Feature Moving Toward Quality Payment CMS has proposed changes to the 2019 physician fee schedule that would require eligible PTs to participate in Medicare's Quality Payment Program next year. To prepare, PTs must understand what's behind these efforts, what they need to do, and what may lie ahead. By Christine Lehmann, MA, NTP | November 2018 In January, Medicare payment for outpatient services is expected to move dramatically toward value-based payment. Physical therapists (PTs) and other providers likely will be added to the provider types that must participate in Medicare's Quality Payment Program (QPP). The impact on physical therapy? An estimated 55,200 physical therapists (as of 2016)1 in noninstitutional settings who bill Medicare Part B for outpatient services will be eligible to participate in QPP. The plan, included in the Centers for Medicare and Medicaid Services's (CMS) proposed Medicare physician fee schedule rule for 2019, would require certain PTs, occupational therapists, social workers, and clinical psychologists to participate in QPP after having been excluded for the first 2 years of the program. The goals of QPP, CMS says, are to improve beneficiary outcomes, reduce burden on clinicians, increase adoption of and maximize participation in Advanced Alternative Payment Models (Advanced APMs), improve data and information sharing, ensure operational excellence in implementing programs, and deliver technology capabilities that meet users' needs. "This is a landmark event for PTs" says Craig Johnson, PT, MBA, chief operating officer of Therapy Partners Inc in Oakdale, Minnesota, "because it creates an opportunity to participate in value-based care and payment, and commercial health plans may take notice." Johnson, a board member of APTA's Private Practice Section, adds, "It's been hard to move forward with value-based care models at the local level because payers are uncertain about how to approach it. PT providers could do well in value-based models, because we have shown ourselves to be effective providers who can lower episodic costs." Rick Rausch, PT, DPT, president of Sovereign Rehabilitation in Chicago and a member of APTA's Public Policy Advisory Committee, agrees: "Having PTs included in the QPP program is a win for the profession. We might not like the extra work, but it acknowledges that CMS sees us as a vital part of the health care team and part of the solution for escalating costs." How Did We Get Here? PTs have engaged in quality reporting under Medicare Part B since CMS created the Physician Quality Reporting System (PQRS) in 2007. Eligible professionals using the claims-based PQRS program received bonus payments or were subject to penalties based on their level of compliance with the program's reporting requirements for covered services provided to Medicare Part B fee-for-service beneficiaries. The vast majority of PTs billing Medicare Part B participated in PQRS. Of the 56,387 eligible clinicians in 2016, 82% reported—10% higher than the national average participation rate of 72% that year, according to CMS 2016 data.2 Meanwhile, the Medicare Access and Children's Health Insurace Program Reauthorization Act of 2015 created QPP, establishing 2 tracks for participation: the Merit-based Incentive Payment System (MIPS) and Advanced APMs. Clinicians who successfully participate in an Advanced APM are exempt from MIPS reporting. PTs are eligible to participate in Advanced APMs; however, to date only physicians, physician assistants, and nurses have been eligible to participate in MIPS for the potential payment incentive or penalty. With the onset of MIPS, PQRS expired at the end of 2016. Since then, PTs have been allowed to voluntarily report to MIPS without any assessment or impact on payment. But despite encouragement from APTA for PTs to continue reporting as they did under PQRS, participation understandably dropped off significantly once PQRS expired and MIPS reporting remained voluntary. However, with PTs expected to participate in MIPS next year, APTA anticipates their quality reporting rates to increase. How MIPS Works MIPS combines aspects of various expired programs, including the defunct PQRS. Providers participating in MIPS must collect data throughout the year and submit it for an annual score, similar to the PQRS process. The reported data is used to measure clinicians' performance in 4 areas: Quality (which succeeded PQRS), Promoting Interoperability (renamed from Advancing Care Information and successor to the defunct meaningful-use program to encourage use of electronic health information), Clinical Practice Improvement Activities, and Cost. "A big problem in health care is the variation in treatment with little outcomes data," Rausch observes. "CMS is trying to guide