Drinking From the MACRA Fire Hose

“Thank You for Being Late: An Optimist’s Guide to Thriving in the Age of Accelerations” by Tom Friedman provides an insightful look at the 21st century. Friedman notes that since the development of the iPhone, we are in a transformative time with change that is outpacing our ability to adapt. I couldn’t help but think about this concept while attending the ACC’s 2017 Cardiovascular Summit which focused on thriving in a time of change and included numerous sessions on the Medicare Access and CHIP Reauthorization Act (MACRA), one of the biggest transformations for clinicians.

The Cardiovascular Summit helped me move a little closer to the intersection of human adaptability and technology that Friedman calls “learning faster and governing smarter.” The education at the Cardiovascular Summit, which centered around finance, operations, quality and data, is vital to our future and it’s clear we can no longer bury our heads in the sand – change is upon us! The time for whining and pining for the past is over.

First, we need to shore up our MACRA implementation team in our practices and hospitals now that the Quality Payment Program (QPP) is officially underway. In my practice, this team is led by a highly intelligent and computer savvy physician and an information technology director/clinical informatician, and includes representatives from our entire operation. Our answer to MACRA (and/or valuebased care) has to be embedded throughout our practices. In a smaller practice, the physician leader needs to own this response, get educated and get going. Anyone who is touched by the QPP should be a part of the team. This will pull people outside of their comfort zones, but it’s necessary in this new era of value-based care.

Second, in 2017, most cardiovascular professionals will participate in the Merit-Based Incentive Payment System (MIPS) track of the QPP, as opposed to the Advanced Alternative Payment Model (APM) track. Reporting is at the center of MIPS. The 2017 transition year provides an opportunity to make sure you’re performing well on the Quality, Improvement Activities, Advancing Care Information and Cost categories before things really kick into gear in 2018. Cathleen Biga, MSN, RN, co-director of the Cardiovascular Summit, recommends aiming for 70 points for MIPS in 2017 to gain access to extra reimbursement. Otherwise, you are taking a cut or staying close to neutral.

Here are some tips for success with MIPS:

  • Start by looking at how you are doing in the Physician Quality Reporting System, Electronic Health Record (EHR) Incentive Program (Meaningful Use) and the Value Modifier.
  • Ensure you know how your EHR is creating data points and how you are going to report (through the EHR or through a registry like the PINNACLE Registry).
  • Dashboard the 15 Quality metrics and benchmark them to national deciles with a plan to narrow these down to your best six (remember never to report poor performance).
  • Attempt to report for the full year as opposed to the other three “Pick Your Pace” options for 2017 – you get a bigger denominator and more power.
  • Understand the Cost category even though it does not count this year and make sure you are correctly categorized in the Provider Enrollment, Chain and Ownership System.
  • Review the Advancing Care Information base measures and performance measures, and plan to attest with proof that you really did them.
  • Look at the 94 options for the Improvement Activities category and get at least one provider in your group to do enough of these activities to accumulate 40 points (four medium, two high, or a combination).

Third, it’s not too early to start looking at Advanced APMs. As the tide rises on the MIPS categories and we all get better at value-based care, we are going to be pushed to the next level. You might as well start thinking about how you are going to move into the Advanced APM bucket now.

Finally, even though we all want to focus on seeing patients, this new era of Medicare payment requires us to continuously reduce variability in care, understand cost and episodes of care, coordinate care and better document care.


This perspective is authored by Andrew P. Miller, MD, FACC, governor of ACC’s Alabama Chapter.

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