CSM Preview: All You Ever Wanted to Know About MIPS
By Kara Gainer, JD
Value. Quality. Outcomes. Costs. The United States is moving away from the traditional fee-for-service reimbursement structure, one in which providers are rewarded solely for the volume of services provided, to one that holds providers accountable for patient outcomes and costs.
Beginning January 1, 2019, the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP), which offers incentive payments to help eligible clinicians focus on care quality and making patients healthier, will include many physical therapists who participate in Medicare Part B.
While we estimate only about 5% of Medicare-enrolled physical therapists in private practice will be mandated to participate or face a penalty, almost all physical therapists in private practice will be eligible. Considering that there are no more scheduled payment updates to the Medicare physician fee schedule after 2019, QPP participation is something you should seriously think about if you're one of those eligible PTs.
At APTA's Combined Sections Meeting in January, we will answer your most pressing questions about QPP:
- What do these acronyms mean?!
- How does it work?
- If I am not required to participate, what is the benefit to me if I do?
- What is the difference between the Merit-based Incentive Payment System (MIPS) and an Advanced Alternative Payment Model (APM)?
- How can I maximize my incentive payment?
Nothing is simple when it comes to Medicare, and QPP is no different. The devil is in the details—and there are a lot of them.
APTA Director of Quality Heather Smith, PT, MPH, and I will be diving into the nitty gritty of what physical therapists need to know if they want to successfully participate in QPP, whether through MIPS or Advanced APMs.
You may be asking yourself: "Do I really need to attend this session?" Well, here is what one California PT who attended a similar session on Medicare payment said:
So, if you're ready to get out of your comfort zone and transform your practice, join us on Friday, January 25, in downtown Washington, DC, for "Emerging Issues in Medicare: Quality Programs and Alternative Payment Models," where you will learn more about QPP and how you can participate in Medicare payment models that reward value over volume, achieving better patient outcomes.
CSM advance registration discounts end December 5.
Kara Gainer, JD, is APTA's director of regulatory affairs. You can connect with Kara on Twitter at @karagainer.
7 Things You Need to Know About Value-Based Care
Whether you love it, hate it, or still don't completely understand it, value-based care is here to stay. We've put together a brief explainer to clarify the what, how, and why of value-based care. (For a more in-depth discussion, check out APTA's podcast series.)
Value = Health outcomes achieved / Dollars spent. Changing the payment paradigm from volume to value forces greater efficiency in the health care system; that is, delivery of the highest quality of care, and the best outcomes, at a controlled cost. Implementing a payment structure that examines outcomes and cost also will drive better-informed decisions by the patient, the payer, and the clinician.
Value-based care is NOT fee-for-service. Value-based care shifts from payment solely based on the volume of care, such as traditional fee-for-service, to payment more closely related to outcomes of care. Value-based payment models use measures of quality and cost to determine payment to providers. These models also can be referred to as alternative payment models, or APMs.
It's all about collaboration. APMs incentivize collaboration among members of the health care team to achieve high-quality, cost-effective care.
Value-based care is not just for Medicare patients. Although 1 of the models PTs may be most familiar with is the Medicare comprehensive care for joint replacement (CJR) model, it is not the only model out there. There is a desire by all payers to move in this direction.
Data collection is critical to success. To complete the value equation, outcomes must be quantified through the use of patient-reported outcomes measures or performance-based measures. This is 1 reason the Physical Therapy Outcomes Registry is so important—it will allow much broader data collection than any 1 EHR product.
PTs should consider getting involved sooner rather than later. You will need to understand your practice and the patients you serve to decide when to participate in an APM and which model might work best. It could be a condition- or disease-specific model, such as joint replacement bundled care, or it may be population-based, such as an accountable care organization. Opportunities also may arise with specific payers.
The details matter. No 2 APMs are the same. If you decide to participate in an APM, you will need to contract with the model organizer (or convener). Contracting is a critically important step, because you will have to negotiate the amount of risk you are willing to take on the possible financial reward you could achieve.
Want to learn more? Listen to the full podcast series. You also can check out "Quality Measures That PTs Can Impact" on the APTA website.
The Road Less Traveled
By APTA President Sharon L. Dunn, PT, PhD, OCS
Anyone delivering care in the current environment can see the evidence of change ahead. We know that care delivery in a few years—even later this year—will look vastly different from how it looks today.
In fact, some changes are already here. Medicare will flip the switch on its Comprehensive Care for Joint Replacement Model (CJR) on April 1. Providers serving patients with TKA or THA in 67 US regions will be impacted by this collaborative bundled care model, which will change the way providers, including PTs, are paid. And that is just the beginning.
So, why the drive toward change in health care? It's all about the value-vs-volume equation. Payment decisions are rightly being driven by how to provide value-based care to our patients, rather than by the volume of services provided. It's a change we sorely need.
We can't—and often shouldn't—oppose change, but we can—and should—be involved in advocating for our profession as a part of the change. That's not always a clear path. Deciding which road to travel involves a lot of planning and strategy, with the hope that the environment also delivers a healthy side of opportunity that we can seize.
Of course, seizing opportunity to move the profession forward, to aid our transformation, isn't without risk. But there's an even greater risk: not acting and having someone else decide our path. That's the philosophy that drives APTA to take a proactive approach to payment reform and, more specifically, toward working with collaborators among our members and other provider stakeholders to reform the way physical therapists code services.
So let's keep thinking about how we can position ourselves for the long-term changes, but let's also prepare for the changes at hand, especially the 2 big changes coming this year. We want to make sure you are ready. First, make sure you understand what the CJR is and how it will affect you. Second, educate yourself on the new evaluation codes coming January 1, 2017, and the thinking (and process) behind their creation. Here are some resources that can help:
Health care is evolving, and our profession has a transformational vision. That's a lot of change to keep up with. But I know this profession and this association, and I'm sure that in partnership with one another, we can take on the road before us.