• LecturehallConfused About MIPS - Here are the answers in 30 minutes
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Unidentified Male Speaker 1: We've asked Dr. Jeffrey Lehrman, who's a podiatric physician and wound care specialist, outside of Philadelphia. He's going to be talking on Merit-Based Incentive Payment System as well as a talk on compression therapy.

    Background, he is involved with the American Society of Podiatric Surgeons. He is the director of a wound care center at Crozer Wound Healing Center. He's on the staff at Temple University School of Podiatric Medicine.

    And at this point in time, I'm going to introduce Dr. Jeffrey Lehrman. Please welcome him to our program.

    Jeffrey Lehrman: Good morning. This program that we're going to talk about this morning is unjust and unfair, and a pain for us. And there has been zero literature to have been published that suggests that any of this improves the quality of care that we provide for our patients, but it's here and we have to deal with it. And if you want to be a doctor in the United States, in 2018, we have to deal with it. My goal is that 30 minutes from now, you have the information you need to decide, if you want to participate, at what level you want to participate and how you are going to participate.

    This program has nothing to do with who the president is or who holds the majority in the house. You can see the robust bipartisan support that it enjoyed when it passed. And despite all of MedPack's recommendations and their opinions, there has been no movement in Congress to change this, modify it, or get rid of it.


    So it's here and as long as it's here, let's tackle it. And there is no reason why anybody in this room should have a penalty in 2018 with the information that I'm going to share with you over the next 29 minutes. And beyond just avoiding a penalty, you will get what you need to also earn bonus money.

    The way this program works if you don't already know, and I know there are people in the audience that have heard me do this before, and there are people that have heard me do this multiple times. So for those, I hope the refresher is welcome, but there are some significant changes in 2018 from the program's first year in 2017. So there is some new content here.

    The way the program works is we're all going to work in 2018 and we are going to submit stuff or not submit stuff. We're going to do some of these things or not do some of these things. We're going to jump through their hoops or not jump through their hopes. And based on what we do or we do not do in 2018, all of us are going to accumulate a 2018 MIPS score. So we're going to work this year. We're going to do this stuff or we're not going to do this stuff, do a lot, do a little. And at some point in 2019, we're going to get a letter in the mail that says, "Dear Doctor, your 2018 MIPS score was X."

    That MIPS score is going to be publicly reported. For anybody who's interested can look it up and we're going to talk about why that's something you may want to consider. That 2018 MIPS score is also going to impact your 2020 Medicare Part B physician fee schedule.


    And you can see that with some exception, it's going to adjust your 2020 Part B physician fee schedule anywhere from minus 5% to plus 5%, and that is a continuum. It could be minus three. It could be plus two, anywhere in that range. What you did in 2017, which is over, you can't do anything about that now, impacts your 2019 fee schedule only. We get asked a lot if there's any carryover? There's not. You got a clean slate. If you did nothing last year, it's okay. You get to start fresh this year. What you did in the past has no impact on 2020. It's what you do this year impacts your 2020 fee schedule.

    And just to be clear on what we mean about the 2020 fee schedule, January 1, 2020, you can go on your Max website, right? NGS for New York people, Novitas for New Jersey people, and download your Medicare Part B physician fee schedule. Hopefully, everybody does this and is very familiar with that Excel document, and every CPT code has a dollar value associated with it. If you do nothing in 2018, when you open up that fee schedule on 2020, you take every single number on there and reduce it by 5% and that's what you will get for that service for the entire year.

    So for example, let's take 11721. I think that's a code we're all familiar with and let's pretend I'm just making this up, that in 2020, that has a value of $50. If you do nothing this year and you take a 5% penalty in 2020, you now get $47.50, instead of $50, for every single 11721 you do that year. If you do well and you get a 5% bonus, that $50 for you turns into $52.50.


    And that's every code, E&Ms, surgery, everything, will be adjusted by this amount. The most common question we get is, "What do I need to do avoid a penalty?" And that's fine. That is your prerogative. That's your choice. That is not my suggestion that you do the bare minimum. That is not APMA's suggestion. I think you should go for bonus money because it's easy and we'll take free money, right? But that's your choice if all you want to do is just avoid a penalty. Last year, you needed a MIPS score of three. This year in 2018, the bar has been raised and you for 2018 need a MIPS score of 15 to avoid a penalty. I'm going to show you how you can very easily achieve a MIPS score of 15 for 2018.

