Proposed MACRA Quality Payment Program and Anesthesiology

June 10, 2016

Summary

On April 27, 2016, the Department of Health and Human Services issued a Notice of Proposed Rulemaking to implement key provisions of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The proposed rule would implement the changes required by MACRA through a new system called the Quality Payment Program (QPP)¹.
The QPP includes two provider reimbursement programs, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). Most Medicare clinicians will initially participate in the Quality Payment Program through the MIPS².
MIPS combines the Physician Quality Reporting System (PQRS), Value-based Modifier (VBM), and the EHR Incentive Program (Meaningful Use) into a single program. A fourth component, Clinical Practice Improvement Activities (CPIA), will be added to promote ongoing improvement and innovation in clinical practice.
Under MIPS, providers will be paid for delivering high-value care based on their performance in the following four categories: Quality, Cost, Advancing Care Information and Clinical Practice Improvement Activities (CPIAs).
Performance scores in these four categories will be used to calculate a single Composite Performance Score (CPS) on a 0-100 point scale. The CPS will be used by CMS to determine whether a provider will receive an upward, neutral, or downward payment adjustment to their Medicare Part B payments³.
The quality data submission requirements are similar to the PQRS, but have two critical differences. First, data must be submitted on at least six measures instead of nine measures. There are no domain requirements. Second, for clinicians reporting through a registry, the threshold for reporting is increased from 50% to 90% of all patients eligible for any specific measure³.
The performance period for year one of MIPS will begin January 1, 2017 and the data collected will affect payments in 2019.
Anesthesiology groups should begin to prepare for these changes in data collection and submission for 2017 as soon as possible in order to maximize success in MIPS.

Introduction

In recent years, the Centers for Medicare and Medicaid Services has been transitioning from a fee-for-service payment system toward a system based on fiscal accountability and the provision of high-quality care. This transition received a boost on April 27, 2016 with the release of proposed rulemaking on the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The proposed rule would implement the changes required by MACRA through a new system called the Quality Payment Program (QPP).

The goal of the MACRA Quality Payment Program is to provide financial reward for eligible clinicians who provide high-quality care with efficient resource utilization and who engage in quality improvement activities. The proposed rule clarifies how the QPP will be implemented, how data will be submitted, what metrics should be collected, as well as the financial implications of participation or non-participation. The proposed rulemaking is open for comment until June 27. CMS will release the Final Rule in the fall of 2016.

The QPP includes two provider reimbursement pathways, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). The MIPS allows CMS to calculate a composite quality score and reward or penalize clinicians much like as is done within the PQRS and VBM programs. The second pathway rewards clinicians for participation in Alternative Payment Model (APM) programs in which a significant portion of their care is reimbursed based on quality and costs, and where they have a risk of financial loss. Most Medicare clinicians will initially participate in the QPP Program through the MIPS².

MIPS

Under the MACRA, the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and the Electronic Health Record Incentive Program (Meaningful Use), along with a fourth component, Clinical Practice Improvement Activities (CPIA), will be rolled into a single program called the MIPS. In this model, health care providers and groups will be paid for delivering high-value care based on their performance in the following four categories: Quality, Cost, Clinical Practice Improvement Activities (CPIAs), and Advancing Care Information (ACI). Weighted performance scores in these four categories will be used to calculate a single Composite Performance Score (CPS) on a 0-100 point scale (Figure 1). This score will be used by CMS to determine whether or not a physician receives an upward, neutral, or downward payment adjustment to their Medicare Part B payments². Like the PQRS, the payment adjustments will take effect two years after the performance period. The performance period for year one of MIPS will begin January 1, 2017 and the data collected will affect payments in 2019.

While similar to the PQRS and VBM programs, some of the terminology is different under the MIPS. The program affects a similar group of health care providers, but instead of being referred to as Eligible Professionals (EPs), these providers will be referred to as MIPS Eligible Clinicians (ECs). Eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists³. Under the proposed rule, CMS defines those clinicians who bill for 25 or fewer patient facing encounters, such as office visits, outpatient visits, and surgical procedures, as non-patient-facing clinicians. The MACRA allows for special consideration to be given to these clinicians under the MIPS. Using this definition, the majority of clinicians enrolled in Medicare with specialties such as anesthesiology were identified as non-patient-facing³.

