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Abstract
The annual cost of healthcare delivery in the USA now exceeds US$3 trillion. Fee for service methodology is often implicated as a cause of this exceedingly high figure. The Affordable Care Act created the Center for Medicare and Medicaid Innovation (CMMI) to pilot test value based alternative payments for reimbursing physician services. In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) was passed into law. MACRA has dramatic implications for all US based healthcare providers. MACRA permanently repealed the Medicare Sustainable Growth Rate so as to stabilize physician part B Medicare payments, consolidated pre-existing federal performance programs into the Merit based Incentive Payments System (MIPS), and legislatively mandated new approaches to paying clinicians. Neurointerventionalists will predominantly participate in MIPS. MIPS unifies, updates, and streamlines previously existing federal performance programs, thereby reducing onerous redundancies and overall administrative burden, while consolidating performance based payment adjustments. While MIPS may be perceived as a straightforward continuation of fee for service methodology with performance modifiers, MIPS is better viewed as a stepping stone toward eventually adopting alternative payment models in later years. In October 2016, the Centers for Medicare and Medicaid Services (CMS) released a final rule for MACRA implementation, providing greater clarity regarding 2017 requirements. The final rule provides a range of options for easing MIPS reporting requirements in the first performance year. Nonetheless, taking the newly offered ‘minimum possible’ approach toward meeting the requirements will still have negative consequences for providers.
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Introduction
The current generation of neurointerventional specialists has become accustomed to the present fee for service (FFS) schema of reimbursement. The cost of delivering healthcare in the USA now exceeds US$3 trillion per year.1 This dollar figure would rank as the fifth highest gross domestic product in the world if it was a national economy, and FFS methodologies are often implicated as a cause. Despite these high costs, the quality of care is often criticized for being inferior to comparable industrialized countries, representing poor value. The foundation of the FFS system was a complex interplay between two powerful committees of the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS).2 ,3 While not uniquely represented by either of these two committees, neurointerventional imperatives are evaluated and decided upon with input from interested societies, such as the American Society of Neuroradiology, the American Association of Neurological Surgeons, and the American College of Radiology.4–6
In 1997, the US federal government made the remarkable decision to balance its budget by curbing part B expenditures in Medicare. The Medicare sustainable growth rate (SGR) was enacted by the Balanced Budget Act of 1997 as an amendment of section 1848 of the Social Security Act.7 The SGR imaginatively linked growth in part B FFS medical expenses to the US gross domestic product. Physicians were lulled into a sense of complacency in the early years that followed enactment of the legislation as positive adjustments to fees occurred. This changed in 2002 with the first negative fee adjustment. The years that followed were filled with anxious expectations for both healthcare providers and Medicare beneficiaries awaiting legislatures' passage of yearly temporary fixes or patches to the scheduled cuts, often described as ‘temporary doc fixes’.
The Affordable Care Act of 2010 (ACA) created the Center for Medicare and Medicaid Innovation (CMMI) to pilot and test value based alternative payments to compensate for physician and hospital services. These alternative payments were designed to pay for value over volume, but needed a stable reimbursement environment for pilot testing. Agreement emerged that a solution was needed for the SGR conundrum.8 Unfortunately, while improving healthcare economics made permanently fixing the SGR viable, reaching a consensus solution among the branches of government proved challenging.9
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed into law on April 16, 2015.10 A core aspect of this legislation that was well received by the healthcare community was its permanent repealing of the dreaded SGR. However, an even more important aspect of MACRA was its development of a new framework for paying for healthcare delivery altogether. Payment would now be divided into the Merit based Incentive Payment System (MIPS) and advanced alternative payment methods (APMs).11–13 The CMS released a 962 page proposed rule in April 2016 that further refined the original legislation,14 and gave a name to the initiative: the CMS Quality Payment Program (QPP). This proposed rule helped solidify the legislative intent by developing rules for payment to clinicians participating in MIPS and/or advanced APMs. CMS solicited comments on the MACRA proposed rule, and many organizations with ties to neurointerventional specialists took advantage of that opportunity.
Merit based Incentive Payments System
MIPS built on the historical context of relativity that characterizes the FFS system. Critically, it consolidates multiple existing, disparate, quality programs into a single overriding unified approach.15 The programs include quality, which was historically thought of as the physician quality reporting system (PQRS), cost as considered through the value based payment modifier, meaningful use of electronic health records which is now termed advancing care information (ACI), and clinical practice improvement activities (IA) which have until recently been known as CPIA and has similarities to historic physician quality improvement initiatives, as well as activities already performed in pre-existing APMs.
