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In Practice
Tools Will Help Small Practices Succeed Under MACRA


The AAN Medical Economics and Management Committee has developed several tools to help AAN members meet the requirements of the Medicare Access and CHIP Reauthorization Act of 2015.

The future of many of the government's health care payment reform initiatives is uncertain, but the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is likely not in jeopardy. The Centers for Medicare & Medicaid (CMS) is pursuing the regulations it announced last year. Thus, neurologists who take a wait-and-see attitude about MACRA this year will suffer a financial penalty in 2019 and may lag behind their peers' ability to succeed in the program in the years ahead.

“We haven't seen any indication that MACRA will be changing significantly,” said Amanda Becker, senior director for policy and practice innovation at the Academy. “We are on the track of going forward with it as it stands today.”

MACRA won wide bipartisan support as the successor to the unpopular sustainable growth rate (SGR) method that determined Medicare's physician fee schedule each year. The legislation created a new Quality Payment Program with two pathways: Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

“We are working aggressively to inform our members so they can be ahead of the curve and be successful in private practice, solo practice or in a multigroup specialty practice,” said Constantine Moschonas, MD, director of Four Peaks Neurology in Scottsdale, AZ, and a member of the Academy's Medical Economics and Management (MEM) Committee.

The Academy's MEM Committee, in collaboration with the Quality & Safety Subcommittee and AAN staff, has developed several tools to help its members — particularly those in solo and small practices — understand the MIPS requirements and how to either avoid a penalty or pursue a bonus based on their performance this year.

“Our vision is for all members to avoid the penalty, and that should be an easy thing — we can help you figure out the bare minimum you need to do,” said Amanda Becker, the Academy's senior director for policy and practice innovation. “Beyond that, we want to support people with their desired level of participation in the Quality Payment Program.”


Nearly 25 percent of neurologists will be excluded from MIPS for one of these reasons: They are participating in an advanced alternative payment model, such as an accountable care organization, that meets the CMS criteria; they are newly enrolled as a Medicare provider in 2017; and they had $30,000 or less in Medicare Part B charges or 100 or fewer Medicare patients for the time period from September 1, 2015 through August 31, 2016.

CMS estimates that about 18 percent of neurologists fall into this group, Becker said, but physicians who think they meet the “low volume” criteria to be excluded need to verify that from their own records. As of press time, CMS was not providing a way for physicians to check using Medicare's own payment records.

For all other AAN members, the Academy has developed a flow diagram that allows neurologists to see the big picture of MIPS participation. It shows the level of reporting needed that corresponds with penalties and bonus opportunities. This includes, for example, no reporting in 2017: A penalty of 4 percent on all Medicare pay in 2019; a report on one quality measure or improvement activity during 2017: no penalty or bonus in 2019; a report on six measures for at least 90 days in 2017: neutral pay or small bonus in 2019; and a report on six measures for the full year in 2017: a bonus of up to 4 percent in 2019, depending on performance.

The diagram also identifies three reporting methods: through the Academy's Axon Registry or another qualified clinical data registry; via electronic health record (EHR) technology; and through a third-party registry such as CECity (for physicians that do not use electronic health record technology).


The MIPS quality measures replace the CMS Physician Quality Reporting System. The CMS online quality measures search tool includes 271 measures, most of which do not apply to neurology practice:


DR. CONSTANTINE MOSCHONAS: “We are working aggressively to inform our members so they can be ahead of the curve and be successful in private practice, solo practice or in a multigroup specialty practice.”

“It can be overwhelming for individuals who are not familiar with quality measures,” said Amy Bennett, the Academy's manager of quality improvement.

That's why the Academy developed a primer, “Finding MIPS Quality Measures in Three Easy Steps,” designed to help members find the measures most appropriate for their practices.

Bennett encourages members to report on neurology-specific measures if possible. “This will become increasingly important in years ahead when neurologists are compared with their peers rather than physicians in general practice,” she said. “If individuals can find neurology measures that match their patient populations, we encourage them to use them so they are better prepared for future years.”


Pursuing clinical improvement activities is a new requirement being introduced by the MIPS payment formula.

CMS has identified 92 improvement activities, ranging from depression screening to “engagement of community for health status improvement,” that support care coordination, patient engagement and patient safety.

Wading through all of the possibilities to identify activities that relate directly to neurology practice is time-consuming, so the MEM Committee did it on members' behalf.


DR. ALLAN D. WU: “Theres no more picking and choosing to customize the reporting of your individual use of electronic health records to your way of using it. If you are in a multispecialty group with neurologists and non-neurologists, youre all held to the same measures.”

“We hand-picked 18 suggestions for neurologists to consider implementing to qualify for the MIPS incentives for improvement activities,” Dr. Moschonas said.

The recommendations were chosen based on their pertinence to neurology practice and/or ease of implementation. For example, the committee recommends using the incentive, “seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare.” CMS does not define “timely manner” so neurologists have leeway in how they implement it.

“The key is that they don't have to wait six or 10 months and that is proved in the EHR, where you have a communication from a referring physician and the appointment for the patient,” Dr. Moschonas said.

Attesting to the performance of a single improvement activity during 2017 is sufficient to avoid a penalty in 2019, although Dr. Moschonas said he hopes most neurologists will pursue the highest bonus. That requires that large practices report on at least four activities and small practices report on at least two.

“Doing one to stay neutral is OK, but why not get a bonus, which would set into motion the likelihood of maintaining that bonus in the future?” he said.


The MIPS category “Advancing Care Information” (ACI) replaces the government's Meaningful Use incentive program, which encouraged the adoption and robust use of EHR technology.

ACI differs from the Meaningful Use program in two significant ways, according to Allan D. Wu, MD, a neurologist at UCLA Health and a member of the Practice Management and Technology Subcommittee.

For one thing, all providers who report to the MIPS program as a group get the same ACI score.

“There's no more picking and choosing to customize the reporting of your individual use of electronic health records to your way of using it,” Dr. Wu said. “If you are in a multispecialty group with neurologists and non-neurologists, you're all held to the same measures.”

The other change is that, instead of the pass/fail approach used in the Meaningful Use program, each provider gets an ACI score that influences his or her overall MIPS score that determines bonus payments.

“100 points in ACI scoring is equivalent to earning a full 25 percent credit for your MIPS score,” Dr. Wu said, referring to ACI's weight in the payment formula. “But partial credit is also possible.”

Dr. Wu developed an Excel spreadsheet that Academy members can use to calculate their ACI score. The calculator is not designed to be a reporting vehicle, but rather a way that neurologists can understand how their EHR use translates into the ACI score.

“This is a working tool that provides insight into how the government is trying to incentivize us to use these electronic records appropriately,” Dr. Wu said. “For example, using this tool immediately lets a physician know that ‘It is really important to do electronic prescriptions and the more I do, the more credit I will get. And if I do none, I will penalize my entire organization.”


• AAN resources on MACRA: