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Physician Expert, Clinical Documentation Key to MIPS Success

An industry expert advised practices to develop physician-led MACRA implementation teams that emphasize clinical documentation improvements for MIPS success.

Jacqueline LaPointe
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Published: 10 Aug 2017

Since the Obama administration signed MACRA into law in 2015, healthcare providers have been attempting to understand the Quality Payment Program and its Merit-Based Incentive Payment System (MIPS). But regular updates and tweaks to MACRA have made it increasingly difficult for providers to not only understand MIPS, but implement the necessary resources and workflows to succeed.

Just recently, CMS released a proposed rule that would modify Quality Payment Program requirements for the 2018 performance period. If finalized, some major changes to the MIPS track would include increased participation thresholds, an extended transitional period, and additional points for clinicians treating medically complex patients as well as those working in practices of 15 or fewer physicians. 

Rebecca Altman, Managing Director at Berkeley Research Group, discusses MACRA implementation and MIPS success.

Understanding the changes while keeping track of performance periods for the Quality Payment Program’s value-based reimbursement tracks have proved to be an obstacle for providers, Rebecca Altman, Managing Director at Berkeley Research Group, recently explained to RevCycleIntelligence.com.

“We have put a lot of challenges on our providers, but that’s why I say the critical piece to this is not just having physician leadership and engagement, but having the human capital and the resources embedded in your practice to really assist these physicians in making the changes in the EHR, ensuring that the data is being collected and it is complete when you submit it, and ensuring when those performance periods are,” the former registered nurse said.

“There really needs to be somebody on the administrative or operative side who is the one that tackles MACRA,” she added.

However, finding the right clinician or staff member to lead a MACRA implementation initiative may not be easy for many practices.

A majority of practices are reluctant to hire additional staff to manage MACRA implementation activities. A recent Physicians Practice report revealed that 87 percent of practice leaders do not plan to add staff to help with MACRA implementation and most anticipate training existing staff to facilitate the Quality Payment Program transition.

But educating clinicians and staff members already working within the practice may be an issue. Even though providers have had a couple years to digest MACRA implementation rules, recent surveys showed that provider and staff knowledge about the Quality Payment Program is lacking.

A poll from the American Medical Association and KPMG found that about one-half of respondents said they were somewhat knowledgeable about MACRA rules and another 41 percent said they had heard of the Quality Payment Program, but would not consider themselves knowledgeable.

Another survey from Nuance Communications showed that while 61 percent of hospital finance executives felt confident in their understanding of MACRA, over three-quarters could not correctly identify the greatest MIPS penalty that eligible clinicians could receive based on 2017 performance.

One-half of the executives also either underestimated or did not know the number of days required for data submission under MIPS.

“But making sure that you have some good physicians who are wanting to lead that charge is one critically important strategy.”

Altman recommended that practices across the size spectrum identify one to two physicians to become experts in MACRA implementation and Quality Payment Program requirements.

“It is hard to get physicians to take time out of seeing their patients, especially because we are progressively moving away from sheer volume and fee-for-service base to more of that value based purchasing process,” she stated.

“But making sure that you have some good physicians who are wanting to lead that charge is one critically important strategy,” she continued.

Practice leaders should start the selection process by looking to their current workforce, Altman advised. Leaders should ask themselves if their practice already has a clinician who has engaged with value-based reimbursement or MACRA implementation.

If so, practices should consider modifying the clinician’s responsibilities to focus more on managing MACRA implementation activities and MIPS reporting.

Other practices may have to look beyond their practice walls for a MACRA implementation expert.

“If you are looking for someone to come in and actually take it over and be part of your staff, I would want somebody who has a bit of a clinical background in data,” she suggested. “So, a clinical informaticist type who could really help you with quality in data. Also, any type of a quality person.”

Once practices pinpoint physicians and other clinicians to spearhead MACRA implementation and MIPS participation, the leaders should ensure that the clinicians prioritize data completeness and EHR workflow implementation for MIPS success.

Ensuring data completeness may earn practices additional MIPS points

Coding and clinical documentation improvements will be key to earning maximum points under MIPS, which will translate to more favorable value-based incentive payments. But ensuring that eligible clinicians meet the myriad of quality reporting requirements could be a major challenge for practices.

“Some of the quality reporting standards will be very tough for many physicians to keep track of,” Altman said. “One thing that is going to be a challenge will be data completeness because if they are submitting data and they do not have all the complete components of the data that they need, they will get points taken away.”