Neurointerventionalists' existing familiarity with FFS makes the pathway forward with MIPS seem quite natural. However, the intent of CMS is that transforming volume based paradigms to ones that are underscored by value will require meaningful practice modifications to be successful in the new schema.16 Under MIPS, clinicians will be evaluated based on a ‘final score’ that is determined using a 100 point scale (until recently called the composite performance score). Subscores within each of the four MIPS performance categories determine the final score. The components described above each impact the final score by different weights that will change over time as the program evolves, emphasizing quality, information, practice improvement, and eventually value through cost control and resource utilization.
The map to success with MIPS keeps getting updated. The changing regulatory landscape means that terms providers only recently learned (eg, cross cutting measures such as blood pressure control) in support of MIPS are no longer applicable. Quality will require reporting of at least six measures, including one outcome measure (if available). Those familiar with PQRS should note that there would no longer be specific National Quality Strategy Priority requirements,17 and the number of measures was reduced from 9 to 6. The fundamental difference between the quality performance category in MIPS versus the PQRS system is clinicians will be given a score based on performance of a measure as opposed to just receiving credit for reporting a measure. In 2019, quality will account for 60% of the final score. ACI requires reporting five measures across a set of four objectives for a base score within the first performance year. Additionally, participants can choose among nine measures from four objectives to receive a performance score. A number of bonus points are also available by overlapping activities within the IA performance category. ACI will compose 25% of the 2019 final score. IA became important over the past years as part of quality initiatives often associated with maintenance of certification.18 MACRA incorporates nine priority categories that include care coordination and patient engagement. Neurointerventional specialists routinely perform some of these activities without compensation and it is refreshing to know that MACRA will reward these efforts to the tune of 15% of the 2019 final score. Cost will eventually make up an increasing amount of the final score, but was weighted to 0% of the 2019 adjustment year to allow a gradual phase in for the initial adjustment year but rising up to 30% in ensuing years.
The final score has dramatic implications.10 Performance in MIPS in 2017 will be used to determine the 2019 final score. In 2019, the Medicare part B payments will be adjusted in either direction by up to 4%, multiplied by a budget neutrality scaling factor ranging between 0 and 3. By 2022, this will grow to ±9%, multiplied by a budget neutrality scaling factor ranging between 0 and 3. The scaling factor ranging between 0 and 3 could theoretically result in a 27% bonus on part B payments for those that are successful with MIPS. Beyond that, there is also an exceptional performer bonus of 10% multiplied by a scaling factor of 0–1. In total, the implication is that both rewards and penalties can be very meaningful under MIPS.
Mr Slavitt, the acting administrator of CMS, has repeatedly stressed that his organization is interested in feedback pertaining to MACRA. Per above, extensive feedback was provided regarding the April 2016 proposed rule for the QPP. Multiple organizations and providers expressed concern with the pace of implementation of the MIPS program (ie, 2019 assessments being based on 2017 performance data). Prior to issuing the final rule, CMS clarified that it would allow physicians and organizations to ‘pick your pace’; such plans were formalized in the final rule.18 ,19 As the terminology implies, this approach now allows providers to gradually opt in to MIPS in 2017 without being charged maximal penalties. The options are:
Testing the QPP—designed to allow providers to make sure their system for submitting measures is up to snuff for fuller participation.
Participate for only part of 2017—providers may start on a date later than January 1 and still receive a small positive payment adjustment.
Participate in MIPS measures for the full calendar year.
Participate in an advanced APM for the full calendar year.
There are many ways to approach reporting measures for maximizing the final score. Interestingly, the original legislation itself points to an advantageous method.9 The statute states, …“under MIPS, the Secretary shall encourage the use of qualified clinical data registries (QCDR)”.9 CMS is rigorously enforcing this concept by making QCDR participation potentially helpful in all components of the final score excepting, at this time, cost.
Highly specialized physicians like neurointerventionalists need to be aware of and active with this opportunity. Theoretically, entities such as the Society of NeuroInterventional Surgery can propose measures that are unique for their specialty to CMS. This can presumably occur in collaboration with the already existing Neurovascular Quality Initiative and interested members of the Society of NeuroInterventional Surgery. Future manuscripts will endeavor to explore this specific opportunity. The criticality of this approach cannot be overstated. Beyond allowing for measures that are specifically relevant to neurointerventional specialists, a far greater flexibility will exist than what was covered in the CMS proposed MACRA rule.12 QCDR can nominate up to 30 non-MIPS measures for review by CMS and approved for reporting purposes. CMS further proposes giving bonus points that are beneficial to the final score for those that choose to report ‘high priority measures’. Examples of these measures relate to patient outcomes and safety, appropriate utilization, and care coordination.