providers down a certain path so that we include specific reporting requirements in our evaluations and interventions." Based on their performance in the 4 categories, providers are awarded points that make up their total score. That score determines whether providers earn a payment incentive, incur a penalty, or neither. Similar to PQRS, payment incentives and penalties under MIPS will kick in 2 years after the data-collection year. For example, for 2019, when mandatory reporting is expected to start for PTs, MIPS data will determine incentives and penalties in the 2021 payment year. Payment incentives and penalties are much higher for MIPS than they were for PQRS: 4% plus or minus in 2019, 5% in 2020, 7% in 2021, and 9% in 2022 and beyond. Here is what PTs need to know about how MIPS would be applied to them according to the 2019 proposed physician fee schedule. (The final rule is expected sometime this month. APTA will provide an update as soon as the rule is released.) Initially, PTs would be assessed on only 2 of the 4 MIPS categories. Unlike physicians, who must report on all 4 categories, PTs in 2019 would be assessed only on quality and clinical improvement activities. Their quality score would count for the majority of their overall performance score. PTs would need to meet 3 criteria to qualify for mandatory participation. CMS determines MIPS participation based on meeting or exceeding a "low-volume threshold." Medicare providers must meet these 3 criteria: have $90,000 or more in Medicare Part B allowed charges, treat 200 or more Part B-enrolled individuals, and provide more than 200 covered professional services to Part B enrollees. PTs who do not meet all 3 criteria would be exempt from mandatory MIPS reporting. MIPS would apply to PTs in private practice only, and group practices would be assessed as a whole. MIPS participation initially would be limited to PTs in outpatient private practices. But, unlike PQRS, group practices participating in MIPS would be assessed as a whole for reporting, rather than by individual clinician. Practices that exceed the low-volume threshold would have an opportunity to participate in MIPS but would not be required to do so. If a practice chooses to participate, all clinicians in the practice would be treated as MIPS-eligible clinicians for that year. PTs still would be able to participate in MIPS voluntarily to learn about the system before being required to report. Beginning next year, PTs who do not meet the MIPS low-volume threshold could participate in 1 of 2 ways: (1) Through an annual MIPS opt-in option their performance would be assessed like that of other MIPS participants, making them eligible for a payment incentive, a penalty, or neither; or (2) as in previous years, they could report voluntarily to MIPS without a performance assessment and related payment adjustments. APTA encourages noneligible PTs to participate voluntarily in MIPS to become familiar with a system that is likely to expand its reach. Practices of 15 or more eligible clinicians would be required to report to MIPS electronically. Group practices of more than 15 eligible clinicians would need to report via electronic health records (EHRs) or registries. An eligible clinician participating in MIPS would be required to use certified EHR technology (CEHRT) for the Promoting Interoperability category. (Because PTs would not report in this category in 2019, CMS would apply an automatic reweighting policy for this category for PTs, meaning their MIPS scores would be redistributed among the 2 categories in which PTs would report.) Clinicians also would use CEHRT for clinical quality measure reporting if they are seeking the electronic reporting bonus in the Quality category. Claims-based reporting still would be an option for solo practitioners and smaller practices. However, APTA advises PTs in these solo or smaller practices to start learning and investing in electronic reporting soon, as this appears to be the direction in which CMS is heading. The association is helping to make MIPS reporting easier through its Physical Therapy Outcomes Registry, which has been recognized by CMS as a qualified clinical data registry (QCDR) for electronic reporting. (See "APTA's Physical Therapy Outcomes Registry" on page 25.) Implementation Challenges Although PTs use electronic health records, many EHR systems do not have CEHRT status—which is not required in 2019 for PTs but may be in future years. "Cost is the biggest barrier for PTs, especially those in small private practices, to move to EHR platforms," Craig Johnson says. "Although grant money was available to physicians willing to adopt EHRs 3 to 4 years ago, that program has expired." Now that CMS requires PTs to use CEHRT to participate in APMs, Johnson