The Centers for Medicare & Medicaid Services (CMS) updated its policies for the 2020 Quality Payment Program (QPP) as part of the calendar year (CY) 2020 Medicare Physician Fee Schedule (MPFS) final rule released November 1, 2019. This article highlights the finalized policies of the QPP and select American College of Surgeons (ACS) positions, and offers important information and guidelines to help surgeons successfully participate in the QPP’s Merit-based Incentive Payment System (MIPS).
The QPP was implemented in 2017 as part of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015, which replaced the sustainable growth rate (SGR). The QPP offers two pathways for participation—MIPS and qualifying participation in an advanced Alternative Payment Model (APMs). MIPS consolidated three legacy programs—the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VBM), and the Electronic Health Record (EHR) Incentive Program—and recast them as the Quality, Cost, Improvement Activities (IA) and Promoting Operability (PI) (formerly known as Advancing Care Information) performance categories.
Overview of important QPP and MIPS policies for the 2020 performance year
The MPFS final rule comprises the following key policy changes:
- CMS finalized the implementation of the MIPS Value Pathways (MVPs)—a new framework intended to streamline the program starting with the 2021 performance year.
- The MIPS performance threshold required to avoid a penalty increased from 30 points in 2019 to 45 points in 2020.
- As required by MACRA, the 2020 performance may result in a Medicare payment adjustment of up to +/– 9 percent in 2022.
- The performance category weights are unchanged from 2019 to 2020—Quality: 45 percent, Cost: 15 percent, IA: 15 percent, PI: 25 percent.
- For 2020, CMS increased the data completeness threshold for the Quality category by 10 percentage points; clinicians will now need to report each measure for at least 70 percent of applicable patients.
- Starting in 2020, groups can attest to an IA only if at least 50 percent of the clinicians in the group or virtual group complete the same activity during any continuous 90-day period. Previously, at least one clinician in the group needed to complete the activity for the group to receive credit.
- The Cost category includes 10 new episode-based measures for a total of 18 episode-based Cost measures.
- CMS reduced the threshold for a group to meet the definition of hospital-based and qualify for reweighting of the PI component. Instead of 100 percent of clinicians, more than 75 percent of the clinicians in a group must meet the definition of hospital-based for the group to have this category reweighted for the 2020 performance year/2022 payment year.
MVPs: New MIPS participation option for 2021
CMS finalized the implementation of MVPs, which is designed to align measures and activities across Quality, Cost, PI, and IA to simplify MIPS; create a more meaningful participation experience with a set of measures tailored to an episode of care or condition; include population health measures; reduce clinician burden; and better align with APMs to help ease the transition between the two tracks.
In this year’s proposed rule, CMS sought public feedback on MVPs in the form of a Request for Information (RFI), and although the agency finalized the start of the program in 2021, CMS will propose additional program details and plans to implement MVPs in next year’s 2021 rulemaking cycle. See Figure 1 for an example of what a surgical MVP might look like.
Figure 1. MIPS value pathways: Surgical example
The ACS supported the new MVP framework and emphasized that CMS’ willingness to allow for innovation and a truly patient-centric program will be critical to the success of MVPs as it moves away from the siloed structure of MIPS and past legacy programs. The College provided guiding principles for the development of MVPs and supported an MVP framework that includes the following: participation in a verification or accreditation program, such as Commission on Cancer Accreditation; conformance quality, which includes clinical standards and monitoring high-risk events related to preventable harms; and performance quality as measured through condition- or procedure-specific patient reported outcomes (PROs). This framework includes measures that are actionable to clinicians and meaningful to patients, which could increase value for stakeholders. The ACS believes that verification or accreditation programs should be a key component to MVPs because they are rooted in the assurance that the systems in which clinicians practice pursue excellence and avoid errors by verifying that the resources, staff, and infrastructure are in place to provide the highest quality patient care. The College stressed the need to test MVPs before national implementation. The ACS will track the development of the MVP program and will be working with CMS to develop surgical MVPs.
In addition, the ACS has partnered with the Harvard Business School (HBS) Institute for Strategy and Competitiveness to create ACS THRIVE (Transforming Health care Resources to Increase Value and Efficiency). This initiative will help inform the development of Surgical MVPs. The goal of THRIVE is to define value based on health care outcomes that matter to patients and the costs of delivering those outcomes. THRIVE will help hospitals and surgical practices improve patient outcomes while lowering the cost of delivering care as reimbursement shifts toward APMs and away from fee-for-service care—an approach that increases transparency and accountability. For more information on THRIVE, visit the ACS website.
