On September 8, Andy Slavitt, the Acting Administrator of the Centers for Medicare & Medicaid Services (CMS), published a post on the official blog for CMS shedding a little more light on the Agency’s plans for the timing and reporting options available to participating providers. In the post, Slavitt confirmed that the “ Quality Payment Program ” provisions of the Medicare Access and CHIP Reauthorization Act (MACRA) will begin as proposed on January 1, 2017. Slavitt also announced that providers will be afforded more options than originally proposed to successfully participate the first year and avoid a negative payment adjustment in 2019.
- Option 1: Report Some Data; Providers are given an opportunity to avoid a negative payment adjustment and test the system by submitting “some” data to CMS as they prepare for full participation in the following performance years.
- Option 2: Participate for a Portion of the Performance Year; CMS is offering providers the ability to successfully report for a performance period that starts after January 1, 2017 and still qualify for a small positive payment adjustment. Exactly what that minimum time period is and positive adjustment could be is not defined yet.
- 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.
- Option 3: Participate for the Entire Performance Year; 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.
At first look, this is certainly good news for many anesthesia providers and practices around the country as it provides them a greater chance of avoiding a negative payment in 2019. However, to know for sure we will have to wait until the exact details surrounding these options are defined in the Final Rule which Slavitt noted would be published by November 1, 2016.
What we do know about MACRA
The Medicare Access and CHIP Reauthorization ACT (MACRA) passed by Congress in 2015, repealed the Sustainable Growth Rate formula and moved CMS further down their desired path of paying for quality. This program was designed to streamline several existing programs that CMS had been utilizing to adjust provider’s Medicare payments in years prior. In April of this year, CMS revealed the first details of the “Quality Payment Program” in the proposed regulations. Please keep in mind that everything we currently know is proposed and subject to change when the regulations are finalized in late October.
MACRA looks to pay 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). CMS expects that majority of providers to participate via MIPS the first year and abeo believes that includes almost all anesthesia providers and practices. Providers participating via MIPS in 2017 will have the ability to earn up to a 4% upward payment adjustment on 2019 Medicare reimbursements and failing to successfully report could result in a penalty of -4%. While this 4% penalty is less than the -6% maximum penalty that providers face for failing to successfully report under current CMS programs today, the penalties escalate year over year to -9% in 2021 (see Figure 1).
Since MIPS is the most likely path for most and provides providers the ability to satisfy requirements, let’s take a closer look at the program. MIPS is broken down into 4 performance categories. Each performance category is individually scored, weighted, and then combined to give the provider or practice a Composite Performance Score between 0 – 100.
This performance category is weighted at 50% and looks to replace the existing Physician Quality Reporting System (PQRS) and requires providers to report on 6 Quality Measures, including 1 cross-cutting measure if applicable. Reporting methods as proposed continue to include Qualified Registry, QCDR and Claims. CMS does propose to make major changes from previous years; participants reporting via a Qualified Registry will now be required to report on all patients and not just Medicare. Additionally CMS is proposing increasing the minimum reporting rate from 50% to 90% for QCDR and Qualified Registry and from 50% to 80% for claims. This is a major increase and could pose logistical issues for many providers and practices. Several professional associations including the ASA have urged CMS to reconsider this.
This performance category is weighted at 10% and looks to replace the Cost Composite score that was included in the Value-Based Payment Modifier (VM) program. Similar to the VM, CMS gathers the data from Medicare claims and reimbursement and uses the attribution of beneficiaries to determine what measures would apply and how to score the provider or practice. Most anesthesia providers and practices have historically not been attributed beneficiaries and thus will likely have insufficient data to be scored in the performance category. CMS has stated that if a provider or practice has insufficient data and a score is unable to be calculated then the weights of the remaining categories will be increased; however, exactly how those categories would be re-weighted to is undefined.
Advancing Care Information
This performance category looks to replace the EHR Meaningful Use program and is weighted at 25% year one. There are a wide variety of measures that providers and practices are able to report on regarding how they use certified EHR technology. A provider’s or practice’s score will be calculated on their actual performance and based on reporting alone. Under the previous EHR Meaningful Use program most Anesthesia providers were exempt from required reporting. CMS is no longer providing exemptions from a performance category based on specialty listing. Instead, they are proposing a possible exception for “non-patient facing” providers as defined by the submission of 25 or more specific billing codes on Medicare claims. The detailed list of billing codes is not yet defined or published, but is likely to be similar to those codes used to identify the requirement of a cross-cutting measure. Additionally, “hospital based” providers or those providers who furnish 90% or more of their Medicare claims from facilities identified as inpatient hospitals, may also be exempt from reporting this category. This does pose a potential problem for outpatient facility or ASC based anesthesia providers who have limited to no control over a facility’s EHR decision. This is a concern that ASA and other associations have raised with CMS. Again, if a provider or practice has insufficient data and a score cannot to be calculated, then the weights of the remaining categories will be increased to a yet undefined percentage.
Clinical Practice Improvement Activities
A new category of reporting in 2017, the Clinical Practice Improvement Activities, requires providers and practices to report on a selection of about 90 proposed activities that center on expanded practice access, population management, patient safety and care coordination. The number of activities required to report depends on the activity’s weight, some are weighted high and others medium. The proposed regulations require a provider or practice to report on three high-weighted activities or six medium-weighted activities. CMS is proposing to offer providers designated as “non-patient facing” the ability to report on only two activities regardless of weighting and receive full credit for the performance category.
CMS has proposed some exemptions beyond those listed in each performance category that would exempt some anesthesia providers from the entire program. The proposed exemptions include:
- A provider that is in year one of their enrollment with Medicare;
- A provider that has less than or equal to $10,000 in Medicare charges and less than or equal to 100 Medicare patients; and
- Providers participating in an Advance Payment Model.
What we still don’t know
There are still several key details that we are awaiting final decision and clarity on in the late October rule. We have highlighted some of the uncertainties below.
- Which performance categories will apply to CRNAs, AAs and Nurse Practition?
- How will CMS define “non-patient facing” providers?
- How will the performance categories be re-weighted when one or more categories cannot be reported on by a provider?
- What are the available reporting methods for providers to report measures in the Advancing Care Information and Clinical Practice Improvement Activities categories?
Stay tuned for more…
Keep in mind that everything that was covered is only proposed at this time and subject to change in the Final Rule. We encourage all providers to stay focused on reporting quality in 2016. We assure you that as the details are finalized we will be back in touch with all the specifics on how you and your practice can navigate the Quality Payment Program in 2017. Please reach out to your client manager with any specific questions.
The information provided is intended to be a general summary and reflects information that is current at the time it was issued. This information is not intended to take place of either written law or regulations.