1 Track 2

Access and Continuity

1.1 Achieve and maintain at least 95% empanelment to practitioner and/or care teams

1.4 Regularly offer at least one alternative to traditional office visits to increase access to care team and clinicians in a way that best meets the needs of the population, such as e-visits, phone visits, group visits, home visits, alternate location visits (e.g., senior centers and assisted living centers), and/or expanded hours in early mornings, evenings, and weekends

1.2 Ensure patients have 24/7 access to a care team practitioner with real-time access to the EHR

1.3 Organize care by practice-identified teams responsible for a specific, identifiable panel of patients to optimize continuity

Track 1 Track 2

Care Management

2.1 Risk-stratify all empaneled patients 2.1 Use a two-step risk stratification process for all empaneled patients: Step 1 - Based on defined diagnoses, claims, or another algorithm (i.e., not care team intuition Step 2 - adds the care team's perception of risk to adjust the risk-stratification of patients, as needed



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2.2 Provide targeted, proactive, relationship-based (longitudinal) care management to all patients identified as at increased risk, based on a defined risk stratification process and who are likely to benefit from intensive care management

2.6 Use a plan of care centered on patient's actions and support needs in management of chronic conditions for patients receiving longitudinal care management

2.3 Provide short-term (episodic) care management along with medication reconciliation to a high and increasing percentage of empaneled patients who have an ED visit or hospital admission/discharge/transfer and who are likely to benefit from care management

2.4 Ensure patients with ED visits receive a follow up interaction within 3 days of discharge

2.5 Contact at least 75% of patients who were hospitalized in target hospital(s) within 2 business days

Track 1 Track 2

Comprehensiveness and Coordination

3.1 Systematically identify high-volume and/or high-cost specialists serving the patient population using CMS/other payer's data

3.3 Enact collaborative care agreements with at least two groups of specialists identified based on analysis of CMS/other payer reports

3.2 Identify hospitals and EDs responsible for the majority of patients' hospitalizations and ED visits, and assess and improve timeliness of notification and information transfer using CMS/other payer's data

3.4 Choose and implement at least one option from a menu of options for integrating behavioral health into care

3.5 Systematically assess patients' psychosocial needs using evidence-based tools

3.6 Conduct an inventory of resources and supports to meet patients' psychosocial needs

3.7 Characterize important needs of sub-populations of high-risk patients and identify a practice capability to develop that will meet those needs, and can be tracked over time.



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Track 1 Track 2

Patient and Caregiver

Engagement

4.1 Convene a PFAC at least once in PY2017, and integrate recommendations into care, as appropriate

4.1 Convene a PFAC in at least two quarters in PY2017 and integrate recommendations into care, as appropriate

4.2 Assess practice capability and plan for support of patients' self-management

4.2 Implement self-management support for at least 3 high risk conditions

Track 1 Track 2

Planned Care and Population Health

5.1

Use feedback reports provided by CMS/other payers at least quarterly on at least 2 utilization measures at the practice-level and practice data on at least 3 electronic clinical quality measures (derived from the EHR) at both practice- and panel-level to inform strategies to improve population health management

5.2 Conduct care team meetings at least weekly to review practice- and panel-level data from payers and internal monitoring and use this data to guide testing of tactics to improve care and achieve practice goals in CPC+

Program Track Payment Models

CMS acknowledged in the Comprehensive Primary Care program that practices who agreed to

the level of required practice and care redesign would require resources and funds to successfully

implement that redesign. In an effort to help practices meet these needs, CMS implemented Care

Management Fees (CMFs). Based on the success of the CPC program, CMS has determined it

will continue to pay practices CMFs under CPC+.

CMS and commercial payers will issue monthly CMF payments on a prospective basis to both

Track 1 and Track 2 practices. The use of these funds, however, must be used to support staffing

and training necessary to meet the model requirements according to practice needs. Patient-

specific CMF payment will be based on the risk tier identified by CMS, which will be based on

the Hierarchical Condition Categories utilized by the practice. The risk-tier payments for each

track established by CMS are:



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Risk Tier Attribution Criteria Track 1 Track 2

Tier 1 1st quartile HCC $6 $9

Tier 2 2nd quartile HCC $8 $11

Tier 3 3rd quartile HCC $16 $19

Tier 4 4th quartile HCC for Track 1; 75-89% HCC for Track 2

$30 $33

Complex (Track 2 only)

Top 10% HCC OR Dementia

N/A $100

Average PBPM

$15 $28

In addition to the CMF payments, CMS has also implemented Comprehensive Primary Care

Payments (CPCPs), which are intended to “promote flexibility in how practices deliver care that

is traditionally provided face-to-face, and requires practices to increase the depth and breadth of

primary care they deliver.” (Comprehensive Primary Care Plus (CPC+) Fact Sheet) While Track

1 practices are not eligible for these payments and will continue to receive traditional fee-for-

service payments under the CPC+ model, Track 2 practices will receive a combination of fee-for-

service and CPCP. Practices are permitted to elect what percentage of fee-for-service and CPCP

payments they would like to establish for each performance year. The following is a summary of

the options available to practices by performance year:

2017 2018 2019 2020 2021

CPCP%/FFS% Options Available to Practices, By Performance Year

10%/90%

25%/75% 25%/75%

40%/60% 40%/60% 40%/60% 40%/60% 40%/60%

65%/35% 65%/35% 65%/35% 65%/35% 65%/35%

In an effort to ensure the quality of care is also considered under the CPC+ model, performance-

based incentive payments have also been introduced. These payments will be issued based on

performance on patient experience, clinical quality, and utilization measures. Track 1

participants will receive a payment of $2.50 per beneficiary per month and Track 2 participants

will receive $4 per beneficiary per month. It should be noted that although these payments will



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be paid to practices at the beginning of the performance year, CMS may recoup all or a portion of

those payments if quality and utilization thresholds are not met. This risk caused many practices

to carefully consider whether or not they should participate in the model, using their past

performance as a guide.