For performance year 2020, the Quality category is the most heavily weighted component of the MIPS final score and measures health care processes, outcomes, and patient experience.* The College continues to oppose the constructs of the Quality category because it neither measures health outcomes that matter to patients nor provides actionable quality improvement metrics to surgeons.
CMS finalized notable changes to the MIPS Quality category in the 2020 final rule, including updates to the general surgery specialty measure set and a 10 percentage point increase in the data completeness threshold. CMS did not finalize a proposed increase in the Quality category weight; therefore, Quality is weighted at 45 percent of the MIPS final score for the 2020 performance year, which is unchanged from 2019.
Data submission requirements
CMS finalized a 10 percentage point increase in the data completeness threshold, which means surgeons or groups must report Quality data for 70 percent of all patients to whom the measure is applicable, regardless of payor. To achieve the maximum points available in the Quality category, surgeons should report at least six Quality measures, including one outcome measure.
The ACS opposed the increase in the data completeness threshold because CMS has not demonstrated statistical reliability supporting this policy, which could result in misclassification of care. Based on its last two decades of experience in quality measurement development and analytics, the College has demonstrated that reliability must be determined on a measure-by-measure basis and account for event rates for a specific surgical procedure. The ACS warned that it is very difficult to measure surgical outcomes at the individual level and is more reliably determined at the hospital or system level.
2020 MIPS Specialty Measure Sets
CMS offers many specialty measure sets that provide recommendations on MIPS quality measures most relevant to certain specialties. In the 2020 final rule, CMS finalizes updates to many of the specialty measure sets, including the General Surgery measure set. Surgeons can report these measures through the ACS Surgeon Specific Registry or through other registries listed in the QPP resource library on the CMS website.
Table 1 shows the finalized general surgery specialty measure set. For the most part, surgeons will receive three to 10 points for Quality measures that have a benchmark when they report at least 20 cases and meet 70 percent data completeness. However, to receive the full weight of the MIPS points available for the Quality category, a surgeon must earn 60 points (10 points for each measure). If a surgeon chooses to report a quality measure that does not have a benchmark or does not meet the 20-case requirement, the measure can receive only three points. Measures that don’t meet data completeness will earn zero points.
Table 1. General surgery specialty measure set for registry reporting
Another factor important to understand to optimize your MIPS score is that some of the measures in the general surgery set are considered topped-out, which CMS defines as measures with a median performance score of 95 percent or higher where performance is “so high and unvarying that meaningful distinctions and improvement in performance can no longer be made.” The maximum amount of points clinicians can earn on topped out measures is seven out of 10 points. When measures are extremely topped out, surgeons may need to achieve a performance score of 100 percent performance to receive the maximum amount of points available for the measure. For example, when reporting on Quality Measure #021, Perioperative Care: Selection of Prophylactic Antibiotic—First- OR Second-Generation Cephalosporin, if a surgeon performs less than 100 percent on this measure, the surgeon would only receive three points, even with a performance score of 99.99 percent.
In short, it is very difficult to earn 60 points in the Quality category. Therefore, when planning for 2020 Quality reporting, surgeons may want to report measures with 10 maximum points available and be prepared to report more than six Quality measures to receive the full amount of MIPS Quality points. While CMS will only provide performance scores for a physician’s top six performing measures, CMS will allot two bonus points for reporting additional outcome measures and one bonus point for reporting additional high priority measures beyond what is required for full Quality reporting. Even if these measures are not included in the surgeon’s top six measures, it is still possible to receive the bonus points as long as the measure meets case minimum and data completeness requirements. In addition to these possible bonus points, surgeons also can receive up to 10 bonus points for demonstrating an improvement in overall performance in the quality category from the previous year.
The MIPS Cost performance category measures resources clinicians use in patient care, providing MIPS participants insight on how their care decisions result in spending and how their outcomes differ from similar clinicians’ outcomes.† Cost measures are calculated using Medicare Part B claims data; therefore, clinicians have no reporting requirements. The ACS has continued to question the utility of the cost measures in MIPS. For several years, the ACS has commented that the Cost measures provide inaccurate, unactionable information, making it difficult for surgeons and other participating clinicians to reduce costs and improve the value of care.
