Looking forward – November 2016

David B. Hoyt

David B. Hoyt, MD, FACS

Efforts to execute the payment policies outlined in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) are in full swing. Specific details regarding how the Centers for Medicare & Medicaid Services (CMS) will implement the Quality Payment Program (QPP) should be clarified when the final regulation for the 2017 Medicare Physician Fee Schedule (MPFS) is released. (At press time, it was scheduled for release in late October or early November.)

Nonetheless, the American College of Surgeons (ACS) has had a fairly good sense of the general direction that CMS was heading because of the provisions outlined in the proposed rule released in April, and our ongoing negotiations with the agency. The ACS Division of Advocacy and Health Policy (DAHP) has been working tirelessly with CMS to ensure that the QPP is implemented in a way that is fair and equitable to all physicians and that keeps the patient at the center of reimbursement decisions.

The ACS staff and leadership also have been developing strategies to ensure that ACS Quality Programs and registries are compliant with the reporting requirements for the QPP and useful to surgeons who want to participate without being subject to complex and onerous administrative burdens. In addition, we have developed a series of educational videos to help surgeons prepare for the QPP.

How the QPP will work

The October issue of the Bulletin included an article, “The new Medicare physician reimbursement system: Building the Quality Payment Program,” by Christian Shalgian, Director, DAHP, and Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, DAHP, which outlined the basics of the QPP. To review, physicians have two pathways to participation in the QPP: through the Merit-based Incentive Payment System (MIPS) or through Advanced Alternative Payment Models (APMs). At present, limited options are available for surgeons to participate in APMs; thus, most surgeons will be in the MIPS program, at least initially.

Payment adjustments under MIPS will be based on a composite performance score (CPS) derived from four components: Quality, Resource Use, Advancing Care Information (ACI), and Clinical Practice Improvement Activities (CPIA). The first three correspond to certain elements of the present MPFS and can be described as follows:

  • The Quality component corresponds to the Physician Quality Reporting System (PQRS) and will determine 50 percent of a physician’s CPS and payment adjustment. One difference that many surgeons will likely welcome is that physicians will be required to report only six quality measures rather than the nine they are expected to report using PQRS.
  • The ACI replaces the Electronic Health Record (EHR) Incentive Program. This component will account for 25 percent of a physician’s payment adjustment and will be derived from a base score (50 percent) and a performance score (up to another 50 percent, depending on whether the base score is achieved).
  • The Resource Use component replaces the Value-Based Modifier (VBM) and will account for 10 percent of a physician’s CPS. Surgeons will not need to comply with any reporting mandates for the Resource Use component. Medicare will complete the calculations based on claims data.

The fourth component of MIPS—the CPIA component—is new and has no analogous previous program requirement. According to the proposed rule, in the first year of MIPS (2017), CPIA reporting will be by attestation. Physicians will choose from a list of 94 activities, each with an assigned value. To receive full credit for the CPIA component, providers will need 60 points, although it will be possible to receive partial credit.

Be prepared: The College can help

The College urges all Fellows to prepare for the transition to MIPS and is offering a range of resources and services to help them to succeed in 2017 and beyond.

First, surgeons who have been participating in the PQRS program already have an edge in terms of meeting the Quality component requirements because, although measure options and reporting thresholds may change in 2017, PQRS will continue to serve as the foundation of this component. It is important to understand which measures are most applicable to an individual’s practice and to learn how to incorporate data collection into the workflow. This information can be obtained through a review of PQRS feedback reports. Understanding one’s PQRS measure reporting and past performance rates will be useful in determining the best strategy for MIPS reporting.

Surgeons who are not yet participating in the PQRS still have time to start, and the ACS has two registries that can be used for PQRS reporting in 2016—the Surgeon Specific Registry (SSR) and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Both databases are PQRS-Qualified Clinical Data Registries.

To fulfill the ACI component, the ACS recommends that surgeons confirm that their EHR is certified by the Office of the National Coordinator for Health Information Technology (ONC). (To determine whether an EHR system is certified, go to the Certified Health IT Product List.) The College also urges Fellows to review the list of measures and objectives for the current EHR Incentive Program. Although reporting thresholds will likely change, most of the current objectives and measures of EHR meaningful use will form the basis of the ACI score. Surgeons who do not have an ONC-certified EHR or who have not participated in the EHR Incentive Program should review the ACS Basic EHR Starter Guide.

To take full advantage of the Resource Use component, the ACS suggests that surgeons review their Quality and Resource Use Reports (QRURs) from CMS. This information is useful in benchmarking one’s performance on quality and cost measures against those of other Medicare providers and in determining how practice patterns might affect one’s score. At press time, our understanding was that CMS intends to use much of the same cost data it currently collects under the VBM to calculate the MIPS Resource Use component score.

To comply with CPIA, the College recommends that surgeons review the list of suggested CPIA activities at the end of the proposed rule and identify six activities aimed at advancing clinical practice that they are likely to perform. An example would be engaging in a patient safety and practice assessment activity, such as using the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Risk Calculator.

Moving forward

Surgeons will be relieved to know that, according to CMS Acting Administrator Andy Slavitt, physicians will be allowed to pick their pace for transitioning to MIPS. The ACS and other stakeholders have advocated for incremental implementation and are pleased that CMS has agreed to take steps to ensure a smooth transition.

Physicians will have four reporting options in 2017: test the QPP, participate for part of the calendar year, participate for the full year, or participate in an Advanced APM. Physicians who choose to test the QPP may submit some data to the QPP after January 1 and will avoid a negative payment adjustment under the QPP. Surgeons who participate for a portion of 2017 may submit QPP information for a reduced number of days and qualify for a nominal positive payment adjustment. Health care professionals who opt to participate for the entirety of 2017 would need to submit all relevant information regarding quality measures, how their practice uses technology, and the activities their practices are conducting to improve patient care. These participants may qualify for a modest positive payment adjustment.

Finally, physicians may participate in an Advanced APM. This option, however, is the least viable for surgeons at present because only two bundles are applicable to surgery—cardiac care and joint replacement. Nonetheless, the College anticipates that physicians eventually will face greater pressures to move into Advanced APMs. Therefore, we are engaged in ongoing efforts with Brandeis University, Waltham, MA, and Brigham and Women’s Hospital, Boston, to develop surgery-specific APMs.

For more information about the QPP and what you can do to prepare for success under this new payment system, check out the series of four educational videos the ACS has created on the QPP—Navigating the Quality Payment Program; What Is MIPS?; What Can You Do Now to Prepare for MIPS?; and CMS Allows You to Pick Your Pace. These videos were unveiled at Clinical Congress 2016 and are now available on the ACS website, along with other resources.

I truly believe that surgeons will do well under MIPS as it moves payment incentives away from volume and toward a focus on value. The ACS has led the charge toward patient-centered, evidence-based care for more than 100 years. Our members are as ready as anyone to meet this latest challenge.

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