Under MIPS, eligible clinicians will receive maximum points for quality performance if they meet data completeness requirements. If at least 50 percent of possible data is submitted, clinicians qualify for maximum points.

However, if a measure cannot be reliably scored against a benchmark because of a lack of data completeness, clinicians only qualify for a maximum of three points out of a possible ten.

For large practices that have certified EHR technology and specific resources for quality data collection, data completeness should not be a major issue. However, smaller practices may struggle to allocate resources and human capital to guarantee completeness.

“That takes a lot of not just work, but it takes the resources to be able to do that,” Altman elaborated. “Because a physician can’t see patients and then also try to implement, collect, and monitor the data and things like that. You really do need resources.”

“For the smaller rural practices that are wanting to, or at least embarking on this, they will need additional resources,” she added. “That’s probably an expense they can’t necessarily afford.”

CMS recognized quality reporting hardships and recently proposed to extend the Quality Payment Program’s transition period into the 2018 performance period. The proposed rule would also award clinicians in small and rural facilities additional points.

“One thing that is going to be a challenge will be data completeness because if they are submitting data and they do not have all the complete components of the data that they need, they will get points taken away.”

While the additional time may help practices of all sizes implement the resources necessary for quality measurement and reporting, Altman argued that it may not be enough to truly help small practices prepare.

“They have bumped the original timeline and stretched it out to 2020,” she explained. “That has been helpful, but there are no resources being provided. All they have done is push out some timelines and adjust the points to still ensure that the rural and the smaller physician groups are gaining points or at least keeping points even if they don’t complete everything.”

“Unless the practices are participating in the Comprehensive Primary Care Plus program or they are part of some health system’s ACO and the health system is providing those resources, I would say CMS directly is not sending boots on the ground to provide those resources,” she continued. “They are certainly not sending somebody to these small rural practices to implement and look over the data and things like that.”

To overcome quality reporting and data challenges, Altman recommended that practices and their physician leaders emphasize coding and clinical documentation improvement, especially if proposed 2018 Quality Payment Program changes are finalized.

Not only would clinical documentation improvements advance data completeness, but clinicians could earn additional points. The proposed rule would award clinicians extra MIPS points for treating chronically ill and medically complex patients.

“It is critically important that they really leverage that because a lot of these rural and even midsize to large facilities take care of complex chronic patients,” she stated. “They really need to be pragmatic in their coding practices and making sure that they are collecting that specific data to ensure that they are getting those credits for taking care of those patients because that is the bulk of the work, ensuring those patients are cared for properly out in the community and preventing readmission.”

The physician-led MACRA implementation team should turn to EHR optimization to advance coding and clinical documentation and earn additional MIPS points.

Implementing EHR workflows to check off MIPS requirements

Physician-led MACRA implementation teams should encourage proper coding and clinical documentation to boost MIPS performance scores. But the team should also turn to their EHR systems to support clinicians with meeting quality reporting standards.

Altman advised practices to implement EHR workflows that prompt clinicians to meet MIPS quality measures, such as delivering certain vaccines as part of a wellness check.

“On some of the wellness checks, especially for those who are 65 years and older, you have the typical questions about if they are taking their influenza shots or the Pneumococcal vaccine to hit some of those measures,” she explained.

“Instead of on paper, if you have an EHR, the question is how are you quantifying, or how are you hardwiring it into your EHR so that when the patient is coming for their wellness check that that comes up on the screen.”

“Folks need to really optimize and utilize their EHR to hardwire some of these measures directly into the EHR.”

Hardwiring quality measure checklists that align with MIPS is key to maximizing performance scores and earning a value-based incentive payment rather than a penalty.

“Folks need to really optimize and utilize their EHR to hardwire some of these measures directly into the EHR,” she said. “Then, it is documented that the vaccine was given. It has been completed. You are then collecting that for all your patients versus trying to do it on paper and trying to have a checklist on paper for each patient.”

Engaging in an EHR optimization project to hardwire MIPS quality measures into the health record system should also make data collection and reporting easier.

“They can turn around and pull that information out on all the patients that have received the pneumococcal vaccine as part of their requirements for MIPS and then they can submit it,” she stated.

Altman emphasized the importance of investing in human capital and technological resources as part of a successful MACRA implementation strategy.

While the rules and scoring methodology continue to adapt to stakeholder and CMS concerns, relying on the foundation of a physician-led MACRA implementation team and technological support for clinical documentation improvement should ensure that practices are ready for any version of the Quality Payment Program.

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