    I said we're going to through the year and we're going to have this adjustment of anywhere from minus five to plus five. This is mostly a budget neutral adjustment, mostly, which means however much penalty money there is, that's how much bonus money there is going to be. So you do not need a score of 90 to get bonus money. The performance on this overall is poor. This is every doctor in the country, not just podiatrists, and most people have no idea what they're doing, are performing at a very poor level. They get penalized and if there's a lot of penalty money, there's a lot of bonus money. And I've described it this way before, it's almost like an organic chemistry exam that was graded on a curve. If the best score in the class was a 78% in O chem, then a 78 was an A. So because of this budget neutral situation, you do not need an exceedingly high score to get bonus money.


    As a matter of fact in 2018, it is expected that anything that over 15 will get you in to the bonus category. And of course the higher you go, the more bonus money there is for you. If you score over 70, you are deemed by CMS to be an exceptional performer. So if you go over 70, they label you as an exceptional performer and you can get more than 5%. There's additional reward money set aside for exceptional performers. We don't know how much because it's this budget neutral deal so it depends how money exceptional performers there are. That will determine how much you get.

    Now I mentioned the publicly-reported option and I suggested this is something you should consider. We talked about the impact on your free schedule and some people say, "Well, I don't see Medicare patients. I don't care." Or, "I have a very small Medicare population. Let them hit me for the 5%. It's worth it, did not have to worry about this craziness." Okay. That's fair. But please also consider this and it's up to you. You might say, "I don't care. I'm doing fine the way I am." But I think this is at least worth considering, this publicly-reported situation where your MIPS score will be online, anybody can look it up.

    And the first thing to consider is that CMS has built this Physician Compare website where they are going to publish our MIPS scores and they've made it sound like they're going to make it look like theses scores are reflection of the quality of care that we provide which we know is a joke but that's their plan. And this is something to consider if you're worried that your patients are going to go on Physician Compare to doctor shop, you may care what your MIPS score is just something to consider. If you want my opinion, my opinion is that website stinks and nobody is using it.


    I can't even find my own listing on there. I keep trying. It is not user-friendly. It's difficult to navigate. I have, how did you find out about us on our intake forms just like you do, and I see Healthgrades and Google and RateMDs. I have never seen Physician Compare but it exists. Maybe it will evolve, who knows? Just something to be aware of. Yelp at one point negotiated. This did not happen but they negotiated. This was publicly reported, not rumor. They negotiated with CMS so that CMS could send MIPS scores to Yelp and Yelp would integrate those scores into their ranking algorithm.

    Now, that did not happen but if it did, now they got my attention. That would be important to me because when I said "How did you find out about us" on the intake form, we see Yelp. People use that. Now, that did not happen. That's not going to happen as of today but something to consider maybe potential employers. Again, this is just stuff I want you to think about perhaps and I would think this would be more likely in a big giant hospital institution or university model maybe where a potential employer might care what your MIPS score is.

    And the biggest threat is that the only adjustment that we talked about was to your Medicare fee schedule but what normally happens? Don't deprive it, it normally follow CMS with stuff like this. They're doing all the work for them. They're posting it. All they have to do is do a Google search and they can. None of them have announced their intent to do so but they certainly could also adjust fee schedules. They could use that to decide who they'll allow on their panels. I've read speculation, no fact, just speculation that they might even adjust patient copays and stratify copays based on your MIPS score, just stuff to think about.


    And when I hear somebody say, "I don't care. My Medicare population is really small." It makes me a little nervous because I want you to consider everything including this stuff when you decide at what level you want to participate.

    We're going to go through the different categories and reporting these different things. One important note is that with one exception, you report this stuff on all of your patients, not just Medicare patients which is weird because the adjustment is to your Medicare fee schedule but yes, they care what you're doing for all of your patients regardless of payer, regardless of even if they have insurance. So for the most part, you're reporting on everybody you see with one exception and that is if you report your quality measures via claims, you only report your quality measures on Medicare people.

    Now, if you participated in the program last year and if you have a comfort level that made sense to you, if this is new to your, I know that that statement didn't make sense but it will in less than 10 minutes. The exclusion criteria for 2018 changed from what it was in 2017. This is a significant change because for 2017, it was $30,000 or 100 Medicare beneficiaries. For 2018, it changed and there are people in this room, I'm sure of it that were in for 2017 but based on this are going to be out for 2018. So if you have less than $90,000 in Medicare Part B allowable, not charges, not collections, allowable, hopefully everybody knows what that is, that column on your EOB.