Practice Analysis Required Prior to Participation

While the desire to expand on primary care capabilities and financial incentives were very

attractive to many practices in Round 1 of CPC+, those practices had to undertake a careful

analysis to determine if they would be able to succeed under the model. Failure to properly

utilize prospective payments and/or meet quality and utilization targets presents a significant risk

for practices. Practices considering taking part in Round 2 of CPC+ will need to do similar

analyses in order to determine if the new payment model will be beneficial for their practice.

Regional Requirements

The first piece of analysis for practices was fairly simplistic. Practices had to determine if their

region was included in the CPC+ program, and if so, what commercial payers were also going to

participate in the model. Then, what amount of the practices payer mix was accounted for by the

combination of Medicare and commercial payers. For practices in regions such as Arkansas or

Oregon, where there were a significant number of commercial payers committed to the model,

there may have been significant upside opportunity to improve their practice capabilities with the

use of prospective payments. For practices in the Greater Kansas City region, however, there was

only one commercial payer selected to participate. Practices in that region were required to do a

thorough analysis to determine if the volumes accounted for by Medicare and Blue Cross Blue

Shield of Kansas City would provide enough of an upside opportunity to participate.



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EHR Capabilities

EHR capability was another area where practices had to undertake an extensive analysis.

Because practices are required to use Certified EHR Technology (CEHRT) under the model, they

had to not only verify their systems were considered CEHRT, but also determine what, if any,

upgrades or add-ons to existing systems would be required and what the associated costs may be.

Practices were also required to provide a Memorandum of Understanding (MOU) from the Health

IT vendor as a part of their application to the CPC+ program. If practices determined their

systems were not considered CEHRT, or the cost of necessary upgrades were too great, those

practices likely did not apply for the program, or their application was denied by CMS.

Practice Capabilities

Perhaps the most complex required analysis is how the organization operated prior to CPC+ and

the determination of whether or not systems, staff (both clinical and non-clinical), and processes

could be changed to comply with the requirements of the model. From an IT perspective,

practices not only needed to determine if upgrades could be done to their systems to comply with

the model, and the cost of those upgrades, but also how the system may be used. For example,

one of the requirements of the model is that Track 2 practices is to offer at least one alternative to

traditional office visits to increase access to care team and clinicians in a way that best meets the

needs of the population. But if the practice did not currently have this technology in place and

operational, a careful consideration of costs and timing related to purchasing, installation, and

implementation would have been required. And without a better understanding of how to

appropriately and effectively use the technology, the practice may risk failing to meet the

requirement.



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Another area requiring significant analysis is the service offerings of the practice. One of the

primary goals of CPC+ is to expand the scope of services offered in the primary care setting.

This includes services such as extended office hours, remote visits, and possibly even the

integration of behavioral health, depending on the Track the practice is in. And while the

additional funds offered by CMS in the form of proactive payments can help with some of the

staffing costs associated with these additional services, there is one aspect which may be harder to

determine…the staff’s willingness to accept and operate under the new model. Clinical staff may

not be interested in holding weekly care team meetings, remote visits, or the implementation of

behavioral health. Non-clinical staff may take issue with the extended office hours and the need

to create additional reports to comply with the new practice model. Practice Managers interested

in pursuing Round 2 of CPC+ will need to take these things into consideration and determine if

the practice is positioned for participation.

The final key area of review for practices is the payment model itself. While there is certainly

interest in finding additional revenue for the practice, the care management fees must be utilized

to enhance the practice’s’ capabilities and the applicable expenses must be reported to CMS on an

annual basis. And these funds cannot be used for the purchase or upgrade of HIT. Instead,

practices are permitted to use the funds for wages for new or existing staff, care delivery tools, or

training and travel related to CPC+ educational events. So there needs to be careful analysis done

to ensure not only how much the practice can anticipate in funds, but also how those funds will be

spent.

There also needs to be careful analysis done when determining which track of CPC+ the practice

hopes to participate in. Track 1 still reimburses practices under the traditional fee-for-service

methodology, while Track 2 includes tiered options for fee-for-service and Comprehensive

Primary Care Payments. Because of the potential impacts to practice revenue, management must



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have a solid understanding of not only which revenue model is best for the practice, but also what

tier the practice should elect if selected for Track 2.

Overall the CPC+ model can allow forward-thinking, well equipped practices a means by which

the practice can continue to evolve and add additional services for patients. However, practice

managers need to carefully analyze not only the financial implications of the model, but also the

service offerings and reporting requirements. Failure to accurately report data to CMS or

substandard quality outcomes may lead to the practice having to pay back proactive payments to

CMS, some of which may have already been spent in expanding the practice’s capabilities and

offerings. Practices considering applying for inclusion in CPC+ when the application period

opens will need to begin their analysis today in order to make the best possible decision regarding

participation.

MACRA Implications

Another aspect of CPC+ that may make the model appealing to practices is CMS’s designation of

the CPC+ model as an Advanced Alternative Payment Model (APM). As is the case with CJR,

practices taking part in CPC+ will be exempt from reporting Merit-Based Incentive Payment

System (MIPS) data to CMS and will be eligible for a 5% lump sum bonus on an annual basis

from 2019 through 2022. This lump sum payment will be made to the practice in addition to

payments received under the CPC+ model, which could make CPC+ a very attractive option for

practices that are able to successfully complete the operational requirements of the model.

Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)

For the past 13 years, practice managers have been waiting for a new reimbursement

methodology to replace the Sustainable Growth Rate (SGR) formula. Each year practices were

informed of a need to fix the SGR and to do so would require large cuts to the physician fee



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schedule. But each time those needed cuts were announced, Congress issued a “patch” which

allowed the physician fee schedule to remain relatively unchanged, sometimes with a slight

increase. When the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) was

passed, CMS not only addressed the issues with the SGR, but also continued the shift toward

value-based Medicare reimbursement.

Background

With the replacement of the SGR formula, CMS signaled a desire to move away from the

traditional fee-for-service reimbursement methodology to one that paid clinicians based on

quality and value, instead of simply volume. The MACRA regulation, also referred to as the

Quality Payment Program (QPP), also aimed to simplify physician reporting requirements, which

previously had to be done under three different programs: The Physician Quality Reporting

System (PQRS), The Value-Based Modifier (VBM), and Meaningful Use (MU).