In response to ongoing concerns about the measures used in this category and the feedback provided on these measures, CMS opted to maintain the Cost category weight at 15 percent of the MIPS final score for 2020, rather than increase it to 20 percent as originally proposed. CMS also maintained the Medicare Spending Per Beneficiary (MSPB) and Total Per Capita Cost (TPCC) measures in this category from previous years but made some important updates to these measures. Of note, CMS finalized a change in the attribution methodology of the MSPB measure to distinguish between medical episodes (where the index admission has a medical Medicare Severity-Diagnosis Related Group [MS-DRG]) and surgical episodes (where the index admission has a surgical MS-DRG). The updated methodology attributes specialists who are more likely to be involved in managing the patient’s care for which they are being attributed. CMS also changed the name from MSPB to Medicare Spending Per Beneficiary Clinician (MSBC) to distinguish this version of the measure from its use under other CMS programs. CMS also revised the TPCC measure so that it does not attribute costs that occurred before a clinician sees a patient, and generally excludes specialists who are not providing primary care. Although the revisions to these measures may improve appropriate attribution overall, the ACS continues to oppose the use of broad cost metrics such as these because they do not break down all the services billed related to the patient’s experience and are generally not actionable for surgeons.
Episode-based cost measures
CMS also finalized the addition of 10 new episode-based measures for a total of 18 applicable episode-based measures for 2020. The following 12 episode-based measures are relevant to surgeons in 2020:
- Knee arthroplasty
- Revascularization for lower extremity chronic critical limb ischemia
- Routine cataract removal with intraocular lens implantation
- Screening/surveillance colonoscopy
- Elective primary hip arthroplasty
- Femoral or inguinal hernia repair
- Hemodialysis access creation
- Lower gastrointestinal hemorrhage (applies to groups only)
- Lumbar spine fusion for degenerative disease, 1–3 levels
- Lumpectomy partial mastectomy, simple mastectomy
- Non-emergent coronary artery bypass graft
- Renal or ureteral stone surgical treatment
CMS made no changes to the attribution methodologies to these measures or case minimums. If clinicians are not attributed to a sufficient number of patients under any of the episode-based measures, they could still be scored on the MSPB and/or TPCC measures if they are attributed to a sufficient number of beneficiaries. Clinicians also may be scored on both an episode-based cost measure as well as the MSPB and/or TPCC measure.
CMS will continue to use the following methodology for episode-based measures:
- Acute inpatient medical condition episode-based measures: An episode is attributed to each MIPS eligible clinician who bills inpatient E/M claim lines during a trigger inpatient hospitalization under a tax identification number (TIN) that renders at least 30 percent of the inpatient E/M claim lines in that hospitalization.
- Procedural episode-based measures attribution: Episode is attributed to each MIPS eligible clinician who renders a trigger service as identified by Healthcare Common Procedure Coding System/CPT procedure codes.
ACS initiatives to improve value
The ACS’ comments highlight that to achieve value-based care, quality measurement and cost measurement should occur or the same episode of care. Yet, many of the MIPS episode-based cost measures do not have complementary, actionable, and meaningful quality measures. Instead, the ACS supports the CMS Episode Grouper for Medicare and tools capable of producing a patient-specific expected price with a breakdown for all services assigned to the episode within the following phases of care: prehospital, inhospital, and postdischarge. To move from fee-for-service to value-based care, delivery systems need to understand both the cost and price aspects of care. As discussed previously, ACS THRIVE is designed to help surgical teams understand the cost of delivering outcomes for an episode and the price to patients so they can make more informed decisions. While this approach does not appear feasible under the current MIPS structure, the ACS is hopeful that the newly proposed MVP option would allow for measurement of both Cost and Quality across a single episode of care.
Although surgeons are not required to report data to CMS to receive points for Cost, the College recommends that surgeons become familiar with their 2018 MIPS performance feedback reports, which include confidential performance feedback on these measures, to get a sense of how they may score in this category in 2020 and beyond. CMS plans to release the 2019 MIPS performance feedback reports by July 2020, and surgeons can access them by logging on to the CMS website with their Enterprise Identity Data Management credentials. CMS also offers more information about the episode-based cost measures on the MACRA Feedback page, and in the QPP Resource Library. For additional assistance, e-mail qualityDC@facs.org.