    If you had less than $90,000 in Medicare Part B allowable or you saw fewer than 200 Part B beneficiaries, you are excluded for 2018. This is Part B, not Medicare advantage, not the weird Medicares, just Part B Medicare. If you are excluded, you do not have the option to get a bonus or a penalty. You could do it if you want and if you do, you will have a publicly-reported MIPS score. However, if you meet these exclusion criteria whether you like it or you don't like it, that MIPS score will not impact your fee schedule.

    There are some others that maybe exempt. If you were impacted by hurricanes Harvey, Irma or Maria, you can file an exception for 2018. They are going to publish an application which they haven't yet that you will have to fill this out and you will have to attest that the impact that the hurricanes had on you is not allowing you to participate in 2018. Now, those storms were terrible and had catastrophic events but just be careful, you are going to have to back up and attestation if they ask you and explain why, what happened in what was that guys? August, September? We have Puerto Rico friends here. What happened in September did not allow you to participate in 2018.

    Who was affected? Everybody in Florida, everybody in Georgia, everybody in Puerto Rico, everybody in the Virgin Islands and parts of Louisiana, South Carolina and Georgia. They are all laid out there – and Texas, parts of Texas as well. This is on the APMA website if you want to go through that list.


    This is what will make up your 2018 MIPS score, these four categories. Quality looks very similar to PQRS. If you did PQRS, quality is like almost the same thing. That's the quality category. ACI stands for Advancing Care Information. That is the new meaningful use, meaningful use for providers. For us is over, it's dead, it doesn't exist. That's now for hospitals only. Our new meaningful use is advancing care information. CPIA stands for Clinical Practice Improvement Activities. That's the really easy one and that's the way it's going to be really easy to avoid a penalty this year if you want. So we'll get to that and the cost category is new.

    The only one of these that requires an EHR is Advancing Care Information The only one that you must have in EHR in order to participate is ACI. If you do not have an EHR, you can do quality and you can do CPIA and everybody's in for the cost category. You'll see what I mean when we get to that. So you do not need at EHR to participate in MIPS. You only need an EHR to participate in the ACI category of MIPS. If you don't have EHR, you cannot do ACI, you can do the others.

    These percentages, the percentage with which each of these categories counts towards your final MIPS score that is pictured here is if you are in a group greater than 15 providers. If you're in a group of greater than 15, these are your waitings. And if you're in a super group, that does count everybody. However, this is a significant change for 2018 and one that I think applies to almost everybody here, this is a big change. And in my opinion, a welcome change. If you are in a group of 15 or fewer and yes, that includes solo practice.


    For 2018, you can file for an exception from the ACI category. That's the one that requires EHR. Most that don't have EHR are in a group of 15 or fewer. If you're in a practice of 15 or fewer including solo, you will be able to apply for an exception from the ACI category saying, "I'm in a small practice. We haven't implemented EHR yet. I don't want to do ACI." And you could even have EHR and choose to not participate in ACI. That's what I'm going to do because it's easier, just less boxes to check. You can apply for an exemption and if you do, now, you're out from ACI. That 25% moves to quality, 50 plus 25 reweights the quality category to 75%. So now this becomes much each easier. And again, these are the percentages with which each category counts towards your final MIPS score. So let's check in.

    We said the highest score you can get is a hundred. That's the best possible score you can get. If you are perfect in the quality category, how many MIPS points will that get you? Seventy-five, 75% of a hundred, right? If you're perfect in the clinical practice improvement activity category, how many MIPS points will that get you. Fifteen, and what was the threshold to avoid a penalty in 2018? Fifteen. So if you are perfect which I'm going to show you how to do in the clinical practice improvement activity category that – which is easy, that will earn you 15 MIPS points which all you need to avoid a penalty.


    One other addition for 2018. If you are in a group of 15 or fewer and you participate on any level, you are getting five bonus points just for being in what they consider a small practice. Now if you do nothing, you don't get five, you have to do something if you participate in any level, you're getting five bonus points. So if you do enough to earn 12, your final score will be 17 if you're in a group of 15 or fewer.

    With the time we have left, I want to touch on each of the four categories. The quality category which count for either 50 or 75 depending on the size of your practice, these are quality measures, measures that you choose and then you report on. There are 271 of these quality measures. If you want to fully participate in the quality category, if you want a perfect quality score, you have to choose six. You choose six of the 271 quality measures. On the APMA website with the webinars and the documents that are there, we went through all 271 and narrowed it down to a list of 10 which makes it much easier for you to choose from, 10 appropriate measures for podiatrist that we can pull off.

