Physician Data Analytics and Your EHR – Impact of MACRA, MIPS, and SGRs (Part 1 of 3)

Healthcare Payments

By Richard Howe, PhD, Executive Director, North Texas Regional Extension Center

Last month, I briefly touched on some data quality issues that must be addressed to improve overall use of an EHR in a physician practice. Improving data quality will significantly enhance daily practice operations and long-term data analytics and population health management (PHM). Over the next three monthly blogs, I would like to discuss how some of the recent regulatory changes will impact your electronic health record (EHR) and the data analytics coming out of your EHR.

By way of background, the Department of Health and Human Services (HHS) has set a goal of migrating 30% of traditional fee for service (FFS) payments to quality and/or value-based payments through Alternative Payment Models (APMs) by 2017. The APM goals are further increased to 50% of FFS by 2018. These APMs include bundled payment initiatives (BPI) and Accountable Care Organizations (ACOs). This migration will pressure physicians to work in larger groups where the cost of EHRs and quality reporting becomes more efficient compared to individual reporting.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation (April 16, 2015) introduced the Merit-Based Incentive Payment System (MIPS) for physicians and repealed the sustainable growth rate (SGR) formula. Under this legislation, physicians must eventually participate in a MIPS or an APM system.

As originally conceived, the SGR was supposed to update the Medicare physician fee schedule — but the SGR formula never really worked out and it was a continual source of conflict between CMS and physicians. Without MACRA, on March 31, 2015, SGR cuts of 21% would have gone into effect.

Now, however, MIPS replaces SGR in January 2019.
The new MIPS legislation will apply to: doctors of medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric medicine, doctors of optometry, chiropractors, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists.

MIPS purportedly was going to replace not only the SGR formula, but also Physician Quality Reporting System (PQRS) and Meaningful Use (MU). However, when you read the proposed MIPS rule, you can see that PQRS and MU are incorporated as two of the four “merit-based performance categories” (see next month).

The Centers for Medicare and Medicaid Services (CMS) is obviously shifting the basis for Medicare payments from volume to value. MIPS is a new program in the Medicare fee-for-service payment system. It consolidates three existing programs — the Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBPM), and meaningful use (MU) — into a single program.

Certainly, migration to MIPS or to APMs from FFS will require an up-to-date EHR in your practice that can track and report clinical quality, and not just billing. Next month I will describe in more detail how MIPS, PQRS, VBPM and MU will become integrated into a single program. Stay tuned!