CMS further clarified the goals of MACRA in a document titled “Strategic Objectives for the

Quality Payment Program.” In that document CMS outlined six primary objectives:

1. Improve beneficiary outcomes and engage patients through patient-centered Advanced

APM and Merit-based Incentive Payment System (MIPS) policies.

2. Enhance Clinician experience through flexible and transparent program design and

interactions with easy-to-use program tools.

3. Increase the availability and adoption of robust Advanced APMS.

4. Promote program understanding and maximize participation through customized

communication, education, outreach, and support that meet the needs of the diversity of

physician practices and patients, especially the unique needs of small practices.

5. Improve data and information sharing to provide accurate, timely, and actionable

feedback to clinicians and other stakeholders.



21

6. Ensure operational excellence in program implementation and ongoing development.

The first performance year for MACRA is calendar year 2017 and any applicable changes to

provider reimbursement based on 2017 performance will be made in 2019. This two year

lookback period will continue throughout the program. However, the 2017 performance year will

be different from later years as providers are being given the opportunity to “pick your pace”

regarding how much data is reported to CMS. This is being done to allow providers to begin

operating under the new legislation with as little risk as possible to future provider payments.

Any provider or provider group that submits at least some 2017 data to Medicare (e.g., one

quality measure for one day in 2017) will have a neutral adjustment to its Medicare Part B

payments in 2019. 2018, however, will be a full performance year, where providers are required

to report all required data to CMS, with any applicable changes to Medicare Part B payments

taking place in 2020.

Model Overview

The MACRA legislation created two new tracks for Medicare Part B reimbursement: The Merit-

Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

The MIPS track most closely resembles traditional fee-for-service reimbursement, but

adjustments to provider payments will be based on the successful reporting of four categories:

Quality, Resource Use, Advancing Care Information, and Clinical Practice Improvement

Activities. The APM track, however allows practices to achieve higher levels of reimbursement

while assuming some risk related to patient outcomes. Providers in the APM track are also

exempt from MIPS reporting.

MIPS Track

As stated above, the MIPS track most resembles traditional fee-for-service reimbursement

methodology, and aspects of the track will feel very familiar to practice managers and providers.



22

However, instead of provider fee schedules being impacted in a uniform manner across a region,

the increases or decreases to Medicare Part B reimbursement will now be based on the quality

and value of care, as well as increased capabilities of the practice.

At the end of each performance year practices will submit MIPS reporting data to CMS for

analysis and comparison to other practices throughout the country. And because MACRA is a

budget neutral program, those practices who have a decrease applied to their Medicare Part B

payments will effectively fund the increased to those practices who perform well. This is most

significant in the 2017 performance year. As mentioned above, if practices are allowed to submit

just one piece of data in order to avoid negative payment adjustments, the available funds for

payment increases will be limited in 2019. However, if practices fail to be fully capable of

reporting MIPS measures in 2018, and therefore receive a maximum possible negative payment

adjustment, there is a potential for many practices across the county to receive the maximum

possible positive payment adjustments. The table below from CMS illustrates the maximum

possible positive or negative adjustments per year, under the MACRA rule:

The MACRA legislation also applied MIPS reporting requirements to more than just physician

providers. In the 2017 and 2018 performance years, the following provider types were

determined to be eligible: Physicians (MD/DO and DMD/DDS), Physician Assistants, Nurse



23

Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists. In 2019 it

is possible the following provider types will be added to the list of eligible clinicians (although

final determination will be announced by CMS at a later date): Physical Therapists, Occupational

Therapists, Speech-Language Pathologists, Audiologists, Nurse Midwives, Clinical social

Workers, Clinical Psychologists, Nutritionists, and Dieticians.

However, it should be noted that there are instances where providers will be exempt from MIPS

reporting. The first group of providers exempt from MIPS reporting are those providers who

participate in APMs. Because the APMs themselves implement guidelines similar to MIPS

measures, CMS will not require data submission for both CMS and the APM.

Those providers who are in their first year of Medicare Part B participation are also exempt from

MIPS reporting. CMS understands that these providers, being new to healthcare reimbursement,

may need time to get used to billing and coding requirements. These providers can still submit

MIPS data to CMS, but their reimbursement will not be impacted. They will, however, receive

feedback from CMS which can help them better prepare for years in which they are required to

submit data and receive adjustments to payments.

Finally, those providers who fall below a low volume threshold will not be required to submit

data under MIPS. CMS has established the low volume threshold of either $30,000 in allowed

Medicare Part B charges or 100 separately identifiable Medicare beneficiaries. Individuals or

groups who fall below either of those thresholds, as identified by CMS through claims

submissions in the previous calendar year, will be exempt from MIPS reporting. This

determination will be made each year by CMS and providers will be notified of exemption in

December of each year.



24

As mentioned above, practices will be assigned a composite score based on the data they submit

to CMS each year. How the composite score is determined will vary by year, with the Quality

category making up the highest percentage of the composite score for the 2017 performance year.

Specifically, CMS has established the following category weights for the first three performance

years:

In order to receive the highest possible composite score in each year, practices will need to report

the following information by performance category.

Quality

The quality category accounts for 60% of the composite score for performance year 2017 and

replaces PQRS and the quality component of the Value-Based Modifier Program. Because of the

heavy weighting during the first two performance years, many practices are very carefully

15% 15% 15%

25% 25% 25%

10%

30%

60%50%

30%

2017 2018 2019

Category Weighting

Quality

Resource Use

Advancing Care Information (ACI)

Clinical Practice Improvement Activities (CPIA)



25

considering how this category is reported. In order to receive full credit for the category,

practices must report at least 6 measures, with each measure assigned a grate of between 1 and 10

points. At least one of the reported measures must be an outcome measure, although if an

outcome measure is not available for a practice it can report another high quality measure instead.