The IA performance category will continue to be weighted at 15 percent of the MIPS final score. As in 2019, most surgeons must select and attest to having completed up to four activities in at least 90 consecutive days within a 12-month period to achieve full credit in this category. For 2020, CMS has revised the list of activities in the IA inventory by consolidating and removing closely related activities, and adding new activities. For example, CMS finalized the removal of eight IAs related to participation in a Qualified Clinical Data Registry (QCDR) and consolidated the activities into two medium-weighted encompassing activities: Participation in a QCDR that promotes use of patient engagement tools and use of QCDR data for ongoing practice assessment and improvement. The College supported the consolidation of these activities to reduce complexity in MIPS but advocated for the new activities to be high-weighted so that surgeons who have reported multiple QCDR-related IAs and will now have only two to choose from could still receive full IA credit. The ACS strongly encouraged CMS to recognize participation in nationally validated and risk-adjusted clinical data registries, such as the ACS National Surgical Quality Improvement Program (NSQIP®), as an activity that could achieve the full IA score, but CMS did not expand the definition beyond QCDRs nor did it increase the weight of QCDR-related activities.
CMS also removed many other activities because they duplicate existing measures and are less robust. For the 2020 Performance Year, CMS finalized removal of the annual registration in the Prescription Drug Monitoring Program (PDMP) activity but retained the Consultation of the PDMP. Based on reporting trends from the ACS Surgeon Specific Registry (SSR™) in 2018, many Fellows attested to the annual registration in the PDMP activity. Therefore, surgeons who reported the Annual Registration in the PDMP IA should report the Consolidation of the PDMP IA in 2020 instead.
The College commented that MIPS-eligible clinicians and physicians should be free to choose which IAs are most meaningful to their practice.
CMS also finalized a revision to the group reporting policies for the IA category. Starting in 2020, group practices (that is, TINs) can only attest to an improvement activity if at least 50 percent of the clinicians in the group or virtual group complete the same activity in any continuous 90-day period in the performance year. This requirement calls for a significant increase in reporting from past years’ policy, which required only one clinician in the group to attest to the completion of an activity for the group to receive credit.
The College opposed this new policy because it greatly reduces the number of meaningful IAs available to surgeons, especially individuals in multispecialty groups, and increases administrative burden on practices. The College commented that MIPS-eligible clinicians and physicians should be free to choose which IAs are most meaningful to their practice.
The PI category was finalized with few significant changes. The PI category is composed of four broad objectives, each containing a set of measures: public health and clinical data exchange, electronic prescribing health information exchange, and provider to patient exchange. Minor changes have been made to several of the measures within the objectives, but of particular note is the continuation of the Query of the PDMP measure, which is optional and worth five bonus points. CMS also finalized that, beginning with the 2019 performance year, this optional measure will only require a yes/no response instead of the submission of a numerator/denominator. If a surgeon is using a PDMP, attesting to this optional measure is a low-burden way to earn five additional points, particularly as the overall performance threshold increases to 45 points.
The other measure changes for the CY 2020 PI category are within the e-prescribing and health information exchange objectives. CMS finalized that the Verify Opioid Treatment Agreement measure has been eliminated. The ACS supported the removal of this measure, as it required manual documentation and created undue reporting burden. Within the Health Information Exchange objective, CMS clarified that any participant who is exempt from the Support Electronic Referral Loops measure(s) will have the points (20 points if excluded from one measure, 40 points if excluded from both) redistributed to the Provide Patients Electronic Access to their Health Information measure. The College agreed with the clarification of this redistribution, because surgeons often are exempt from both of the measures in the Health Information Exchange Objective, making it necessary to redistribute points to another objective. This change will be applied retroactively in the 2019 performance year.
Surgeons who meet CMS’ definition of hospital-based clinician or hospital-based group are eligible to have the PI category weight redistributed to the quality category (making the quality weight 70 percent, instead of 45 percent). It is important to note that the criteria for a hospital-based group changed for 2020, so even surgeons who did not meet the definition in the past may now be eligible for an automatic exemption from the PI category in 2020.
