On October 14, the Centers for Medicare & Medicaid Services (CMS), published the “Quality Payment Program” Final Rule laying out the details for the all-inclusive pay for performance program. The Quality Payment Program applies to anesthesia physicians, CRNAs, NPs, PAs, and AAs and moves towards paying providers based on the quality of care and value they provide through two major pathways, the Merit-Based Incentive Payment System (MIPS) or advanced Alternative Payment Models (APMs).
In this overview we will focus on MIPS, as it is the most likely pathway for applicable anesthesia providers to satisfy reporting requirements. MIPS is broken down into 4 performance categories. Each performance category is individually scored, weighted, and then combined to give the provider or group a Composite Performance Score between 0 – 100. In the Final Rule, CMS modified the originally proposed weights for the 2017 “transitional year” reducing the Resource Use or Cost category to 0% and it will not be included in the calculation of the Composite Performance Score.
Providers participating via MIPS in 2017 will have the ability to avoid a penalty and earn up to a 4% upward payment adjustment on 2019 Medicare reimbursements by successfully using one of the various participation levels listed below.
- Option 1: Report Some Data; Providers are given an opportunity to avoid a negative payment adjustment and test the system by submitting one measure in the Quality category, or one activity in the Performance Improvement category; or report the required measures of the Advancing Care Information Performance category.
- Option 2: Participate for a Portion of the Performance Year; CMS is offering providers or groups the ability to successfully report for a minimum 90 consecutive days starting January 1, 2017 in each applicable performance category and avoid the penalty and possibly qualify for a small positive payment adjustment.
- Option 3: Participate for the Entire Performance Year; Providers and practices that are ready to start reporting on January 1, 2017 and continue to do so for the full performance year, could qualify for a positive payment adjustment up to the maximum of 4+%
- Option 4: Participate in an Advance Alternative Payment Model (APM); Providers and practices that receive enough of their Medicare reimbursements through an approved Advanced Payment Model could qualify for a 5% incentive payment in 2019.
Do nothing in 2017, and it will cost you a 4% penalty on Medicare Reimbursements in 2019. But before determining your options you should review the various provider classifications and exemptions that have been specified in the Final Rule.
Classifications and Exclusions
In the Final Rule, CMS outlined several provider classifications and exclusions that will determine if a provider or group can participate in MIPS entirely or if they have reduced reporting or exclusion exceptions to a particular Performance category.
- Newly Medicare Enrolled: Providers in their first year of practice are exempt from MIPS reporting.
- Low Volume Threshold: An individual provider or group that has less than or equal to $30,000 in Medicare Part B allowed charges; or less than or equal to 100 Medicare patients during September 1, 2015 – August 31, 2016 will be excluded from the program for 2017. CMS will look to provide clinicians and groups this information before or shortly after the start of the 2017 performance year via the Quality Payment Program Website.
- Non-patient Facing Providers: CMS will consider individual providers that have billed Medicare for 100 or fewer face-to-face encounters as non-patient facing. Groups can be also be considered as non-patient facing if 75% of the NPI’s in their group bill for 100 or fewer face-to-face encounters. CMS will publish an official list of these encounter codes on the Quality Payment Program Website at a later date, but abeo expects these codes to mirror those that defined if a cross-cutting measure was required in previous years. CMS will analyze claims during the September 1, 2015 – August 31, 2016 time period to make this designation.
- Hospital-based: An individual provider who furnishes 75% or more of his or her Medicare covered professional services during September 1, 2015 – August 31, 2016 in sites of service using Place of Service codes categorized as inpatient hospitals, on campus outpatient hospital, or emergency room settings will be deemed Hospital-based.
Weighted at 60% for 2017 and possibly as high as 85% for those providers designated as Non-patient Facing Providers or Hospital-based, this performance category requires providers to report on 6 Quality Measures, including 1 outcome measure if available or 1 high priority measure. There is no cross-cutting measure requirement for 2017. Reporting methods available to anesthesia providers continue to include Qualified Registry, QCDR, EHR and Claims. Participants reporting via a Qualified Registry, QCDR, and EHR are now required to report on 50% of all patients regardless of Payer. The available measures have gone unchanged for 2017 and include:
- Measure 044– Coronary Artery Bypass Graft: Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
- Measure 047– Advance Care Planning*
- Measure 076– Prevention of CVC-Related Bloodstream Infections*
- Measure 130– Documentation of Current Medications in the Medical Record*
- Measure 317– Screening for High Blood Pressure and Follow-up*
- Measure 404– Anesthesiology Smoking Abstinence
- Measure 424– Perioperative Temperature Management
- Measure 426– Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit
- Measure 427– Post-Anesthetic Transfer of Care: Use of a Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit
- Measure 430– Prevention of Post-Operative Nausea and Vomiting
*Denotes a Claims eligible measure.
This performance category is weighted at 0% for 2017 and will not count towards a provider’s or group’s Composite Performance Score. However, CMS will calculate the scores for the measures in this category for informational purposes. There are no specific reporting requirements of providers or groups for this performance category as CMS calculates this off of claims data for the performance year. Historically, most anesthesia providers have failed to qualify for these cost measures due to the lack of primary care or evaluation and management codes billed by anesthesia providers. Until CMS adds more applicable episode based measures it is possible this trend will continue.
ADVANCING CARE INFORMATION
This performance category replaces the EHR Meaningful Use program and is weighted at 25% year one. To fulfill the minimum reporting requirements and achieve the base score providers or groups will be required to report on 5 designated measures for a minimum of 90 consecutive days. We will provide more details on the measures and methods for reporting in future communication. Additionally. CRNA’s NPs and AAs are all exempt from the performance category in 2017.
NOTE: Anesthesia providers that are designated as Non-patient Facing or Hospital-based are exempt for reporting in 2017 and this category will be re-weighted to 0% and the Quality category will be re-weighted to 85% for the transitional year.
CLINICAL PRACTICE IMPROVEMENT ACTIVITIES
A new category of reporting in 2017 and weighted at 15%, requires providers and groups to report on a selection of about 90 proposed activities that center on expanded practice access, population management, patient safety and care coordination. Providers and groups are required to report on two high-weighted activities or four medium-weighted activities. We will provide more details on the measures and methods for reporting in future distributions.
NOTE: Anesthesia providers that are designated as Non-patient Facing or Hospital-based are required to report on one high-weighted or two medium-weighted activities.
REVISED PERFORMANCE CATEGORY WEIGHTING FOR NON-PATIENT FACING ANESTHESIA PROVIDERS
abeo believes that many anesthesia providers or groups will be classified as Non-patient Facing and/or Hospital-based. This means that many providers and groups will see a performance category weighting structure more aligned the below.
More Details to Come…
With over 2,000 pages of requirements, we are still reviewing the various details for each performance category, measure, and scoring. Once we have had time to properly digest and validate the information in the Final Rule we will provide more detailed updates on the requirements including for those providers participating in an Advanced APM. Until then, be assured that abeo will continue to work to provide our clients with the information and specifics needed to successfully navigate the Quality Payment Program in 2017. Please reach out to your abeo client manager with any specific questions.