Practices can also earn bonus points by reporting additional outcome measures or high quality

measures that fit the way the practice operates or by submitting measures with end-to-end

electronic reporting.

CMS has identified more than 200 measures available for practices to select from and over 80%

of those measures have been tailored for specialists. These specialized measures resulted in CMS

developing Specialty Measure Sets, which are groups of quality measures that have been selected

for individual specialties (e.g., radiology, cardiology, etc.). Practices who elect to report on all

measures of a specialty set will receive full credit for the number of measures reported, regardless

of the number of measures in that specialty set. For example, if a specialty set contained only 4

measures, a practice that submitted all four of those measures would be eligible for full credit

under the quality category, although the stated minimum number of measures has been set at 6.

Conversely, if a specialty set contains 8 measures and a practice submits all 8 of those measures

to CMS, only the 6 highest scoring measures will be used when computing the composite score

for the practice. While this may not benefit a multi-specialty group, groups who are able to

submit data for a specific specialty set may see the flexibility and tailored measures as a way to

make reporting easier and more valuable.

In order to assist practices in determining which measures will be reported, CMS has created a

measure selection tool (https://qpp.cms.gov/measures/quality). The tool will allow practices to

filter measures based on keywords, priority level, data submission method (claims, registries,

https://qpp.cms.gov/measures/quality



26

EHR, etc.), and specialty measure sets. Practices have the ability to export all measures or a

filtered list of measures in .csv format for additional analysis of each individual measure.

Resource Use (Cost)

The Resource Use category replaces the cost component of the Value-Based Modifier Program.

Although this category will not be considered as a part of the practice’s composite score for the

2017 performance year, CMS will provide feedback to practices throughout the year to prepare

for future performance years. Scores will be based on Medicare Part B claims adjudication so

there is no reporting required for the practices. CMS will base the practice score on total per

capita cost and Medicare spending per beneficiary. There will also be over 40 episode-specific

measures to account for reimbursement differences among specialties. Practices should carefully

review the reports provided by CMS during 2017 to identify areas of improvement for future

performance periods.

Advancing Care Information

The Advancing Care Information category replaces the former Medicare Meaningful Use

program and will account for 25% of the 2017 composite score. Perhaps the greatest advantage

of this new category is that it moves away from the “all or nothing” scoring methodology in place

under Meaningful Use and implements a benchmarked scoring system where practices can

achieve partial credit and still receive some awards if unable to achieve a score of 100%.

There are five required measures under this category, which account for 50% of the category’s

total score. The positive news for practices is that these categories are very similar to the

requirements previously in place under Meaningful Use: security risk analysis, provide patient

access, send summaries of care, participate in electronic prescribing, and request and accept

summaries of care. Practices can earn the remaining 50% of the category score through actions

such as patient education, coordination of care through patient engagement, and clinical



27

information reconciliation. Bonus points can also be earned for participating in public health and

clinical data registry reporting and the use of Certified Electronic Health Record Technology

(CEHRT) to complete certain improvement activities. As with the Quality category, CMS has

published the available Advancing Care Information measures to its website and those measures

can be filtered and exported for further review.

It should be noted, however that some practices may not be required to submit data for the

Advancing Care Information category. Practices or providers who fall into one of the following

categories will have the Advancing Care Information category reweighted to 0% and the Quality

category will be reweighted to 85%:

1. Practices or providers who submit fewer than 100 patient facing encounters, as

determined by CMS after analyzing annual claims adjudication.

2. Practices or providers who are awarded a hardship exemption by CMS.

3. Practices or providers who perform at least 75% of professional services in a hospital

environment (either inpatient, outpatient, or emergency department), as determined by

CMS after analyzing annual claims adjudication.

4. Non-physician providers will receive exemptions for the 2017 performance period.

Just as with Quality metrics, practices are able to view and download the various Advancing Care

Information metrics through a quality selection tool (https://qpp.cms.gov/mips/advancing-care-

information). Practices will need to review this information as soon as possible to begin forming

or finalizing their reporting strategy.

Clinical Practice Improvement Activities

The Clinical Practice Improvement Activities category will account for 15% of the 2017

performance period composite score and activities have been determined by CMS to be either

https://qpp.cms.gov/mips/advancing-care-information

https://qpp.cms.gov/mips/advancing-care-information



28

“high-weighted” or “medium-weighted” measures. Practices will be required to attest to the

completion of up to four improvement activities for a minimum of 90 days and like Quality and

Advancing Care Information, measures can be exported for this category from the CMS website

for additional analysis.

CMS has acknowledged that this category may be difficult for some practices, or that some

practices are already implementing these types of activities into their practice. For that reason,

CMS has announced preferential scoring methodologies for the following groups of practices:

1. Groups with fewer than 15 providers will only be required to attest to the completion of

two activities for a minimum of 90 days.

2. Groups in a geographical area identified as rural or a health professional shortage area

will only be required to attest to the completion of two activities for a minimum of 90

days.

3. Practices that have been certified by CMS as a patient centered medical home will

automatically receive full credit for this category.

4. Participants in APMs who do not have enough volume of either patients or revenue

flowing through that APM are still required to submit data under MIPS. However, these

practices will receive full credit for this category.

Again, practices are able to view the available metrics as well as download metric-specific

information at the Quality Payment Program website (https://qpp.cms.gov/mips/improvement-

activities) and should do so as soon as possible in order to finalize a reporting strategy.

APM Tracks

APMs allow practices the opportunity to earn additional revenue while assuming some risk as it

relates to patient outcomes. Practices who participate in an APM, and have enough volume of

https://qpp.cms.gov/mips/improvement-activities

https://qpp.cms.gov/mips/improvement-activities



29

either patients or revenue flowing through that APM, can earn a lump-sum payment of 5% of

Medicare Part B allowable charges for participating in that model. In addition, the practice will

be permitted to earn rewards under the APM model itself. For practices who have already

implemented many of the activities listed under the MIPS track, moving to the APM track may be

a viable opportunity, but careful consideration must be made prior to changing to that

reimbursement track.