hopes that funding would be made available to offset the costs of adoption. PTs who do not already use EHRs will have a bigger hurdle in transitioning to MIPS than those who do, notes Rausch. "They will have to scramble to be ready to participate by January 1 or face payment reductions. In contrast, PTs who used EHRs for PQRS reporting should have a fairly easy transition." Mark Besch, PT, chief clinical officer for Aegis Therapies in Frisco, Texas, says, "We fit into the category of having no experience with MIPS. As a result, I expect a steep learning curve." MIPS reporting would affect the 70 outpatient clinics Aegis operates in multiple settings, including retail locations, senior living communities and health clubs. Aegis uses an EHR system for documentation and billing, but Besch says it has limited interoperability with other electronic medical records systems. "Meeting Medicare's requirements for interoperability poses a greater challenge in terms of timing and expenditures for postacute providers than it does for acute providers such as hospitals," Besch notes. He is a member of APTA's Post-Acute Payment Work Group and belongs to 2 APTA sections—the Academy of Geriatric Physical Therapy and the Section on Health Policy and Administration (HPA the Catalyst). MIPS Alternatives PTs also can participate in QPP through Advanced APMs or an option that involves a Medicare Advantage demonstration. "APMs have experienced remarkable growth in the past 3 to 5 years," Besch says. "The type of APMs PTs can participate in will depend on their employment settings. A hospital-based APM will look very different from an APM that is open to independent clinics and private practices," he observes. Advanced APMs are a subset of APMs that qualify under QPP to offer participating clinicians incentive payments for improving quality and reducing care costs. Advanced APMs address a specific clinical condition, episode of care, or patient population. Participants can earn higher incentive payments when they take on risks based on Medicare spending and patient outcomes. And, as noted earlier, clinicians and practices that participate successfully in Advanced APMs need not report to MIPS. Craig Johnson, who is a member of APTA's Payment Policy Advisory Committee, believes practices that otherwise would be required to participate in MIPS next year may want to look at Advanced APMs sooner rather than later. "Right now, they will need to collaborate with health systems and other medical providers to meet the APM criteria," he says. "We know coordinated and collaborative care with other providers benefits patients." To be eligible for the Advanced APM incentive payment, in 2018, clinicians must either receive at least 25% of their Medicare Part B payments or provide care to at least 20% of their Medicare Part B patients through the Advanced APM. This threshold increases annually. Physical therapy facilities can propose their own Advanced APM to CMS or can participate in an existing one. (The models that have been approved by the Centers for Medicare and Medicaid Innovation are listed on their website at innovation.cms.gov.) For 2019, 3 criteria must be met to qualify as a Medicare Advanced APM, according to the proposed fee schedule: The model must require at least 75% of all eligible clinicians to use CEHRT. The model must use quality measures that are comparable to those used in MIPS. The model must bear financial risk for underachieving. CMS is proposing that the risk would need to be equal to 8% of the average estimated total Medicare parts A and B revenues of providers and suppliers in the Advanced APM, or 3% of the expected expenditures for which an APM entity is responsible. Not all PTs are comfortable with assuming risk, Johnson notes. "I think it's the right direction for us to be heading," he says, "and PTs can successfully manage risk. Still, it's still an area where most PTs lack knowledge and experience." Two Types of Advanced APMs The proposed fee schedule describes 2 Advanced APM options available for PT participation: the Medicare Option and the All-Payer Combination Option. The Medicare Option already exists and allows eligible clinicians to become Qualifying APM Participants (QPs) by participating in Medicare Advanced APMs, including CMS-created models such as the Comprehensive Care for Joint Replacement Model (only the CEHRT track qualifies as an Advanced APM), Bundled Payments for Care Improvement Advanced Model, Next Generation Accountable Care Organization (ACO) Model, Medicare ACO Track 1+, and others. The proposed All-Payer Combination Option, which would begin in 2019 for payment year 2021, would allow eligible clinicians to become QPs by participating in both Medicare Advanced APMs and alternative payment