News

On October 14, 2016, the Department of Health and Human Services released its final rule implementing the Quality Payment Program (QPP) as part of the Medicare Access  and  CHIP  Reauthorization  Act  of 2015 (MACRA). The QPP, which begins on January 1, 2017, replaces the Sustainable Growth Rate formula with a new payment   methodology where clinicians are rewarded for delivering high-quality care. The MACRA Final Rule contains significant changes from the Proposed Rule, which was released in April 2016. Through these changes, the Centers for Medicare & Medicaid Services (CMS) has demonstrated its willingness to both listen and respond to clinician concerns over the new payment system. The purpose of this article is to review the basics of the QPP and describe the changes contained within the Final Rule.

Changes to Eligibility Requirements

The QPP transitions Medicare to paying for value through two avenues: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). In the Final Rule, CMS changed the eligibility requirements for participation in  these  two  pathways.  For  2017, physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists are eligible if they meet certain volume requirements. Clinicians will be excluded if their Medicare allowed charges are less than or equal to $30,000 or if they see 100 or fewer Medicare Part B patients.¹ CMS estimates that half of clinicians who bill under the Medicare Physician Fee Schedule (PFS) will be excluded from participation  due  to  provider type or low Medicare volume for the 2017 performance year. Remaining providers, who are not new to Medicare in 2017, will be considered Eligible Clinicians (ECs) and will fall into either an APM or the MIPS. CMS estimates only around 100,000 clinicians will participate through an APM in 2017.1 Because most anesthesiologists will participate in the QPP through MIPS, the remainder of this article will be devoted to the MIPS as detailed in the Final Rule.

Under the MIPS, eligible clinicians’ quality, value and subsequent  Medicare  reimbursement will be determined by performance in four categories: 1) Quality, 2) Advancing Care Information (ACI), 3) Clinical Practice Improvement Activities (CPIA) and 4) Resource Use (Cost). Performance in each category will be scored and weighted in proportion to its percent contribution to a Composite Performance Score (CPS) (Figure  1).²  In  response  to  public  feedback, the Final Rule stipulates a reweighting of the Cost category to 0 percent for the 2017 reporting year.

Each EC or group will receive a CPS of 0-100  points based upon performance in these  categories.  The  CPS will be compared against  a  performance  threshold  and will be used as the basis for payment adjustments in 2019.³ The MIPS is a budget-neutral program, with penalty monies from the poor  performers  going  to  the  high  performers. In the Proposed Rule, the 2019 payment adjustment values varied from a negative adjustment of up to -4 percent of allowable charges to a potential positive adjustment of +4 percent. The Final Rule describes a new Pick Your Pace program, relaxing reporting requirements for 2017, and potentially allowing more providers to avoid a negative payment adjustment.⁴

Pick Your Pace

For the 2017 transitional year, only those ECs who do not submit any data to CMS will be subject to the -4 percent payment adjustment. Submission of data, as outlined below, will allow an EC to obtain a neutral or positive payment adjustment.

Test – If an EC submits one quality measure, one CPIA or ACI measure, he or she will avoid the negative adjustment but will not be eligible for a positive adjustment. ASA has requested further clarity and guidance from CMS on this particular regulation.

Partial – If an EC submits at least 90 days of data on more than one quality measure, more than one CPIA or more than the required ACI measures, he or she will avoid the negative adjustment and may be eligible for a small positive adjustment.

Full – If an EC submits a full year of data on more than one quality measure, more than one CPIA and the required ACI measures, he or she will avoid the negative payment adjustment and may be eligible for a modest positive payment adjustment.

Changes to Category Requirements

In addition to the changes described above, the Final Rule includes changes to the performance categories within the MIPS.