Data Submission
Under the proposed rules, CMS will permit the use of many of the same data submission mechanisms as are currently available under the PQRS and VBM programs. Clinicians or clinician groups may submit data via mechanisms such as claims, qualified EHRs, Qualified Registries, and QCDRs. CMS will also establish a process for group reporting of data that will be similar to the GPRO option for PQRS reporting and permit reporting of data from all performance categories. While CMS will permit clinicians to submit data for each performance category through different mechanisms, they encourage the use of a single reporting mechanism. CMS also strongly encourages the use of QCDRs for reporting if possible.

Figure 1

Source: Quality-Payment-Program-MIPS-NPRM-Slides. CMS Website.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MIPS-NPRM-Slides.pdf

MIPS Composite Performance Score and Effects on Medicare Payments
The scores from the four MIPS categories will be weighed and a single Composite Performance Score will be calculated for every clinician or group. A threshold score will be determined and clinicians who are above that level will receive a positive payment adjustment on Medicare Allowable Charges for the associated payment year. Clinicians who score below this level will be penalized. The penalties for below-threshold performance will be a maximum of -4% for the first payment year of 2019, and this percentage will steadily rise to reach -9% by 2022 (Figure 2). The MIPS program is designed to be cost neutral, much like the VBM program, with the losers paying the winners. CMS anticipates that there will be more penalties than positive payment adjustments initially, and has therefore set the upper limits for bonus payments to high-performing groups at 3 times the penalty. In other words, high performing groups can earn a bonus of up to 12% (3 x 4%) of Medicare Allowable Charges in 2019. CMS estimates that there will be approximately $833 million moved from poor performing clinicians to the top performers. CMS has set aside an additional $500 million in bonus payments to reward exceptional performance in on the Composite Performance Score for clinicians who score above the 25^th percentile.

Figure 2

Source: Quality-Payment-Program-MIPS-NPRM-Slides. CMS Website.https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MIPS-NPRM-Slides.pdf

Performance Categories

Quality – Performance on quality metrics will account for 50% of the total score in reporting year one (2017) of the program. The measures and reporting requirements will be similar to PQRS reporting but with a few key changes (Figure 3). Under PQRS, EPs are required to report on 9 measures, covering 3 quality domains, with at least two outcome measures, if reporting via a Qualified Clinical Data Registry (QCDR). MIPS reduces this to 6 measures. These must include at least one outcome measure. There will no longer be a domain requirement. While patient-facing clinicians are required to also have at least one cross-cutting measure, anesthesiologists, if designated as non-patient-facing clinicians, will be exempt from this requirement.

Figure 3

Source: Quality Performance Category Training Slide Deck. CMS Website.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Performance-Category-training-slide-deck.pdf

Quality measures that can be reported will include over 200 MIPS measures as well as non-MIPS (or QCDR) measures. To make measure selection easier, MIPS measures will be grouped into specialty measure sets (Figure 4)². CMS has placed a priority on the completeness of the data submitted so the performance of each MIPS-eligible clinician can be accurately assessed. Under the PQRS, clinicians were required to submit data on at least 50% of eligible patients for each measure. For the MIPS, clinicians reporting through claims will need to report on at least 80% of eligible patients. For those reporting via registry or EHR, the threshold increases to 90% of eligible patients³.

Figure 4: Proposed Individual Quality Measures Available for MIPS Reporting in 2017 for Anesthesiology

Source: Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the
Physician Fee Schedule, and Criteria for Physician-Focused Payment Models; Proposed Rule. Federal Register May 9, 2016:81(89). Appendix. Table A.

Cost – Cost metrics will compose 10% of the MIPS score in 2017. It will be similar to the Cost Composite score utilized by CMS under VBM program and will be based primarily on two metrics: total per capita costs for all attributed Medicare beneficiaries and Medicare Spending per Beneficiary (MSPB). Administrative claims data will be used for assessing performance in the Cost category. Therefore, clinicians will not need to submit additional data for this category³.