arrangements that meet certain criteria within Medicaid, Medicare Advantage, and commercial payers. These other payer models are referred to as Other Payer Advanced APMs. Under this option, CMS would assess clinicians through their participation in both types of Advanced APMs. For both types, PTs who meet or exceed the payment or patient count thresholds would be exempted from MIPS and would be eligible for a 5% Medicare bonus beginning in 2021 for the 2019 performance year, in addition to any other payment adjustments applicable to that model. To be considered a QP for payment year 2021, PTs must meet certain patient and payment thresholds in 2019, depending on the type of Advanced APM they pursue: Under the Medicare Option, PTs must have either provided services through Medicare Advanced APMs for at least 35% of their Medicare Part B patients or received at least 50% of all Medicare Part B payments through the Advanced APMs. Under the All-Payer Combination Option, PTs must have either received at least 25% of Medicare Part B payments through the Medicare Advanced APMs and at least 50% of all payments through Advanced APMs or provided services to at least 20% of Medicare Part B patients and at least 35% of all patients served by the Advanced APMs. PTs who do not meet these thresholds can participate through a "partial QP threshold" option, with lower payment and patient thresholds. Partial QP participants are not subject to MIPS requirements and payment adjustments, but they can choose to report to MIPS although do not qualify for the 5% bonus. Medicare Advantage PTs also may be able to participate in QPP through the Medicare Advantage Qualifying Payment Arrangement Demonstration (MAQI). Providers who meet the qualifying criteria to participate in a Medicare Advantage Organization (MAO) could be exempted from MIPS reporting and payment adjustments. Providers also would not be required to meet the QP thresholds associated with the Advanced APM options, but they would need to apply for the demonstration project in advance. The demonstration will test whether: There is an increase in clinician participation in payment arrangements with MAOs that meet the criteria of Qualifying Payment Arrangements; Participating in Qualifying Payment Arrangements and Advanced APMs incentivizes providers to transform their care delivery (to be assessed by interviews with participating clinicians); and Utilization patterns change among participants in the demonstration and, if so, how those changes affect Medicare Advantage plan bids. Details for MAQI are available on the Center for Medicare and Medicaid Innovation webpage at innovation.cms.gov/initiatives/maqi. "Participation in APMs and MIPS will establish new standards of care," says Alan Meade, PT, DSc, MPH, director of rehabilitation services at Holston Medical Group in Kingsport, Tennessee, and president of the Tennessee Physical Therapy Association. "Using tools such as EHRs and patient outcomes registries will facilitate reporting of data and hopefully make it easier to convince payers to grant PTs more visits." Christine Lehmann, MA, NTP, is a freelance writer. Download chart in Adobe PDF.Goodbye, Burdensome Medicare Rules In addition to adding PTs to QPP, the proposed 2019 physician fee schedule would end functional limitation reporting (FLR), which has long been criticized by APTA as an undue administrative burden with little value. CMS estimates that PTs in private practice would have saved between 130,000 and 190,000 hours of administrative work in 2017 had FLR not been in place.Mark Besch, PT, comments, "This is a big win. The FLR design was flawed from its inception due to lack of specificity of the information obtained. The categories were too broad and we had to collect a lot of data that was not meaningful. Although CMS eliminated those FLR G-codes, we still need other mechanisms focused on outcomes."Rick Rausch, PT, DPT, offers a different perspective. "I am glad to see some reduction in paperwork requirements as we move into the MIPS system, but I really felt that functional reporting was a step in the right direction. We are all about function as PTs. Not all therapists use assessment tools in their evaluations and treatment, and the FLR system was an attempt to have all PTs use function, and change in function, in their plan of care."Beyond eliminating the FLR requirement, Besch suggests that some of the patient assessment requirements with physical therapy-specific components—such as the Minimum Data Set in skilled nursing facilities (SNFs) or the Outcome and Assessment Information Set in the home health environment—could be simplified by eliminating some categories. A good example of CMS simplifying burdensome assessments is the proposed Patient-Driven Payment