Perhaps the greatest barrier to APM participation at this time (CMS estimates only about 7% of

practices will quality for APM status in the 2017 performance year) is the limited number of

models available. In order to qualify as an APM, the model must meet the following

requirements:

1. Be CMS Innovation Center models, Shared Savings Program Tracks, or certain federal

demonstration programs.

2. Require participants to use certified EHR technology.

3. Base payments for services on quality measures comparable to those in MIPS.

4. Be a Medical Home Model expanded under Innovation Center authority or require

participants to bear more than nominal financial risk for losses.

CMS has published the following list of Advanced APMs and as additional models are approved

they will be published to https://qpp.cms.gov/learn/apms:

1. Comprehensive ESRD Care (CEC) – Two-Sided Risk

2. Comprehensive Primary Care Plus (CPC+)

3. Next Generation ACO Model

4. Shared Savings Program – Track 2

5. Shared Savings Program – Track 3

6. Oncology Care Model (OCM) – Two-Sided Risk

https://qpp.cms.gov/learn/apms



30

7. Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1 – CEHRT)

As mentioned above, simply participating in one of the APM models is not enough to be eligible

for MIPS exemption and the 5% lump-sum bonus. Practices who elect to participate in the APM

track must have certain volumes of either patients or revenue flowing through that APM.

Otherwise, the practice will be responsible for reporting data under MIPS, although preferential

scoring will be available. The following chart obtained from CMS Quality Payment Program

Fact Sheet outlines the required volume levels established by CMS for each performance year:

Because practices will have to have some risk under these models, careful consideration must be

given not only to patient and revenue volumes, but also the possibility of the practice being

successful under the selected model. Failure to produce quality outcomes may result in a loss of

revenue under the APM and the 5% lump-sum bonus received from CMS may or may not be

enough to offset that revenue decrease.

Requirements for Success Under MACRA

While the MACRA legislation is a major change and can be intimidating for some practices, there

are some steps that can be taken now to help practices succeed in both the short and long-term

under the legislation. However, these actions should be taken now so that needed systems and

processes can be put in place prior to the first full performance year of 2018.



31

Understand Financial Risk and Opportunity

Perhaps one of the most important thing to understand about the MACRA legislation is the

financial risk or opportunity faced by the practice. As discussed previously, each performance

year carries a maximum positive or negative adjustment to provider reimbursement. Practices

must be able to determine what those individual percentages mean to a practice, both in each

individual year as well as throughout the life of the program.

In order to complete this analysis, the practice needs to first identify its historical amount of

Medicare Part B allowable charges. For example, if a practice were to determine its average

allowable charges per year was $750,000, the graph below shows the potential risk and

opportunity for revenue in each payment year:

While financial risk and opportunity of only $30,000 and $37,500 in 2019 and 2020 respectively

may not seem significant, the practice must realize that by 2022 that figure will increase to

$67,500 annually, resulting in a total risk or opportunity of $390,000 between 2019 and 2025.

Practices should also keep in mind that these figures assume no additional Medicare patient

volume, no additional providers being added to the practice, and does not take into consideration

$(30,000.00)$(37,500.00)

$(52,500.00)

$(67,500.00) $(67,500.00) $(67,500.00) $(67,500.00)

$30,000.00 $37,500.00

$52,500.00

$67,500.00 $67,500.00 $67,500.00 $67,500.00

$(80,000.00)

$(60,000.00)

$(40,000.00)

$(20,000.00)

$-

$20,000.00

$40,000.00

$60,000.00

$80,000.00

2019 2020 2021 2022 2023 2024 2025



32

the addition of provider types required to submit data under MIPS beginning in 2019. All of

these factors could greatly increase the possible risks and opportunities for future reimbursement.

The financial risks and opportunities, while they may seem small at the beginning of the program,

have the potential to grow very large in future years, so practices must be sure to implement plans

to ensure long-term success and risk mitigation.

Determine 2017 Reporting Option

When determining how information will be reported to CMS, practices need to determine not

only if they will report data as individuals or as a group, but also what means they will use to

actually submit their data. Both group and individual reporting have their advantages and

challenges and practices will need to carefully analyze each to determine which option is best for

their organization.

Individual or Group Reporting

Reporting under MACRA, whether as a group or an individual, is based on the combination of

NPI and Tax ID. If reporting is done at the individual provider level, each NPI will be tied to a

single Tax ID. Group reporting, however, will have multiple NPIs sharing a common Tax ID.

One aspect that must be reviewed by the practice is payment adjustments. If the practices

determines to submit data for each individual provider, then each individual provider will have

his or her payments adjusted based on their individual performance. If the group were to choose

to submit data as a group, then each provider within that group would receive the same payment

adjustment based on the group’s performance. Practice leadership will need to determine if some

providers will accept having their payment adjustments at least partially determined by their

partners. If this will cause any friction within the group, reporting as individuals may be a better

option.



33

Another area of review is how the practice is currently reporting to PQRS, Value-Based Modifier,

and Meaningful Use programs, if they are at all. Reporting as individuals can certainly require

more time and resources than reporting as a group. However, if those resources are already in

place because of past reporting, reporting as individuals may not be overly cumbersome.

However, for those who have always reported data as a group, or have not reported to previous

programs, it may be more simplistic to report as a group.

Practices will also need to take into consideration whether or not they have certain providers who

may fall below the previously mentioned low volume thresholds, and if the practice wants to take

advantage of those exemptions. When reporting as a group, the group’s volume will be taken into

consideration when determining volumes. So in the case of a practice with three providers, if

each saw only 75 Medicare patients in the year, each individual would qualify for low volume

exemption. However, if the practice submitted data as a group, the patient volume would be the

combined number of 225 and the practice would be required to submit MIPS data.

Data Submission Methods

Practices are permitted to submit MIPS data to CMS in a variety of ways including Qualified

Clinical Data Registries, Qualified Registries, and through their Electronic Health Record (EHR).