    If you want to be perfect, you need to choose six from this list of 271. Like I said, we made it easier for APMA members of the six, one must be an outcome measure and all six, you must report by the same mechanism. All six, you must report by the same mechanism. What we mean my mechanism is how you tell them you did this stuff. There are multiple ways you can report the performance of quality measures. For most of us in this room, we're going to be choosing from the first two.


    You can two it via claims. That means putting the code on your claim form or you can do it via registry which means aligning with the registry, you feed them the information, the registry, then communicates that to CMS. There are advantages and disadvantages to each of these. We can spend time on that if you want during Q&A. If you are going to report via claims and you want a perfect quality score, you have to report your measures on 60% or more of your Medicare patients that qualify for your measures. If you report via registry, you have to report on 60% or more of all of your patients that qualify for your measures. This was the distinction that we made earlier about who you report to stuff on.

    So that's the difference between claims and registry as far as who you need to report this on. When you choose your measures, when you go through that list and if you are shopping from the list of 271, you will see that each measure list its description, its numerators and denominators, its codes and its potential reporting mechanisms. One measure write might say you can report this via claims only. Another measure might say you can report this via claims or registry. You need to choose six and all six must be capable of being reported by the same mechanism and you need to report all six by the same mechanism. So the way to do this is to decide whether you're going to do claims or registry and then go shopping for your measures. And if you decide on claims for example, you need six that can all be reported via claims. Like I said on the APMA website, we narrowed down this list and we list 10 claims measures and 15 registry measures from which you can choose.


    The next category is the one that requires EHR and again this is the one that you can claim in exception from if you're in a group of 15 or few which why not. It's going to make this easier, right? Just less stuff to do. If you did meaningful use, you will see that this advancing care information looks very similar to meaningful use. It's like almost the same thing, very similar, this requires use of your electronic health record. If you want to participate in ACI, if you have 2014 certified EHR which most of you do, one or more of the podiatric specific ones is about to graduate to 2015 but you know what your product is, you should. If you're using 2014 certified technology, you have four required measures within this category. If you have 2015 certified technology, you have five required measures in this category.

    Just doing the required measures alone does not get you enough points to max out this category. And if you want to max out this category, you have to choose more measures and there are options here. You can pull more measures if you want to try to max out that category. I'm not spending a lot of time on that because I – talking to a lot of you before we started, I don't think most of you are doing it. Clinical practice improvement activities is the easy one and the one that if you do it perfectly, it can get you 15 points and 15 points, avoids the penalty. And remember, if you're in a group of 15 or fewer, you get five bonus points. So if you get 15, you actually get 20. This is a list of activities. There are 93 activities, activities that they say are ways for us to demonstrate that we've improved our practice.


    Ninety-three activities are listed. All of these 93 activities are considered to either be medium weight or high weight. The medium weight activities are worth 10 points. The high weight activities are worth 20 points. Now we are talking about just the clinical practice improvement activity category. So the whole time we've been talking about MIPS points, you need 15 MIPS points to avoid a penalty. You need 70 MIPS points to be an exceptional performer but now, le us just look at the clinical practice improvement activity category and we're going to score the clinical practice improvement activity category.

    To be perfect in clinical practice improvement activity, you need 40 clinical practice improvement activity points. If you get 40 clinical practice improvement activity points, you will be perfect in the clinical practice improvement activity category. And if you're perfect in that category by getting 40 points in that category, that will get you 15 mix points. So we want 40 clinical practice improvement activity points. We have 93 activities. All of them are either medium or high. The mediums are worth 10, the highs are worth 20 unless you are in a practice of 15 or fewer because if you're in a practice of 15 or fewer, those numbers get doubled which is awesome for those of us that are in practices of 15 or fewer. If you're in a practice of 15 or fewer, a medium weight activity is worth 20 and a high weight activity is worth 40 and you will only need 40 to be perfect. So let's look at the second bullet because I think that's most of the people in this room.


    If you're in a group of 15 or fewer and you want to be perfect in clinical practice improvement to earn you 15 points which will turn into 20, which will allow you to avoid a penalty, you need just one high weight clinical practice improvement activity or two mediums because if you're in a group of 15 or fewer, one high is worth 40 and two mediums is also worth 40, 20 plus 20. If you're in a group of more than 15, you're going to have to do a little bit more. I narrowed down this list to 14 for you of the 93. All 14 of them are listed here and you can see every single one of them is labeled as being either medium or high. There are some really easy things on here. I'll draw your attention to a couple of them, the ones in red.