To qualify as a hospital-based group in 2020, more than 75 percent of the NPIs in the group must meet the definition of a hospital-based MIPS eligible clinician (that is, the clinician furnishes 75 percent or more of his/her services in a hospital setting). The College supported this change, as it will expand the group definition to additional physicians who work primarily within a hospital, which will reduce reporting burden. To check if your practice qualifies as part of a hospital-based group, use the NPI look-up on the QPP Participation Status website.
The proposed rule included multiple RFIs, but CMS has yet to address all of the responses. Additional information and feedback may be included in future policy.
MIPS registry reporting
If you are interested in reporting through the College, the SSR is the QR option for MIPS reporting. In CY 2020, the SSR will include the measure sets for general surgery and for plastic surgery.
Options for registry reporting through MIPS include Qualified Clinical Data Registries (QCDRs), Qualified Registries (QRs), and other health information technology vendors, such as EHR or data analytics vendors. CMS finalized several changes that affect these organizations in an effort to streamline and consolidate reporting mechanisms and options. Beginning in performance year 2021, physicians will be able to report all three performance categories (Quality, IA, and PI) through QCDRs and QRs. In the rule, CMS proposed that registries make these functionalities available to clinicians starting with the 2020 program year. The College encouraged CMS to delay it for at least a year to allow for development and implementation within registry systems. Although surgeons are not required to report all MIPS categories via a QCDR or QR, it will be an option for surgeons who prefer to report from a single source starting in 2021. Surgeons who currently use their EHR and/or Health Information Exchange to report PI can continue to use this method of submission in performance year 2021.
If you are interested in reporting through the College, the SSR is the QR option for MIPS reporting. In CY 2020, the SSR will include the measure sets for general surgery and for plastic surgery.
For the first time, in 2019 CMS will automatically use the Hospital Value-Based Purchasing (VBP) Program score of a facility-based clinician or group in lieu of a MIPS score if the VBP score is higher than the clinician’s combined Quality and Cost score under MIPS. CMS calculates the facility-based score automatically using the facility’s Total Performance Score determined through the Hospital VBP Program. Surgeons are not required to opt-in or take any specific action to be eligible, but should use the QPP Participation Look-Up Tool to determine whether they meet the definition of “facility-based” and to which facility they are attributed. Surgeons who are eligible for facility-based scoring can still report MIPS Quality measures, but CMS will automatically use the facility’s score if it is higher than their individual Quality and Cost MIPS scores. CMS will provide details about how surgeons were scored for MIPS in 2019 MIPS feedback reports, which are expected to be released in July 2020.
Individual clinicians are considered facility-based if they meet all the following criteria:
- Billed at least 75 percent of covered professional services in a hospital setting.
- Billed at least one service in an inpatient hospital or emergency room and can be attributed to a facility with a Hospital VBP score.
- If a clinician works at multiple facilities, CMS will attribute the clinician to the hospital where they provided services to the greatest number of Medicare beneficiaries during the determination window using the same TIN/NPI combination.
- A group practice would be considered facility-based if 75 percent or more of the MIPS eligible clinicians in a group are deemed facility-based. CMS will attribute the group to the hospital where the plurality of clinicians in the group were attributed as individuals.
In October 2019, CMS released the results of the FY 2020 Hospital VBP Program and indicated that 55 percent of hospitals will receive positive adjustments.‡ Facility performance scores associated with the FY 2020 Hospital VBP Program results will be posted on the Hospital Compare website as part of the January 2020 update. Some surgeons are tied to high-performing facilities and could rely on the facility score to achieve a high MIPS score, but that may not be the case for all, making it important to understand how your facility has historically scored and compared with other facilities in the Hospital VBP Program.
Note that hospital-based status is different than facility-based status. Hospital-based status has different eligibility criteria and is used to determine if a clinician or group is exempt from the PI category. As mentioned, facility-based status is used to determine whether the clinician or group is eligible for facility-based scoring. Although the statuses are different, it is possible to fall into both categories. Surgeons who are considered both hospital-based and facility-based will receive an automatic reweighting of PI to Quality and are also eligible to have their facility’s Hospital VBP Program score applied to Quality and Cost.