The following chart identifies how each MIPS category can be submitted to CMS:



34

Submission Methods Quality Cost

Clinical

Practice

Improvement

Activities

Advancing

Care

Information

Qualified Clinical Data

Registry X X X

Qualified Registry X X X

Electronic Health Record X X X

Administrative Claims (No

Submission Required) X X

CMS Web Interface

(Groups of 25 or More) X X X

CAHPS for MIPS Survey X

Attestation X X

For some practices, contracting with either a Qualified Clinical Data Registry or Qualified

Registry may be desired so they have a partner in the data submission process who can help

verify all required data is present prior to submission to CMS. Although there is a cost to using

these services, some practices have determined that cost to be low enough to not offset the

benefits of having a partner. Other practices may determine that submitting data through their

EHR is beneficial since there are available bonus points under MIPS for doing so. Practices

interested in EHR reporting will need to work closely with their vendor to ensure that vendor is

capable of doing such reporting, and also identifying any applicable system upgrades and the cost

of those upgrades.

Ultimately, the goal for a practice should be efficiency in data submission. The ideal submission

methodology would be one that can submit data to CMS for all needed categories so the practice



35

doesn’t have to maintain and track submission under multiple systems. The costs of either a

third-party registry or any IT costs should also be taken into consideration when selecting a

submission method.

Assess Performance Under Previous Programs

Because MACRA replaces the PQRS, Value-Based Modifier, and Meaningful Use programs,

many of the aspects of those programs are present in the MACRA legislation. For those practices

who submitted data under, and performed well, under those past programs, much of the

infrastructure and processes needed for success may already be present. For example, many of

the measures previously available under PQRS are still available under the Quality category of

MIPS. So there may be little time or resources needed for those practices who have already

reported that data in the past. Conversely, those practices who have never reported data may

require additional time and/or resources.

For those practices that either did not submit data or submitted data, but failed to achieve high

scores under previous programs, MIPS may provide an opportunity to improve performance.

Preferential scoring for small practices, a wide variety of available measures, and multiple data

submission methods should provide much more flexibility than existed in the previous programs.

Complete a MACRA Participation Plan

A MACRA Participation Plan is simply the documented plan established by a practice for success

under the new legislation. While the plan itself may be complex, it is by no means set in stone

and may need to be edited as practices determine new opportunities for success.

Perhaps the most important aspect of the plan is the development of a Steering Committee which

can analyze program options, select appropriate measures, oversee data submission, and review

composite scores for areas of improvement. Traditionally these committees are made up of



36

senior administrative leadership, clinician leadership, IT leadership, and representatives from the

organization’s department responsible for quality. Other individuals or teams can certainly be

involved as well, but these groups or individuals will make up the core of the committee.

When selecting measures, the group will need to ensure clinical leadership has a solid

understanding of documentation requirements and what will be required of clinicians. If the

committee simply tells clinicians the measures they will be expected to document and report,

those clinicians may or may not engage with the plan. However, allowing the clinicians to at

least have a say in what measures are selected and how they need to be documented, there is a

greater chance of engagement and success.

Once the committee has developed the measures to be reported, subcommittees can then be

created to specialize in the four MIPS categories. Those subcommittees will then be responsible

for the implementation, tracking, and reporting progress or needed resources back to the steering

committee. Ideally the subcommittees will meet at least twice per month in the early months of

plan implementation and those meetings can become less frequent over time as the plan is

implemented and running smoothly. Steering Committee meetings should be held at least

monthly and include a review of the MACRA Participation Plan as a standing agenda item.

Practices should also be mindful of the fact that the creation of these committees, plans, and

standard meetings will take time to implement. And meeting stated objectives will be a long-term

process involving multiple departments. So the process of planning and committee development

should start as soon as possible to make sure processes and procedures are in place and familiar

prior to the first full performance year of 2018.



37

Evaluate EHR Vendor Readiness

Many practices may choose to report MIPS data through their EHR system as a means to keep

costs low while achieving higher levels of efficiency. However, those practices must ensure their

EHR vendors are capable of reporting. And if the system is not capable, the vendor will need to

indicate whether or not plans exist to implement that capability and what the costs to implement

that capability is anticipated to be. If the vendor does not plan to implement that capability in the

short term, or if the costs are anticipated to be too high, practices may need to either select a new

EHR vendor or choose to submit their MIPS data to CMS in another way.

Review Internal Processes

Internal processes will need to be continually reviewed and evaluated by the organization to

ensure MACRA reporting and data collection is not overly cumbersome to either clinical or non-

clinical staff. And as with the creation of the MACRA Participation Plan, clinical leadership

should be involved in these discussions to ensure processes do not place a burden on patient care.

These reviews should initially take place as a part of the Steering Committee’s initial meeting and

each subcommittee should attempt to identify process improvements that apply to their committee

on a continued basis, especially in the initial months of the plan. This will be especially

important for those practices that are either new to reporting data, or are reporting data they have

not reported previously. Practices who already have processes in place may not need as intensive

of an initial review and analysis, but must be sure to continually evaluate the effectiveness and

efficiency of their processes.

Consider Participating in a Qualified APM

As stated previously there are benefits in participating in a Qualified APM, both financial and

operational. However, practices must be very cautious when selecting an APM to participate in.

Because Qualified APMs have to incorporate at least a minimal level of risk to a practice’s



38

revenue, practice leadership must do their due diligence in identifying APM requirements,

analyzing practice capabilities, and determining patient volumes (both in terms of the number of

patients and revenue). Practices who fail to perform well under an APM model may have their

revenue reduced by more than what was at risk under the MIPS track. And if an insufficient

volume of patients or revenue flow through that APM, the practice will not receive the 5% lump-

sum bonus paid by CMS and will still have to report data under MIPS.

Ultimately, however, successful participation in a Qualified APM can present a significant

opportunity for practices to not only improve the practice’s operations, but also increase revenue.

Because CMS plans to continually announce new Qualified APM models, practices will need to

continually refer to the formal listing at https://qpp.cms.gov/learn/apms to identify and analyze

newly announced models.