Model in SNFs, which would reduce frequent patient assessments to an assessment at the 5-day mark of a SNF stay and another at discharge.MIPS OR NOT?Do you have to participate in MIPS in 2019? Can you participate voluntarily? Or do you sit out participation for now? Use this decision tree to help you determine your status and your options.a. How do I know if I meet the thresholds?To help you estimate whether you or your practice would meet MIPS low-threshold requirements, you can view 2016 data from the CMS "Medicare Physical and Other Supplier National Provider Identifier (NPI) Aggregate Report." On the webpage (https://data.cms.gov/Medicare-Physician-Supplier/Medicare-Physician-and-Other-Supplier-National-Pro/85jw-maq9/data), enter your NPI, then find the columns for "Number of Services," "Number of Medicare Beneficiaries," and "Total Medicare Allowed Amount." Keep in mind this is only an estimate—review the page for further details. CMS will publish 2019 eligibility data in the first quarter of 2019 on the CMS website at https://qpp.cms.gov/.b. If I am not required to, why would I voluntarily participate in MIPS?There are 2 good reasons: First, MIPS allows PTs and physical therapy practices to earn incentive payments and prepare for participation in alternative payment models through the collection of data. Because eligible PTs will report on only 2 MIPS categories in 2019—Quality and Improvement Activities—scoring will be weighted solely on these 2 categories. The Quality category is based on the former Physician Quality Reporting System (PQRS), and PTs who successfully reported under PQRS also potentially would score well in the MIPS Quality category. Second, voluntarily reporting now prepares PTs for the future, when mandatory MIPS participation could extend to wider groups of participants.c. Should I participate as an individual or as a group? Many PTs in group practices may find it easier to participate in MIPS as a group, as this will allow the group to work together in reporting the same quality measures to achieve the highest possible point total for all providers in the group.More Physical Therapy-Related Provisions in the Proposed Rule Several other provisions in the proposed fee schedule would have an impact on physical therapist practice. The rule would:Officially establish the physical therapy assistant (PTA) payment differential. The rule establishes 2 new therapy modifiers that would be used beginning January 1, 2020, to identify outpatient services provided in whole or in part by PTAs. Beginning in 2022, these services would be paid at 85% of the fee schedule, per federal budget legislation in 2018 that put an end to the hard Medicare therapy cap. CMS anticipates that a voluntary reporting system for the new modifiers will be created beginning in 2019. APTA opposes CMS's proposed definition of "in part" and will be advocating for changes before the 2022 implementation date. Mark Besch, PT, DPT, echoes APTA's opposition, saying the focus should be on clinical outcomes when evaluating services for payment. "Our outcomes data show that appropriately supervised PTAs produce similar treatment results to those of PTs." Rick Rausch, PT, DPT, comments, meanwhile, "I would hope future rules will clarify how this new requirement will work. Otherwise, it will cause considerable confusion. The scary thing with this rule is that it could very possibly open the flood gates of private payers paying at the 85% rate for work done by the PTA. If that happens, there will be serious implications for reimbursement for smaller clinics as well as the job demands for the PTA." Increase payment slightly. After applying adjustment factors mandated by the Bipartisan Budget Act of 2018, the proposed fee schedule conversion factor would increase slightly, from $35.9996 to $36.0463.Keep KX modifier requirements. The permanent fix to the Medicare therapy cap enacted in 2018 included requirements to continue using the KX modifiers for claims that exceed a threshold, which in 2018 is $2,010 for physical therapy and speech-language pathology services combined. CMS also references the targeted medical review process, noting the threshold amount of $3,000. That system would continue, but the proposed rule emphasizes that not all claims exceeding the threshold would be subject to review.Indicate that CMS is considering broader use of technology. CMS is proposing that activities such as virtual check-ins, interprofessional internet consultation, and remote evaluation of prerecorded patient information could qualify for some form of payment. While CMS implies these services would be performed by physicians, APTA is advocating that CMS include PTs in the types of qualified health care professionals eligible to furnish and bill for these