The final rule also included policies related to Alternative Payment Models (APMs), but CMS did not finalize many significant changes to the APM track for 2020. For surgeons who are part of APMs or may be in the future, it is important to remember that surgeons who provide a sufficient number of services (that is, payments or patients) through what CMS defines as an Advanced APM (A-APM) are exempt from MIPS and qualify for a 5 percent lump sum Medicare bonus payment. However, absent any legislative changes to the MACRA statute, the 5 percent bonus for APMs will no longer be available after the 2024 payment year (that is, 2022 will be the last year that participation in an A-APM will qualify for a 5 percent bonus). CMS determines eligibility for the APM track of the QPP based on the number of patients or revenue earned through the A-APM. Beginning with the 2019 performance year, these eligibility determinations may take into account participation in a combination of both Medicare and Other Payer A-APMs. CMS provides additional information and resources on the APM tracks on the QPP website.
How to avoid a penalty
There are many ways to achieve a MIPS Final Score of 45 points in 2020 and avoid a payment penalty in 2022. However, unlike past years where reporting in only one performance category could yield enough points to avoid negative payment adjustments, for 2020 most surgeons will need to participate across all reportable MIPS performance categories to earn enough points to avoid a penalty.
Qualifying for an exemption
- Small practices and clinicians that are part of a hospital-based group could qualify for a PI exemption
- A small practice is defined as surgeons in solo practice or a practice of 15 or fewer MIPS eligible clinicians reporting under the same TIN
- A hospital-based group is defined as a group in which more than 75 percent of the NPIs in the group meet the definition of a hospital-based MIPS eligible clinician (that 75 percent of their services are hospital-based)
Tips for successful 2020 MIPS reporting
Following are tips for successful 2020 MIPS reporting:
- As a first step toward successful 2020 reporting, the College recommends checking your participation status using the QPP Participation look-up on the CMS website to determine whether you are required to report MIPS or are eligible for special statuses. Surgeons who qualify for special statuses may receive bonus points or exemptions and have certain performance categories reweighted.
- When selecting quality measures, it is important to remember that many measures have benchmarks that could limit the number of points that you may earn on the measure. For example, many surgery-focused measures are topped-out and subject to a scoring cap of seven points, which may necessitate reporting other measures or reporting on additional outcome or high priority measures that may earn you bonus points.
The following are scoring examples for clinicians who meet a special status category that exempts them from PI. None of these scenarios includes points for the Cost category because CMS calculates Cost using claims data, and scores are difficult to predict.
- Scoring example for physicians who qualify for PI exemptions (see sidebar for information regarding physicians who may qualify for an exemption):
- The 25 percent weight allotted to the PI category is reweighted to Quality, making Quality worth 70 percent of the overall MIPS score
- (26 measure points in Quality = approximately 30 MIPS points) + (fully reporting IA = 15 MIPS points) = 45 MIPS points
- Scoring example for small practices (groups of 15 or fewer MIPS eligible clinicians):
- Small practices receive six bonus points in the Quality performance category if they report at least one quality measure and may apply for an exemption from the PI category.
- (20 measure points + 6 bonus points in Quality = approximately 30 MIPS points) + (fully reporting IA = 15 MIPS points) = 45 MIPS points
Note: This scenario applies if your PI score is reweighted to the quality category.
- (20 measure points + 6 bonus points in Quality = approximately 19 MIPS points) + (fully reporting IA = 15 MIPS points) + (45 performance points in PI= 11 MIPS points) = 45 MIPS points
Note: This scenario applies if you report in PI and it is not reweighted to Quality.
Surgeons seeking assistance in planning for 2020 QPP and MIPS participation or understanding their 2019 MIPS feedback reports should e-mail qualityDC@facs.org.
*Department of Health and Human Services. Centers for Medicare & Medicaid Services. Quality measures requirements. Available at: https://qpp.cms.gov/mips/quality-measures. Accessed December 4, 2019.
†Department of Health and Human Services. Centers for Medicare & Medicaid Services. Cost measure requirements. Available at: https://qpp.cms.gov/mips/cost. Accessed December 4, 2019.
‡Centers for Medicare and Medicaid Services. CMS Hospital Value-Based Purchasing Program results for fiscal year 2020. Newsroom. October 29, 2019. Available at: www.cms.gov/newsroom/fact-sheets/cms-hospital-value-based-purchasing-program-results-fiscal-year-2020. Accessed December 4, 2019.