Sometimes the heat and humidity encountered during the sultry summer months can smother you like a warm, wet blanket. You know the days I am talking about, right? If you wear glasses, when you step outside the condensation on your lenses quickly obscures your view. We’ve been having weather like that of late. A bit oppressive…sort of like MIPS and MACRA.
In spite of the brief reprieve Diana Strubler provided last week, this week it’s back to the sweatshop with yet another MACRA-related post. Recently, I’ve been fielding a lot of questions about the Meaningful Use (MU) Hardship exceptions and their relationship to MACRA. Today, I’d like to spend some time reflecting on that intersection.
Fun with numbers
First let’s take a brief trip back in time. The Office of the National Coordinator, working with Health.Gov, publishes massive data mash ups. Using Excel magic, one can slice and dice that data to surface certain insights. Previously Diana highlighted the precipitous decline in the MU participation rate among nephrologists. Last year that trend continued as the number of nephrologists attesting for MU tickled the 1,000 mark. In fact, as predicted, 2015 saw fewer nephrologists participate in the program than in any year to date. A remarkable fact considering the reporting period last year was 90 days (although no one knew that until early October).
Perhaps more telling is the following tidbit: only 43 of the 1,066 nephrologists who attested last year were in year 5 of the program. That’s right, less than 5% of last year’s participants have been in the game every year since the program began in 2011.
Why the paltry turn out you may ask? While there are several potential explanations, one might imagine the arrival of Stage 2 in 2014 for early adopters, combined with the emerging popularity of the MU hardship exceptions had a lot to do with this picture. Sprinkle in growing experience with MU audits, and it’s no wonder MU participation by nephrology has dropped to its lowest level since the program began.
We’ve previously discussed the hardship exceptions in this blog, and as they have not changed, let’s not recount them today. Instead, let’s think about how they may impact what you do this year, and perhaps next year. This year the answer is easy. Nothing has changed between 2015 and 2016, so if you are eligible to file for a hardship for CY 2016 (in order to avoid the 3% Part B haircut in 2018), have at it. The application is unlikely to be available for several months, but nothing I have seen suggests it will change this year. The only restriction I am aware of is that a provider may only file for a hardship exception for 5 consecutive years. Given the timing of the penalty phase of the program, I doubt there is a nephrologist in the country who has reached that limit.
By the way, as you may recall from one of our posts in May, the MU program comes to a close at the end of 2018. What this really means is that you either attest for MU this year or file for a hardship exception, and then you are free and clear of MU. Before you celebrate that fact, remember MU has a new name moving forward. Apparently the phrase “meaningful use” was so toxic, the powers that be made sure MACRA eliminated that term.
Advancing care information
As Diana pointed out, MU will soon become advancing care information (ACI). Importantly, both the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs) enjoy the same performance year. What you do in 2017 will determine how you fare with both MIPS and APMs in 2019. Most of you will be exposed to MIPS. As you may recall, your MIPS composite performance score is made up of 4 categories:
- Advancing Care Information (aka Meaningful Use)
- Resource Use
- Clinical Practice Improvement Activities
Within the body of the recently published MACRA proposed rule, there is a recommendation for the relative weight each category contributes to your performance score. Suppose, however, you decide to pursue an advancing care information hardship exception in 2017? What’s the impact? Interestingly enough, if you have a valid reason not to report one of the MIPS categories, the remaining 3 are over weighted. Take a look at the pie charts below. On the left you can see the relative contributions for year 1 of MIPS as written in the proposed rule. The chart on the right displays what you would see if you successfully filed for a hardship exception in 2017.
The impact is rather dramatic. If you successfully file for a hardship next year, your quality score will account for two thirds of your entire MIPS score! Remember with MIPS you will be competing with the rest of the docs in the country. This makes it even more important to carefully select the quality measures you intend to report.
Of additional interest is the impact MIPS will have upon nephrology advanced practioners (APs) next year. Recognizing very few APs have participated in meaningful use, ACI is optional for APs in 2017. Sounds like a great idea on the surface, but if an AP elects to not participate in ACI, they will face the same MIPS distribution on display in the pie chart on the right.
To file or not to file?
I think the answer to this question is pretty straightforward this year. Assuming your circumstances have not changed, I’d answer it the same way you answered it last year. Next year, the answer is not so simple. On the surface, CMS has indeed made ACI look a little easier than its predecessor, meaningful use. As always, the devil is in the details, but I must say I find the “base” and “performance” designations Diana recently reviewed more appealing than MU’s current “all or none” framework.
As you make plans for 2017, the size of the quality section of the pie chart on the right should have your undivided attention. If you are contemplating that decision today, pour yourself a tall glass of ice cold lemonade…nothing better to help beat the heat in the MACRA sweatshop.
What are your plans for the hardship exception? Drop us a note and join the conversation.
Terry Ketchersid, MD, MBA, practiced nephrology for 15 years before spending the past seven years at Acumen focused on the Health IT needs of nephrologists. He currently holds the position of Chief Medical Officer for the Integrated Care Group at Fresenius Medical Care North America where he leverages his passion for Health IT to problem solve the coordination of care for the complex patient population served by the enterprise.