MACRA and the Phlebology Practice

by AJ Riviezzo and Cheryl Nash
American Physician Financial Solutions

What is MACRA?

MACRA (Medicare Access and CHIP Reauthorization Act) replaces the Sustainable Growth Rate program, and is supposed to streamline the current PQRS and Meaningful Use programs. It also initiates a movement away from the Fee for Service system to a Quality Payment Program. Ostensibly, Medicare is moving from a volume-based system to a value-based system.

We expect every phlebology practice to participate in the MIPS (Merit-Based Incentive Payment System) rather than the APM (Advanced Alternative Payment Model). The MIPS system is essentially a Fee for Service system with reporting requirements that Medicare calls “performance period and payment adjustments” (up or down). The reporting begins January 1, 2017. Practices that are not participating with Medicare or begin participating with Medicare in 2017 do not have to report. Likewise, practices that treat fewer than 100 Medicare patients during the year do not have to report. MIPS has three performance categories:

  • Quality – Accounts for 60% of your score. This replaces PQRS.
  • Advancing Care Information – Accounts for 25% of your score. This replaces Meaningful Use.
  • Clinical Practice Improvement Activities – Accounts for 15% of your score. This is a new program.

What is the Impact of MACRA?

Based on a practice’s Composite Performance Score of the three performance categories, a practice can have an adjustment of 4% up or down in 2019 (based on reporting year 2017), 5% in 2020, 7% in 2021 and finally 9% up or down in 2022 and beyond. Medicare fully expects small practices to remain payment neutral or have a small positive adjustment if you participate. Historically, phlebology practices faced difficulties in participating in PQRS or Meaningful Use due to the costs and the burdens of reporting. Medicare has tried to make participation a bit easier for small niche practices.

The total aggregate of the three options becomes your CPS. A CPS less than or equal to 25% of the threshold will yield a 4% decrease in your reimbursements. A CPS higher than 25% will result in a neutral to positive adjustment based on the degree to which your CPS exceeds the threshold.

How Do I Avoid It?

We have carefully reviewed the various performance categories and measures therein for a standard phlebology practice. If your practice is still providing other services such as cardiology or general surgery, there may be some other or additional measures that may be more appropriate for your use.

Quality – Practices need to report on six measures to fully comply with this category. Measures are rated as being a high priority, low priority or outcome measure. You must have at least one high priority measure and one outcome measure to receive the maximum score based on your reporting. You can select a specialty measure set or six individual measures. For the phlebology practice, we have selected six individual measures that you can integrate into your operations. These are:

  • Varicose Vein Treatment with Saphenous Ablation Outcome Measure – This is the percentage of patients treated for varicose veins (CEAP 2-6) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment.
  • Closing the Referral Loop: Receipt of Specialist Report High Priority Measure – This is the percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
  • Documentation of Current Medications in the Medical Record – High Priority Measure – This is the percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counter medication, herbals, and vitamin/mineral/dietary (nutritional) supplements, AND must also contain the medications’ name, dosage, frequency and route of administration.
  • Patient-Centered Surgical Risk Assessment and Communication – High Priority Measure – This is the percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to an operation using a clinical, data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.
  • Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan – Low Priority Measure – This is the percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months, AND with a BMI outside of normal parameters. A follow-up plan is documented during the encounter or during the previous six months of the current encounter. Normal Parameters: Aged 18 years and older; BMI => 18.5 and < 25 kg/m2.
  • Surgical Site Infection (SSI) – High Priority Measure This is the percentage of patients aged 18 years and older who had a surgical site infection (SSI). There are quite a number of software applications on the market which will allow you to submit your reports to Medicare. Here is a link showing the Qualified Clinical Data Registries.

“Medicare is not supposed to penalize you for not being able to utilize all of the measures listed for 2017. It is unlikely though that you will receive a high enough score to have a positive adjustment to your Medicare rates.”

Advancing Care Information – We recommend that each practice should contact their EHR vendor and ascertain if the software they are using is Meaningful Use Stage 2 compliant. If it is not, you may have difficulties meeting this category’s measures. These are categorized between required base score measures and performance score measures.

Base Score Measures:

  • e-Prescribing–At least one permissible prescription written by the MIPS-eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology.
  • Health Information Exchange–The MIPS-eligible clinician that transitions or refers their patient to another setting of care or health care clinician (1) uses CEHRT to create a summary of care record, and (2) electronically transmits such summary to a receiving health care clinician for at least one transition of care or referral.
  • Provider Patient Access–At least one patient seen by the MIPS-eligible clinician during the performance period receives timely access to view online, download, and transmit their health information to a third party, which is subject to the MIPS-eligible clinician’s discretion to withhold certain information.
  • Security Risk AnalysisConduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified EHR technology in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician’s risk management process.

There are seven other “Objectives and Measures” that can be submitted to Medicare. However, most of them have very little to do with a Phlebology practice. Medicare notes you should select the measures that best fit your practice. The measures we felt might be applicable for a phlebology practice are:

  • Patient-Specific Education–The MIPS eligible clinician must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide electronic access to those materials to at least one unique patient seen by the MIPS eligible clinician.
  • View, Download, or Transmit (VDT)–View, Download, or Transmit (VDT) – Defined as: At least one patient seen by the MIPS eligible clinician during the performance period (or a patient-authorized representative) views, downloads or transmits their health information to a third party during the performance period.

Medicare is not supposed to penalize you for not being able to utilize all of the measures listed for 2017. It is unlikely though that you will receive a high enough score to have a positive adjustment to your Medicare rates.

Clinical Practice Improvement Activities – Most phlebology practices will only need to report on two out of the 93 measures that are listed. A few of these measures allow you to acquire necessary CMEs. A few that we thought may be plausible for a phlebology practice include “Collection and Follow Up on Patient’s Experience, Administration of the AHRQ Patient Safety Culture,” “Completion of the AMA STEPS Forward Program,” and “Implementation of Use of Specialists Reports to Referring Clinician” (which is very similar to the measure under Quality as well).

Closing Thoughts

If you have a qualified EHR, you can report many of these measures through the technology you already have. Likewise, adding a qualified registry, if needed, will minimize the difficulties in achieving compliance with this program. Further good news, Medicare is allowing practices to get used to the process, and they are not requiring a full year’s reporting. We do recommend reporting for a full 90 days. This soft implementation will only happen during 2017. In 2018, you will need to report for the full year.

You can find all of the measures for the three performance categories on Medicare’s website.