Since anesthesiologists do not provide primary care, they do not have attributed Medicare beneficiaries. The cost category performance will be based on MSPB for selected patients receiving perioperative care. Patients will be attributed to a group by TIN that provides the plurality of Medicare Part B claims (allowable charges) for that encounter. CMS recognizes that for some specialties like anesthesiology, this attribution method holds clinicians accountable for costs that they may have no control over, and that it does not result in accurate cost performance scores. In future reporting years, CMS proposes to address this by allowing individual specialties to develop more accurate methods of cost attribution such as adherence to Choosing Wisely guidelines or Appropriate Use Criteria.

Advancing Care Information (ACI) – This category will account for 25% of the total score in 2017. It is a replacement for the EHR Incentive Program (Meaningful Use) and focuses on the use of technology for information exchange, and use of electronic health records to improve the quality of care. Rather than the all-or-nothing approach employed by the MU program, ACI will allow physicians to receive 50% credit for reporting measures (the base score) and 50% for performance on these measures. ACI will also decrease the number of measures and simplify the reporting requirements.

For clinicians for whom the ACI objectives and measures are not applicable, CMS proposes to reweight the Advancing Care Information performance category to zero, and adjust the other MIPS performance category scores to make up the difference in the MIPS score².

Clinical Practice Improvement Activities – The CPIA category will count for 15% of the MIPS score and is designed to reward provider groups for practice improvement activities focused on care coordination, expanded practice access, patient engagement, and safety initiatives. The proposed rule allows for data for the CPIA performance category to be submitted by qualified registry, electronic health records, QCDRs, or by CMS Web Interface. CMS has placed a priority for the use of QCDRs as a reporting mechanism and working with a QCDR would allow a clinician or group to report activity for multiple CPIAs. Regardless of the data submission method, all MIPS eligible clinicians or groups must select activities from the CPIA Inventory provided in the proposed rule³.

Examples of activities that anesthesiologists could report for CPIA include:

Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes.
Participation in a QCDR, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement.
Participation in a QCDR, demonstrating performance of activities that promote implementation of share clinical decision making capabilities.
Use of QCDR data for ongoing practice assessment and improvements in patient safety.
Regular assessment of patient experience of care through surveys or other mechanisms.
Participation in Maintenance of Certification Part IV for improving professional practice.
Participation in Joint Commission Ongoing Professional Practice Evaluation (OPPE) initiative.
Adoption of a formal model for quality improvement and creation of a culture in which staff actively participates in improvement activities.

A clinician’s score in this category would be determined by weighing the activities on which he or she reports. Highly weighted CPIAs would be worth 20 points while other activities would be worth 10 points. The maximum total points rewarded in the CPIA category would be 60. Eligible clinicians or groups that select fewer than the required number of CPIAs would receive partial credit. If a MIPS eligible clinician or group reports no CPIAs, then the clinician or group would receive a zero score for that category. The eligible clinician or group must perform CPIAs for at least 90 days³. Many of the available CPIA activities are specific for patient-facing clinicians. CMS will allow non-patient-facing clinicians or groups to earn 30 points per activity, regardless of whether the activity is medium or high. Non-patient-facing MIPS eligible clinicians and groups can therefore report on one activity to achieve partial credit or two activities to achieve full credit to meet the CPIA submission criteria³.

Alternative Payment Models

While most physicians will not qualify to participate in MACRA via an Alternative Payment Model, and most existing APMs will not qualify as advanced APMs under MACRA, CMS has taken the stance that APMs are a preferred mechanism of care delivery for the future. Qualifying Advanced APMs are required to provide payments to physicians based on quality measures comparable to MIPS, and physicians participating in APMS must bear more than a nominal risk for monetary losses. Clinicians that are APM Qualified Participants are exempt from MIPS and, thus, do not have the potential of a negative payment adjustment and are eligible to receive an automatic 5% bonus payment on Medicare Allowable Charges. This APM Incentive Payment Program is anticipated by CMS to be a powerful driver for more physicians to participate in APMs in the future.

