I once had a history professor that quipped, “You can tell what problems a country had difficulty tackling by the number and frequency of laws it issued. The more laws about the same problem, the more difficult that problem was.” This notion seems pertinent to the transformation of Medicare into a quality-based reimbursement program.

The latest incarnation of rules under CMS’ now named Quality Payment Program (QPP), a.k.a., the Medicare Access and CHIP Reauthorization Act, or MACRA, was published in a nearly final form in October 2016. Interestingly, this final rule was not quite “final” since it was issued as an interim final rule with a 60-day comment period, leaving the door open to further alterations to the program.

Given the complexity of the programs and the possibility of unintended consequences, allowing for further comment and revision seems extraordinarily wise. Either way, the medical community now has the details necessary to understand and begin to implement the practice-level changes to adapt to the latest round of quality-based payments.

CMS is attempting to meet its stated goal of shifting up to 80% of payments into quality-based models by 2018. Broadly, MACRA offers two possible pathways:

  • The Merit Based Incentive Payment System (MIPS)
  • Alternative Payment Models (APMs).

Under MIPS, Medicare participating providers will report data that results in increasing adjustments to the Medicare Part B fee-for-service (FFS) payments. CMS programs typically use a two-year offset from data collection to payment adjustment, so 2017 data will impact 2019 payments, 2018 data impacts 2020 payments, etc.

NN&I’s Roundtable on MACRA is available for replay

Adam Weinstein, MD, and Diana Strubler, Policy and Standards Senior Manager at Acumen Physician Solutions will help you understand how to navigate this complex payment system.

The adjustments, i.e. the penalty or bonus, are based on the provider’s performance in four reporting categories measuring EHR adoption and use (Advancing Care Information or ACI), quality measure performance (Quality), clinical practice improvement activities (CPIA or just IA for improvement activities), and CMS’ costs of caring for patients attributed to the provider (Resource Use). Performance across these four categories is measured relative to all other clinicians participating in the MIPS pathway. Bonuses and penalties are paid depending which percentile of performance is achieved, with neither bonus nor penalty at the 50th percentile. However, achieving the mean or median score will likely get more difficult, year to year, as clinicians attempt to achieve higher scores. In addition, the percentage of FFS dollars subjected to the penalty/bonus increases from 4% in 2017 to 9% by 2021.

Lastly, the relative importance of the four reporting categories also changes over time, with Resource Use gaining a larger impact in determining the bonus/penalty by 2020.

Using APMs

Under the APM pathway, providers choose to affiliate with an APM entity (such as an Accountable Care Organization) that accepts two-sided financial risk in caring for a defined group of patients under a CMS-approved model of care—called an Advanced Alternative Payment Model. These defined groups may be patients who opt into participation, such as a patient-centered medical home, or be identified by a specific disease process or event, such as patients receiving oncology care or undergoing total knee replacements.

The key benefit of the APM pathway is that providers successfully participating with APM entities will receive a 5% bonus on any FFS dollars not paid through the APM entity and do not have to participate in MIPS data collection or reporting. To be sure though, participating clinicians will be held accountable for APM-specific data reporting, quality metrics, and practice improvement at least equal to those of MIPS, but often specific to the patient population included in their APM entity. However, to qualify for the 5% bonuses, providers who are part of the APM entity must have 20% of Part B patients cared for under or 25% part B dollars paid through the APM entity. These qualifying percentages rise to as high as 35% and 50%, respectively, by 2019.

Based on the currently approved and available advanced payment models, nephrologists who are not participating in End-stage Renal Disease Seamless Care Organizations (ESCOs) will likely need to participate in the MIPS pathway. Either way, success under QPP requires all providers to undergo some degree of practice transformation, to adopt population health tactics, to prepare for longer timelines of return on strategic investments, and to adapt human resource expectations and policies to reflect the increasing dependence on quality-based reimbursement.

Unfortunately, there are no easy answers. Each practice must identify the needed changes based on their unique situation and change at a pace reflective of the organizational capacity to adapt and evolve. However, a broad set of strategies can be articulated.

Practice transformation

Practices attempting to participate in any quality payment programs need an organization-specific operational definition of transformation. In the context of the quality payment program, transformation means to adopt the necessary policies and tactics that allow practitioners to monitor and care for populations of patients at a group level. Specifically, it may mean periodically monitoring a panel of patients with specific diseases and looking for patients who are not receiving ideal therapies or achieving some agreed upon goal. Like any change, this typically requires both business and clinical leadership. CMS’s QPP provides a framework for both the vision and the pathway. But practices should decide the what and the why of the transformation. Will MIPs be the immediate end goal or will working to participate in ESCOs, regional clinically integrated networks, and/or private payer quality incentive programs make the most sense? Which clinicians will be asked to take on these new population health activities or will other new or existing clinicians take on these activities? How will success be measured? What is the opportunity cost of transformation – i.e., at what promised penalty or reward is the time and effort worth the risk?

Strategic investments in using data

All pathways of QPP require that practices use certified electronic health record technology (CEHRT). However, EHRs are just one aspect of the tools necessary to perform population health activities. EHRs do not typically contain a robust set of population health tools. EHRs are typically not well suited to manage populations identified by ICD-10 codes, ER visits, or who have had certain medications or therapies ordered.

As such, practices taking steps to transform must make the necessary strategic investments in analytics/population health tools. Unfortunately, there are not an abundance of affordable, practice-level population health/analytics packages at this point. Most software in this area is used by payers and other organizations that bear financial risk. As such, many practices may find themselves using a few different tools, often those that come with a specific program, such as analytics tools provided with participation in an ACO, a private payer-based quality program, or a regional/state health information exchange. These tools often come in the form of dashboards, learning aids, and lists of patients and specific clinical data points pertaining to specific measures and metrics for which the program or health information exchange is interested.

Unfortunately, these programs often only contain a portion of a practice’s patients­—the portion associated with the payer or program. The RPA’s Clinical Quality Data Registry (QCDR) is an example of an analytics package that allows the practice to choose both the metrics and the patients included. Either way, it is critical to understand that implementing population health strategies requires more than just an electronic health record.

The strategic investments must also include staff time—to learn, understand, and implement the use of these tools. When it comes to participating in the QPP, spending time, money, or both must be considered one of many investments with a long timeline to return on investment (ROI). To this end, it is highly unlikely that the training and software will show significant positive returns in under 24 months. Even the two-year timelines established by the QPP (data reported this year will impact payment two years later) only captures a small part of the time it takes to adapt to population health. As such, in addition to understanding the tools that are required for transformation, it is equally important to understand the financial impact. The move to a population health-focused practice takes investment and yields returns that may span multiple years and come in the form of avoided penalties and earned bonuses from a variety of payment sources. Truly, a mind-boggling accounting endeavor.

Transformation is about human resource management

The goal of all these strategic investments, irrespective of timeline to ROI, is to yield the sort of organizational behaviors necessary to take care of groups of patients. Specifically, this means identifying the correct staff to oversee the necessary granular steps for successful data capture, changes in care delivery based on insights from the analysis of that data, and reporting to CMS or other entities.

This notion spawns several questions.

  • Who in the practice selects measures that are reflective of the work done by the clinicians?
  • Who understands and can train others as to where in the workflow needed discrete data elements can be captured, and where in the electronic health record are those data recorded?
  • Who monitors the integrity of the captured data?
  • Who institutes and monitors improvement programs when gaps in data integrity are identified?
  • Who ensures there is accurate and timely transfer of data between the electronic health record and whatever analytics packages are being employed?
  • Who monitors and reports insights from the analytics package that allows clinicians to be alerted to gaps in clinical performance before data is reported to the payers?

All of this, and more, are roles that are not typical in a traditional medical practice. Undoubtedly, the job descriptions of frontline nursing and office staff will be updated. But these kinds of skills are often best found in new staff, with a background in data management, IT systems integration, and performance improvement. I suspect there will be new employees and contractors working with practices of all sizes in meeting the demands of population health. While it may not be possible to identify each person accountable for these answers on day one of QPP participation, the answer must be clear in time to implement performance improvement before the data is due.

Provider contracting must also be updated. No longer is it realistic to have compensation programs based solely on RVU production. Given the offset between data submission and payment adjustments, there must be elements of provider compensation based on quality data gathering, quality measure performance, and quality program payment adjustments. In addition, contracting should include concepts around the portability and ownership of physician-related data. This will become painfully relevant when a provider changes practices in the middle of the reporting year or is anticipating some sort of bonus payment after a job change. The goal must be to have compensation and work expectations calibrated to reflect the reality of the revenue generation for the practice. The fact is, completing notes and bills, seeing enough patients per day, and capturing hospital charges are no longer enough to be successful. There may very well be a time when a clinician who sees a high-volume of patients, but does not capture the correct discrete data consistently, could earn less revenue than the clinician seeing fewer patients, but who captures data conscientiously, dedicates time each week to population health activities, and works to avoid ER visits or well-coordinated discharges from the hospital. It will take several years to make these changes to typical employment agreements in typical practices. However, this work must be done if we are going to create a chain of accountability from the exam room to the practice’s quality payments two years later.

Tactics to approach MIPS

Many nephrologists will participate in the MIPS program for 2017. As such, it is worth thinking through the application of the above strategies and listing out some specific tactics as they apply to the various MIPS categories. This exercise can be done for any quality payment program, but is more difficult to generalize for advance payment models since the details will vary between any two APM’s. Nevertheless, the questions being asked, especially about data collection and data integrity, are likely universal.

Advancing Care Information (ACI)

Based on Meaningful Use Stage II and III measures, the reporting requirements under advancing care information should be relatively easy to capture if you’re using CEHRT. Nevertheless, because the measure performance now counts toward the overall scoring, it is important to plan and monitor what data is being gathered. This category has a lot of flexibility—155% of points in the ACI category is the maximum score achievable. Ideally, this means achieving high scores in this category will be minimally disruptive to workflow.