services. Let APTA Help You Get Ready For MIPS and Advanced APMs Consider APTA's Physical Therapy Outcomes Registry your MIPS solution (a CMS-Qualified Clinical Data Registry) to earn points for quality and clinical improvement activity standards—2 required categories for MIPS reporting in 2019. www.ptoutcomes.comMake sure you report the 6 CMS-approved quality measures to MIPS, and ensure that your vendor can transmit the required data to CMS in 2019. APTA will update its MIPS webpage once the rule is finalized. www.apta.org/MIPSGet detailed information on MIPS and Advanced APMs from APTA's value-based care podcast series. www.apta.org/VBC/PodcastsAssess your readiness for QPP with APTA's self- assessment quiz. www.apta.org/PaymentReform/StatusQuiz (login required)CMS Program ResourcesRead about Medicare's QPP, MIPS, APMs, and MAQI programs:Quality Payment Program Overview qpp.cms.gov/about/qpp-overviewQPP MIPS Overview qpp.cms.gov/mips/overviewQPP APMs Overview qpp.cms.gov/apms/overviewMedicare Advantage Qualifying Payment Arrangement Incentive Demonstration innovation.cms.gov/initiatives/maqiAPTA's Physical Therapy Outcomes Registry: Ready to Report Data for MIPS and More PTs in private practice who bill Medicare for outpatient services may be eligible—and some even may be required—to participate in the Merit-based Incentive Payment System (MIPS) next year. MIPS is 1 of 2 tracks eligible professionals can choose for participating in Medicare's Quality Payment Program (QPP). Beginning in 2019, PTs in the MIPS program will have to report quality measures and clinical practice improvement activities—2 of the 4 MIPS categories that CMS uses to evaluate clinical performance and determine whether participants will receive a positive, negative, or neutral payment adjustment. The adjustment is based on a clinician's total annual performance score. PTs who participate in MIPS may use APTA's Physical Therapy Outcomes Registry (Registry) to submit data in the required structured format. "The Registry is the conduit by which a practice can submit data to CMS. Most EHR [electronic health record] systems are not designed for that reporting mechanism," says James Irrgang, PT, PhD, FAPTA, professor and chair of the Department of Physical Therapy at the University of Pittsburgh School of Health & Rehabilitation Sciences, and director of the Registry's Scientific Advisory Panel. The Registry also can give clinicians valuable real-time feedback on their performance throughout the reporting year, using visually friendly dashboards to identify performance issues and enable clinicians to see how they measure up against established national benchmarks. APTA has partnered with FIGmd Inc, a health IT company that specializes in EHR-integrated registries, to develop the Registry. FIGmd has developed and maintained numerous registries, including one in collaboration with the American College of Cardiology. It has completed integration projects for more than 80 major EHR vendors. Integration enables seamless EHR data transfer to the Registry database.APTA's Board of Directors approved the Registry in 2015 and then officially launched it in February 2017. The Registry has been a CMS Qualified Clinical Data Registry (QCDR) since 2017, when it began sending data to CMS from users who participated in MIPS voluntarily. No other physical therapy software vendor has as much experience with MIPS data submission. The QCDR designation by CMS allows APTA and other specialty groups to develop and submit new outcomes-based quality measures for MIPS that are beyond the 6 process measures CMS had developed for the previous Physician Quality Reporting System—which was folded into MIPS as the "quality" category. The Registry's Scientific Advisory Panel has reviewed and adopted 12 new outcomes measures for inclusion in the Registry. "The new measures reflect the key domains we want to measure in the Registry: physical function, pain, and quality of life," Irrgang says. "As the Registry matures, PTs will be able to evaluate whether they provided the best evidence-based care for their patients and how their performance compares with other PTs nationally."Irrgang acknowledges that some APTA members are nervous about having payment decisions be based on outcomes-based quality measures. "Ultimately, the measures have to be meaningful to patients and clinicians, and truly reflect the quality of the outcome for the treatment provided," he says, adding, "That's another benefit of participating in the registry—we're collecting information on patients that could be used to explain a clinician's results or adjust the risk based on the results." Visit APTA's Physical Therapy Outcomes Registry website to learn more about the benefits of enrolling (www.ptoutcomes.com).