    The first one, if you have EHR and you can access your EHR 24/7 and patient has access to you 24/7 like an answering service, that is the first activity listed there. If you can attest to the fact that a patient can get in touch with your or whoever is covering for you 24/7 and you are that covering doc and access their record 24/7, you're in. You're done and that is an attestation. That is January 1, 2019, you log in and you click the box and say, "I solemnly swear that I did this in 2018." You're done.

    Number three is a medium weight activity that says you are a specialist which we are. And as a specialist, you send a report back to the referring clinician, should be doing that anyway. That's good practice management. So hopefully, you're now thinking, "Oh my gosh. I'm already doing these things and didn't even realize it." That's a medium weight activity.


    Number seven, this is easy. Assess the patient's experience through surveys. Give them a survey. Were you greeted at the front door? Did you have a positive interaction with the front office staff? Did doctor answer all of your questions? Were you given an opportunity to ask questions? Whatever, some sort of patient survey that gets you halfway there. Number seven is registration with your state's prescription drug monitoring program which for many of us is mandatory. In Pennsylvania, I had to do it anyway, New Jersey also. So I think everybody here may have already done that. If you register with your state's prescription drug monitoring program, that's medium weight.

    The next one is actually using it which you should be doing also. If you query your state's prescription drug monitoring program. Right in narcotic, put the patient's name in, staff should be doing this for your efficiency. That gets you halfway there. Fall risk assessment, many people are already doing that. That gets you halfway there. So you can look through these and find ones you're doing. There are lots of easy ones on there.

    The last category is the cost category. This is new for 2018 and we can cover this briefly because nobody understands it. We had a CMS MIPS person at our APMA CAC-PIAC meeting in November and he said it's on video on our website, on the APMA website. He said, "We still don't totally have this figured out yet." That was in November. So I'll tell you what I know. We don't know a ton. We don't have to report anything. There's nothing we need to do. They're just going to draw this from our claims data. They're going to figure out our cost score based on Medicare spending per beneficiary in total per capita cost measures.


    These are big words I don't totally understand. What we do know is that Medicare spending per beneficiary is the cost incurred to your patients only three days prior to hospital admission, through hospital admission and 30 days after hospital admission. So do the best you can, said a sign. Do the best you can to keep your cost down. We're probably doing that anyway but this is just something to be aware of. Have it on your radar. It was of interest to me that this was the time period that they were interested in, they care about this timeframe, just something to be aware of. And then this total per capita cost is the cost assigned to your patients over the course of the year. It was nice to see that they had specialty adjusted in there. So we always say, "Our people are really sick. Why should we get penalized if they land in a hospital with ketoacidosis?" They say they're going to specialty adjust. So hopefully, that addresses the concern that I just raised.

    The final big change for 2018 was that the quality category. Last year only had a 90-day reporting period. For this year, it is a full year reporting period. Now, if you haven't done anything, it's okay because I hope you remember that I said to be perfect in the quality category, you have to report on 60% or more of your people that qualify for your measures. We are not 60% of the way through the year so it's not too late to jump in. You got to start soon but you have a month to figure this out. If you want to get in and you still want to achieve a perfect score, it's not too late to start.


    Thank you for your attention and we did leave maybe a minute or two for questions before we get in to our next talk. Right. Okay. Doctor asked, what are they going to use? What is the timeframe to determine the exception, the 90,000 is Medicare Part B allowable or 200 Medicare beneficiaries and that is August 31, 2016 through September 1, 2017. August 31, 2016 through September 1, 2017. The thing that stinks is that for – the 2017 reporting period, they had a very easy tool on their website where you could just put your NPI in and then they told you without you having to try to figure it out and they haven't made that available for the 2018 reporting period which makes it hard. If you want to run the report yourself, 8/31/16 through 9/1/17. And one more note on that. When we say 200 Medicare Part B beneficiaries, that's a patient. If you saw a Part B beneficiary seven times, that counts as one.

    We have time for one more. Look, they already docked me five minutes on the next one.

    Unidentified Male Speaker 1: Can you expand on the exemption for the ACI as it relates to a group or a super group?

    Jeffrey Lehrman: Okay. So Doctor asked about the 15 or few exception for ACI group versus super group. The super group, if you are billing under the same tax ID, which you are if it's a real super group. If it's a true super group, you're billing under the same tax ID and you're counting all the doctors that bill under that tax ID. So chances are you're not going to meet the exception because there's probably more than 15 of you. If it's super group, you count the number of clinicians billing under that tax ID.


    And I'll be around in the back when – for questions when I'm done with this.

    TAPE ENDS [36:05]