Below is a list of questions practitioners should consider when developing a strategy for addressing ACI reporting:

  • Which ACI measures will each clinician focus on? Will it be wasteful to aim for the 155% score?
  • What data needs to go in which fields in the EHR to ensure complete data capture?
  • For each field/data element, what is the acceptable range of responses? How can the practice monitor the completeness and integrity of the data being captured?
  • When and by whom will this data be reviewed for integrity and completeness?
  • What feedback reports on ACI measure performance are available and how frequently should they be provided to the clinicians? How frequently should they be monitored by the practice administrator or data manager?


This category is based on PQRS measures, but data from only six measures is required for maximal performance under MIPS. However, unlike the PQRS program, actual performance on each quality measure determines your score. The score is not based on a simple percentage of performance. Rather, each quality measure has a range of scoring based on the distribution of performance in prior years. Thus, your score on any given measure is determined by how your performance compares to the performance from all participants in prior years. Tactical decisions to be thought through include:

Which quality measure can you reasonably report on? This is determined by what numerator and denominator data is required, whether you and your practice workflow can (and do) reliably collect the necessary data, and whether your EHR allows for the recording of the data in a discrete manner (meaning individual data elements in individual EHR fields).

How many quality measures can you report on? If you choose six and don’t perform well on all six, are you putting yourself at a disadvantage? What is the opportunity cost of collecting data on additional measures, even if you only report on six of them?

Of the measures you can collect data for, which ones have the most favorable performance distribution? CMS will be publishing each approved quality measure’s scoring decile ranges. This means that some measures will be easy to achieve high scoring on, some measures will not, depending on how clinicians performed on these measures in prior years. Thus, once you identify a group of quality measures for which you can collect data, you will want to ensure you are choosing the measures for which earning maximal points is reasonably possible (i.e., avoiding measures where only the 99th percentile of performance yields the top scores).

What analytics and reporting software will you use? Should you be participating in a Quality Clinical Data Registry (QCDR), like the RPA’s Kidney Quality Improvement Registry, the only nephrology-specific QCDR, (http://bit.ly/RPAQCDR), to better manage and monitor real-time performance of your chosen quality measures? Does your EHR software offer the analytics tools and feedback necessary to understand data in near real-time? How will the practice and providers engage in performance improvement based on the data to ensure maximal performance prior to the end of the reporting period?

Can you choose quality measures that align with other programs or activities? Other criteria to consider include whether any of the quality measures you’ve identified could help you participate in other activities such as private insurance quality reporting programs, local hospital or clinically integrated network initiatives, or the like? Obviously, the goal is to collect data on the minimum necessary set of quality measures while maximizing the usefulness of the data gathered.

Improvement Activities (IA) a.k.a. CPIA

This category represents a new area of performance under the QPP. Choosing from a library of over 90 options, sssclinicians must attest this year that they have performed between 2 and 4 activities to achieve maximal scoring. Beginning in 2018, practices must demonstrate actual numerical performance to be scored in a graduated fashion, making it more challenging to earn the maximal points.

The activities offer a wide variety of options for participation. Some involve the collection of clinical data that must be documented during face-to-face encounters (such as indicating the glycemic control of a diabetic). Some are simply an acknowledgment of some change in practice patterns, such as extending office hours or implementing the process improvement identified from the use of a clinical data registry. Either way, like quality measures, practices and clinicians should determine what improvement activities they are capable of collecting data for, a workflow for ensuring the necessary data is collected, monitoring the integrity of the collected data, and having the appropriate performance improvement processes in place to ensure maximal performance prior to submission of that data.

Many electronic health record companies are not yet prepared for these activities and workflows surrounding documentation of participation in any given clinical practice improvement activity must be thought through carefully for 2017. It is important to bear in mind that just because the EHR has a place to record a data element does not mean that that data element can be easily extracted or reported upon for the purposes of calculating performance. In other words, most practices should select their improvement activities and work with their EHR vendor to determine the best means of recording the associated data. I suspect throughout 2017 it will become clear and easier to handle the data needed to participate in IAs.


Though CMS’ QPP is another iteration of the programs we have seen since the implementation of PQRS and Meaningful Use, it is a big step. While the concept of collecting and reporting data is not new, it is the first time so many Medicare participating providers will be held to a broad-range of performance-based standards.

Moreover, the standards to which we are being held accountable will change­—with the incentives driving increasing performance year to year and individual performance compared to the rising mean. It is not clear how successful this round of programs will be in getting our health systems closer  to the Holy Grail of low-cost, high quality, and universally accessible care. What is clear is that maximally successful participation will require significant practice transformation and will alter the way clinicians think about their role in the health care landscape.

Editor’s note: This article is reprinted from the January issue of RPA News with the permission of the Renal Physicians Association.