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It's not too Late! Five Best Practices to Meet MACRA Requirements by the End of the Year

Contributed by Kim Hathaway, MSN, CPHRM,

Healthcare Quality and Risk Consultant, The Doctors Company

The last 90-day reporting period for the Medicare Access and CHIP Reauthorization Act (MACRA) in 2017 began on October 2. Physicians and practices who are still interested in avoiding the negative penalty must act promptly. Practices that have not yet developed their MACRA plan face great urgency to complete it--and those who have started may be feeling overwhelmed. Regardless of the reporting stage, these steps can help guide practices to succeed:

1. Review past performance in quality measures such as the Physician Quality Reporting System (PQRS) or specialty measures that your practice has reported. These are strong indicators of how your practice will do in the future. Align activities and quality measures with what you are already doing in your practice and determine how to make capturing the needed data part of your team's workflow. Educate and engage the entire workforce about what you are trying to accomplish and why. Ask for input from the frontline of your practice about the most efficient ways to collect the necessary data elements. Even if you participated in PQRS in the past, there are differences that will require a team effort to be successful. Don't try to do it alone. Consider making quality measurement part of the annual review for employees.

2. Study the specifications for measures you are reporting to better understand its value. For claims or registry reporting, go to Quality Payment Program website and choose the appropriate file under "Documents and Downloads." If you are reporting through your electronic health record (EHR), the vendor can be very helpful in choosing your measures. In fact, not all EHRs will report all measures and there are some that collect data but don't report to the Centers for Medicare and Medicaid Services (CMS). Clarify with the EHR vendor when and how the documentation is captured and counted toward the measure. The same applies to the various registries. Be sure to do your homework and know about pricing and any requirements related to system compatibility.

3. Monitor your data on a weekly or bi-weekly basis. Compare the reports that you run in your office to those generated by your EHR or registry. Investigate any discrepancy so that it can be corrected now by coaching the team on documentation or timeliness of reporting. Don't wait until the end of the reporting period to look at your performance data. There may not be time nor the ability to correct it later.

4. Understand that the scoring process for the quality measures is very different than it was in PQRS. Under PQRS, if you reported the measure enough times, you received credit. And if you reported on one patient, you would get a pass.

Under the PQRS scoring process (based on 100 patients):

Provider 1: 95 patients' performance met, 5 patients' performance not met = PASS

Provider 2: 5 patients' performance met, 95 patients' performance not met = PASS

Under the quality measure, your rate will determine your score (based on 100 patients):

Provider 1: 95 patients' performance measure met, 5 patients' performance not met = 95% Performance Rate

Provider 2: 5 patients' performance met, 95 patients' performance not met = 5% Performance Rate

On top of the change in how much you report versus the performance rate, the scores will be determined based on national benchmarks, with the highest performing deciles receiving a greater point value.

5. Review the Quality Resource Utilization Report (QRUR) to fully understand how the practice performs in quality and cost. Use the 2015 or 2016 QRUR (publishing fall 2017) to identify potential weaknesses and address them before cost returns as a scored category in 2019--because cost will carry a weight of 30 percent toward the Merit-based Incentive Payment System (MIPS) composite score. This is a complex report that requires familiarity to truly understand its content. The biannual report outlines the quality and cost data from PQRS and compares it to a national benchmark. Costs are determined by claims data. There are no reporting requirements for the cost category in 2017. CMS will provide feedback on cost for the 2017 performance period, but it will not be counted in the final composite score for 2017 or 2018.

Groups and solo practitioners may access their QRUR through the CMS Enterprise Portal. The person who accesses this report for the group will need to create a login at CMS' Enterprise Identity Management (EIDM) system. This is a very secure site. It contains questions to verify and confirm the identity of the person registering, as well as information about specific providers in the group. Security is very strict around these reports because they include patient health information so that groups may identify which patients may be attributed to them. For help with interpreting the information on your QRUR, consult the CMS website regarding QRUR analysis and payment. You will find additional resources and links to the EIDM System and what to do if you believe your QRUR is not accurate.

If you would like to know how to participate in MIPS and avoid a penalty, consult with the Quality Payment Program CMS website. For additional information, visit The Doctors Company's MACRA Resource page.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Kim Hathaway is a Patient Safety Healthcare Quality and Risk Consultant at The Doctors Company. She has more than 25 years of experience in healthcare administration, nursing, and progressive leadership experience. Her extensive experience also includes the areas of quality performance improvement and healthcare regulation. Her e-mail address is

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