Quality: Originally weighted as 50 percent of the CPS in the Proposed Rule, the Quality category will count for 60 percent under the 2017 Final Rule. Each clinician or group must report at least six quality measures, including at least one outcome measure. If fewer than six measures apply to the individual MIPS-eligible clinician or group, then the MIPS-eligible clinician or group would be required  to  report  on each applicable measure. The MIPS-eligible clinician must report on at least 50 percent of the eligible clinician or group’s patients that meet each measure’s denominator criteria for the performance period. This is a significant decrease from the 90 percent threshold described in the Proposed Rule. Individual eligible clinicians or groups submitting data on quality measures using Qualified Clinical Data Registries (QCDRs), qualified registries (QRs) or via EHR must report on at least 50 percent of the MIPS-eligible clinician or group’s patients that meet the measure’s denominator criteria, regardless of payer. ECs submitting quality data  using Medicare  Part  B claims  would report  on at least 50 percent of the Medicare Part B  patients  seen during the performance period to which the measure applies.⁵

Advancing Care Information (ACI): The ACI performance category will count for 25 percent of the final score for those ECs to which it applies. To achieve maximum credit for the ACI performance category, the EC or group must fulfill all required measures and achieve a performance score of at least 50 percent for a minimum of 90 days. Some clinicians may not have sufficient ACI measures applicable to them. In such scenarios, the ACI category would be reweighted to 0 percent and the 25 percent redistributed to quality. These clinicians include those determined to be hospital-based  or  those who qualify for a hardship exemption. Under the Final Rule, hospital-based is defined as a MIPS EC who furnishes 75 percent or more of his or her covered professional services in sites identified by certain place of service (POS) codes (21, 22, and 23) that do not include ambulatory surgery centers or off-campus hospital outpatient departments. Reasons for obtaining a hardship exemption through an annual CMS application process include insufficient internet connectivity, extreme and uncontrollable circumstances, lack of control over certified EHR technology or lack of face-to-face patient interaction.⁶

Clinical Practice Improvement Activities (CPIA): Clinical practice improvement activities  are  those  that  support broad aims within health care delivery, including care coordination, beneficiary engagement, population manage- ment and health  equity.⁷  ECs  must  choose  activities  from the approved CPIA Inventory, which includes 93 activities. Several of these activities involve participation in a QCDR.⁸ For participation in the CPIA category, each EC or group must attest to the performance of up to four activities for a minimum of 90 days.  Small providers (<15  providers), rural providers and those in Heath Professional Shortage Areas (HPSA) as well as  non-patient-facing  clinicians  can  receive full credit by completing two activities.⁹

The Quality Payment Program institutes significant change to the way participating clinicians are paid. Educating yourself and your partners is the first step on the path to success under this new program. ASA has made available many resources regarding both MACRA and the QPP.

Please visit www.asahq.org for more information – and good luck!

References:

1. Centers for Medicare & Medicaid Services 42 CFR Parts 414 and 495 [CMS-5517-FC] RIN 0938-AS69 October 14, 2016; page 29.
2. Centers for Medicare & Medicaid Services 42 CFR Parts 414 and 495 [CMS-5517-FC] RIN 0938-AS69 October 14, 2016; page 1212.
3. Executive Summary Centers for Medicare & Medicaid Services 42  CFR  Parts 414 and 495 [CMS-5517-FC] RIN 0938-AS69 October 14, 2016; page 15.
4. Centers for Medicare & Medicaid Services 42 CFR Parts 414 and 495 [CMS-5517-FC] RIN 0938-AS69 October 14, 2016; page 1260-1267.
5. Centers for Medicare & Medicaid Services 42 CFR Parts 414 and 495 [CMS-5517-FC] RIN 0938-AS69 October 14, 2016; page 469-471.
6. Centers for Medicare & Medicaid Services 42 CFR Parts 414 and 495 [CMS-5517-FC] RIN 0938-AS69 October 14, 2016; page 907-920.
7. Centers for Medicare & Medicaid Services 42 CFR Parts 414 and 495 [CMS-5517-FC] RIN 0938-AS69 October 14, 2016; page 32.
8. Centers for Medicare & Medicaid Services 42 CFR Parts 414 and 495 [CMS-5517-FC] RIN 0938-AS69 October 14, 2016; page 705.
9. Centers for Medicare & Medicaid Services 42 CFR Parts 414 and 495 [CMS-5517-FC] RIN 0938-AS69 October 14, 2016; page 703-715.

ASA Monitor “Preparing for MACRA: Final Rule Fast Facts” (Richardson E. [2017; 81(1): 34-36]) is reprinted with permission of the American Society of Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173.