Conclusion

The Centers for Medicare and Medicaid Services (CMS) has clearly communicated its desire to

move away from traditional fee-for-service reimbursement and towards value-based

reimbursement with the implementation of Comprehensive Care for Joint Replacement (CJR),

Comprehensive Primary Care Plus (CPC+), and The Medicare Access & CHIP Reauthorization

Act of 2015 (MACRA), as well as other payment initiatives. For success under these models,

practices will be required to continually analyze aspects of patient care such as cost, quality, and

service offerings to identify areas of improvement.

The Practice Manager may assume ultimate responsibility for success under these payment

models and to continually identify, analyze, and determine whether a reimbursement model is a

fit for the organization. However, in order to perform well that manager will require a team of

individuals dedicated to the practice’s success to assist him or her in selecting and operating




39

within value-based reimbursement. Clinical leadership will need to provide guidance regarding

efficient, quality patient care. IT leadership will need to work closely with vendors to determine

system capabilities and identify needed system changes or upgrades and the cost of those

upgrades. Data and finance leadership will need to analyze financial and outcomes data to

identify care pathways that lead to quality outcomes at low costs and also identify those pathways

that may need to be changed due to either quality or financial outcomes.

Ultimately it will be those organizations that dedicate themselves to these processes and analyses

that are positioned for long-term success in value-based reimbursement.



40

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https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus

https://innovation.cms.gov/Files/x/cpcplus-caredeliverybrief.pdf

https://innovation.cms.gov/Files/x/cpcplus-caredeliverybrief.pdf

https://innovation.cms.gov/Files/fact-sheet/cpcplus-fs-rd1.pdf

https://innovation.cms.gov/Files/fact-sheet/cpcplus-fs-rd1.pdf


https://qpp.cms.gov/measures/quality

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality-Strategy-Overview.pdf



https://qpp.cms.gov/docs/Quality_Payment_Program_Overview_Fact_Sheet.pdf

https://qpp.cms.gov/docs/QPP_Key_Objectives.pdf



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APPENDIX A – MSAs Included in CJR

MSA MSA Title Counties

14500 Boulder, CO Boulder County

16180 Carson City, NV Carson City

17860 Columbia, MO Boone County

19500 Decatur, IL Macon County

22420 Flint, MI Genesee County

23580 Gainesville, GA Hall County

24780 Greenville, NC Pitt County

26300 Hot Springs, AR Garland County

33700 Modesto, CA Stanislaus County

34940 Naples-Immokalee-Marco Island, FL Collier County

35300 New Haven-Milford, CT New Haven County

35980 Norwich-New London, CT New London County

39740 Reading, PA Berks County

40980 Saginaw, MI Saginaw County

42680 Sebastian-Vero Beach, FL Indian River County

46340 Tyler, TX Smith County

19740 Denver-Aurora-Lakewood, CO Adams County, Arapahoe County, Broomfield County, Clear Creek County, Denver County, Douglas County, Elbert County, Gilpin County, Jefferson County, Park County

10420 Akron, OH Portage County, Summit County

10740 Albuquerque, NM Bernalillo County, Sandoval County, Torrance County, Valencia County

11700 Asheville, NC Buncombe County, Haywood County, Henderson County, Madison County

12020 Athens-Clarke County, GA Clarke County, Madison County, Oconee County, Oglethorpe County

12420 Austin-Round Rock, TX Bastrop County, Caldwell County, Hays County, Travis County, Williamson County

13140 Beaumont-Port Arthur, TX Hardin County, Jefferson County, Newton County, Orange County

13900 Bismarck, ND Burleigh County, Morton County, Oliver County, Sioux County

15380 Buffalo-Cheektowaga-Niagara Falls, NY Erie County, Niagara County

16020 Cape Girardeau, MO-IL Alexander County, Bollinger County, Cape Girardeau County

16740 Charlotte-Concord-Gastonia, NC-SC Cabarrus County, Gaston County, Iredell County, Lincoln County, Mecklenburg County, Rowan County, Union County, Chester County, Lancaster County, York County

17140 Cincinnati, OH-KY-IN

Dearborn County, Ohio County, Union County, Boone County, Bracken County, Campbell County, Gallatin County, Grant County, Kenton County, Pendleton County, Brown County, Butler County, Clermont County, Hamilton County, Warren County

18580 Corpus Christi, TX Aransas County, Nueces County, San Patricio County

20020 Dothan, AL Geneva County, Henry County, Houston County



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20500 Durham-Chapel Hill, NC Chatham County, Durham County, Orange County, Person County

23540 Gainesville, FL Alachua County, Gilchrist County

25420 Harrisburg-Carlisle, PA Cumberland County, Dauphin County, Perry County

26900 Indianapolis-Carmel-Anderson, IN

Boone County, Brown County, Hamilton County, Hancock County, Hendricks County, Johnson County, Madison County, Marion County, Morgan County, Putnam County, Shelby County

28140 Kansas City, MO-KS

Johnson County, Leavenworth County, Linn County, Miami County, Wyandotte County, Bates County, Caldwell County, Cass County, Clay County, Clinton County, Jackson County, Lafayette County, Platte County, Ray County

22500 Florence, SC Darlington County, Florence County

28660 Killeen-Temple, TX Bell County, Coryell County, Lampasas County

30700 Lincoln, NE Lancaster County, Seward County

31080 Los Angeles-Long Beach-Anaheim, CA Orange County, Los Angeles County

31180 Lubbock, TX Crosby County, Lubbock County, Lynn County

31540 Madison, WI Columbia County, Dane County, Green County, Iowa County

32820 Memphis, TN-MS-AR Crittenden County, Benton County, DeSoto County, Marshall County, Tate County, Tunica County, Fayette County, Shelby County, Tipton County

33100 Miami-Fort Lauderdale-West Palm Beach, FL Broward County, Miami-Dade County, Palm Beach County

33340 Milwaukee-Waukesha-West Allis, WI Milwaukee County, Ozaukee County, Washington County, Waukesha County

33740 Monroe, LA Ouachita Parish, Union Parish

33860 Montgomery, AL Autauga County, Elmore County, Lowndes County, Montgomery County

34980 Nashville-Davidson--Murfreesboro--Franklin, TN

Cannon County, Cheatham County, Davidson County, Dickson County, Hickman County, Macon County, Maury County, Robertson County, Rutherford County, Smith County, Sumner County, Trousdale County, Williamson County, Wilson County