MIPS eligible clinicians who participate in APMs that do not qualify as Advanced APMs will receive favorable scoring under certain MIPS categories. CMS hopes that this will further encourage clinicians to participate in APMs even if they do not meet the threshold for qualification.
Conclusions

The purpose of the MACRA Quality Payment Program is to create a quality reporting system that is more flexible than the PQRS, VBM, and MU programs, as well as to reduce the complexity and burden of reporting requirements on clinicians. CMS has reached out to clinicians and other stakeholders from a variety of specialties to craft the proposed rules and these rules have received positive reviews from several clinician groups. One of the criticisms of past quality programs was that they have been focused on population health and primary care, making it difficult for non-patient-facing specialties such as anesthesiology to report relevant outcome measures, participate in electronic healthcare record adoption programs, and have cost measures attributed to them in meaningful ways. The proposed rules address many of these concerns. Although the program is still highly focused on improving value provided through population health management, CMS indicates that it will be flexible in the adoption of new rules that align better with differing practice patterns between specialties rather than enforce a one-size-fits all system.

Anesthesiologists will face several challenges in the transition from volume-based to value-based healthcare. First, clinician leaders will face the challenge of helping peers understand that there are significant changes occurring in healthcare reimbursement, overcoming the inertia of familiar practice patterns, and communicating the implications of the new CMS Quality Patyment Program to colleagues.

Second, anesthesiologists who have not been successful with participation in the PQRS and VBM programs will need to move rapidly before 2017 to implement a data collection system that can successfully capture performance metrics in a robust, complete, and verifiable manner. Some quality data capture and reporting may be available within enterprise EHRs. Alternatively, there are numerous third party software vendors that can integrate with existing EMRs or function as stand-alone data capture systems.

Third, anesthesia groups will need to choose a route for data submission to CMS. The easiest process in the past has been to submit data via administrative claims, but this method has become more difficult as CMS has removed quality measures from claims reporting. The proposed rule allows for data to be submitted via qualified registry, electronic health records, QCDRs, or CMS Web Interface. The MACRA legislation specifies that the use of QCDRs should be encouraged under the MIPS⁴. The proposed rule allows for QCDRs to report on the quality, advancing care information, and CPIA performance categories. As administrative claims data will be used to calculate the Cost score, eligible clinicians will not need to report additional information for this category. This approach is meant to reduce administrative burden and simplify the data submission process for MIPS eligible clinicians by having a single reporting mechanism for all three performance categories².

Finally, anesthesiologists should begin to investigate pathways to participation in Alternative Payment Models. Advanced APMs, including certain ACOs and Patient-Centered Medical Homes focus primarily on population health and have patients attributed to primary care clinicians, which traditionally has had limited involvement of anesthesiologists. Although not included in the definition of qualifying APMs, programs such as the Comprehensive Care for Joint Replacement (CCJR), other bundled payment models, and the Perioperative Surgical Home model of care may be considered qualifying APMs in the future. Anesthesiologists should work to increase their knowledge of and participation in these APMs, especially those that tie both financial risk and reward to quality improvement and cost reduction.

It is important for physician leaders to remember that the proposed rulemaking is still subject to revision and change. The public comment period is open until June 27, 2016 and the final rule will not be published until later in 2016. It is possible that many anesthesiology groups will struggle to avoid negative payment adjustments under MIPS, especially smaller groups and groups that did not successfully participate in PQRS for 2014 or 2015. CMS estimates that only 29.8% of small groups (less than 10 ECs) will avoid penalties with MIPS, compared to 81.3% of groups with 100 or more providers. In order to adjust to the rapidly changing landscape of value-based reimbursement, clinician leaders should develop robust quality data collection and reporting processes before the start of 2017.

References
1. CMS website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program.html
• accessed 6/3/16
2. Notice of Proposed Rule Making Quality Payment Program. CMS website. file:///Q:/QUALITY/QUALITY%20STAFF/CMS%20Resources/MACRA_MIPS/NPRM-QPP-Fact-Sheet.pdf page 2 Accessed 6/1/16
3. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models; Proposed Rule. Federal Register May 9, 2016:81(89):28161-28686.
H.R.2 – Medicare Access and CHIP Reauthorization Act of 2015, 114th Cong (2015-2016). Congress.gov. https://www.congress.gov/bill/114th-congress/house-bill/2. Accessed June 3, 2016. Page 129 STAT. 96-99.