35380 New Orleans-Metairie, LA Jefferson Parish, Orleans Parish, Plaquemines Parish, St. Bernard Parish, St. Charles Parish, St. James Parish, St. John the Baptist Parish, St. Tammany Parish

35620 New York-Newark-Jersey City, NY-NJ-PA

Dutchess County, Bergen County, Bronx County, Essex County, Hudson County, Hunterdon County, Kings County, Middlesex County, Monmouth County, Morris County, Nassau County, New York County, Ocean County, Orange County, Passaic County, Pike County, Putnam County, Queens County, Richmond County, Rockland County, Somerset County, Suffolk County, Sussex County, Union County, Westchester County

36260 Ogden-Clearfield, UT Box Elder County, Davis County, Morgan County, Weber County

36420 Oklahoma City, OK Canadian County, Cleveland County, Grady County, Lincoln County, Logan County, McClain County, Oklahoma County



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36740 Orlando-Kissimmee-Sanford, FL Lake County, Orange County, Osceola County, Seminole County

37860 Pensacola-Ferry Pass-Brent, FL Escambia County, Santa Rosa County

38300 Pittsburgh, PA Allegheny County, Armstrong County, Beaver County, Butler County, Fayette County, Washington County, Westmoreland County

38940 Port St. Lucie, FL Martin County, St. Lucie County

38900 Portland-Vancouver-Hillsboro, OR-WA Clackamas County, Columbia County, Multnomah County, Washington County, Yamhill County, Clark County, Skamania County

39340 Provo-Orem, UT Juab County, Utah County

41860 San Francisco-Oakland-Hayward, CA Alameda County, Contra Costa County, San Francisco County, San Mateo County, Marin County

42660 Seattle-Tacoma-Bellevue, WA King County, Snohomish County, Pierce County

43780 South Bend-Mishawaka, IN-MI St. Joseph County, Cass County

41180 St. Louis, MO-IL

Bond County, Calhoun County, Clinton County, Jersey County, Macoupin County, Madison County, Monroe County, St. Clair County, Franklin County, Jefferson County, Lincoln County, St. Charles County, St. Louis County, Warren County, St. Louis city

44420 Staunton-Waynesboro, VA Augusta County, Staunton city, Waynesboro city

45300 Tampa-St. Petersburg-Clearwater, FL Hernando County, Hillsborough County, Pasco County, Pinellas County

45780 Toledo, OH Fulton County, Lucas County, Wood County

45820 Topeka, KS Jackson County, Jefferson County, Osage County, Shawnee County, Wabaunsee County

46220 Tuscaloosa, AL Hale County, Pickens County, Tuscaloosa County

48620 Wichita, KS Butler County, Harvey County, Kingman County, Sedgwick County, Sumner County



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APPENDIX B – Regions Included in CPC+

Region Participating Counties Provisional Payer Partners

Arkansas Statewide

Arkansas Blue Cross Blue Shield

Arkansas Superior Select, Inc.

Arkansas Health & Wellness Solutions

HealthSCOPE Benefits

Medicaid

QualChoice Health Plan Services, Inc.

Colorado Statewide

Anthem Blue Cross and Blue Shield

Colorado Choice Health Plans

Medicaid

Rocky Mountain Health Plans

UnitedHealthcare

Hawaii Statewide Hawaii Medical Service Association

Greater Kansas City

Johnson County, KS

Blue Cross Blue Shield of Kansas City

Wyandotte County, KS

Clay County, MO

Jackson County, MO

Platte County, MO

Michigan Statewide Blue Cross Blue Shield of Michigan

Priority Health

Montana Statewide

Blue Cross Blue Shield of Montana

Medicaid

PacificSource Health Plans

New Jersey Statewide

Amerigroup New Jersey

Horizon Blue Cross Blue Shield of New Jersey

UnitedHealthcare

North Hudson Capital Region (NY)

Albany County

Columbia County

Dutchess County

Greene County

Montgomery County

Orange County Empire Blue Cross Blue Shield

Rensselaer County Capital District Physicians' Health Plan (CDPHP)

Saratoga County MVP Health Plan, Inc.

Schenectady County

Schoharie County

Sullivan County

Ulster County

Warren County

Washington County



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Ohio and Northern Kentucky

Aetna

Anthem Blue Cross and Blue Shield

AultCare

All counties in Ohio Buckeye Health Plan

Boone County, KY CareSource

Campbell County, KY Gateway Health Plan of Ohio, Inc.

Grant County, KY Medical Mutual of Ohio

Kenton County, KY Molina Healthcare of Ohio, Inc. Medicaid

Paramount Health Care

SummaCare, Inc.

UnitedHealthcare

Oklahoma Statewide

Advantage Medicare Plan (AMP)

CommunityCare

Blue Cross and Blue Shield of Oklahoma

Medicaid

UnitedHealthcare

Oregon Statewide

AllCare Health, Inc.

ATRIO Health Plans

CareOregon

Eastern Oregon Coordinated Care Organization (EOCCO)

FamilyCare Health

Oregon Health Authority (Medicaid)

Moda Health Plan

PacificSource

PrimaryHealth of Josephine County

Providence Health Plan (PHP

Providence Health Assurance (PHA)

Tuality Health Alliance (THA)

Umpqua Health

Western Oregon Advanced Health, LLC

Williamette Valley Community Health

Yamhill Community Care Organization, Inc.

Greater Philadelphia (PA)

Bucks County

Chester County Aetna

Delaware County Independence Blue Cross/Keystone Health Plan East

Montgomery County

Philadelphia County

Rhode Island Statewide

Blue Cross Blue Shield of Rhode Island

Medicaid

UnitedHealthcare



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Tennessee Statewide

Amerigroup Tennessee

Medicaid

UnitedHealthcare

Volunteer State Health Plan, Inc.

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