Group versus individual reporting
Historically, healthcare providers needed to decide whether to report their performance data as unique individuals or as a member of a larger group—that is, the Group Performance Reporting Option (GPRO). This group option is attractive for limiting the administrative burden and thereby lowering administrative cost for individuals. The group reporting option requires the use of a single Taxpayer Identification Number (TIN). CMS is allowing many of the MIPS reporting mechanisms, including the QCDR, to report data using the GPRO methodology, and have announced their intention to expand that capability even further. Multidisciplinary neurointerventional groups will need to review their individual practice circumstance carefully; for example, are different specialists included in a single TIN or, conversely, are neurointerventional specialists from different backgrounds members of their base specialty TIN. Once the unique TIN situation is determined, those participating in that GPRO will need to recognize that the measures chosen will determine which group members contribute to the success or failure of the group with MIPS. All those with the same TIN will receive the same reward or penalty. As a further example of such complexity, if all the providers in a given physician organization, regardless of specialty, report using one TIN, it is possible that non-neuro based specialists (eg, primary care doctors) could determine the final score of neurointerventionalists on MIPS. Additionally, while GPRO reporting may lessen the burden of reporting, and have advantages in maximizing performance in quality, ACI, and IA, there may be some disadvantages of reporting as a group in the cost performance category.
The final rule
On October 14, 2016, CMS released its 2398 page MACRA final rule.20 The Department of Health and Human Services characterized this as a …“streamlined Medicare payment system that rewards clinicians for quality patient care”, and “accelerates the shift towards value”.21
As described above, responding to feedback that many groups are not prepared for the approaching approval of the first performance year in 2017, the final rule now allows healthcare providers utilizing MIPS to pick their own pace in 2017. This entails a gradual phase in of previously proposed more robust data reporting requirements. To maintain the integrity of the first adjustment year in 2019, providers will need to submit data for just one quality or IA measure in 2017. Completely opting out will result in the maximal 4% penalty but this will be mitigated if the provider or group submits the limited data mentioned immediately above. CMS also allows for 90 day and full year data reporting requirements in 2017 for the possibility of a small bonus or neutral adjustment. While CMS also left open the possibility to amending the requirements in the 2018 performance year/2020 adjustment year cycle, a change in the 2019 initiation date for penalties and rewards should not be anticipated.
Radiologists have been characterized as non-patient facing providers in MACRA. The implications of this term are complex, given that the designation as non-patient facing is associated with a number of special considerations in performance reporting and determination of adjustments under MACRA.22 The intricacies of these points are beyond the scope of this paper but applicable to some neurointerventional radiologists. The American College of Radiology, American Society of Neuroradiology, and Society of Interventional Radiology each offered detailed comments on this language and its implications.23–25
CMS plans to use administrative claims based data, rather than QCDR reporting, to determine the cost category of the final score. Controlling resource use (cost) is a critical issue for MACRA to achieve CMS goals. Thus it is not surprising that cost will escalate in importance to fully 30% of the final score. Given the many challenges identified by various professional organizations with attribution of costs, it is potentially not surprising that, in the final rule, CMS will not use this category to determine payment adjustments for any provider in the first adjustment year.16 The final rule includes three cost measures:18
Mean spending per beneficiary attributed to the clinician having the plurality of billed Medicare part B services on an index hospital stay. This measure can be attributed to virtually any clinician as the types of services used for attribution include all part B services, not just a specific subset. In other words, the patient and the patient's inpatient costs will be attributed to whichever clinician billed the most during that admission.
Total per capita costs are attributed by primary care services.
Episode groups are attributed to the clinician billing the primary procedure. Only 10 such groups have been finalized for the first year.
Taking the ‘minimum possible’ approach
The easements associated with the final rule are likely welcome news to providers who found themselves unprepared for measurements taking effect in 2017. However, this could also have the unfortunate impact of leading to provider complacency. As stressed above, the plan to award bonuses and charge penalties in 2019 has not changed. A minimalistic approach to reporting quality and IA in 2017 will save providers from being hit with the 4% maximum penalty in 2019, but will not allow practitioners to maximize their bonus.16
Finally, some physicians may be willing to give up their bonuses and in fact accept the maximal financial liabilities if it means shielding them from the seemingly onerous reporting requirements of MIPS. It is important for those physicians to recognize that their performance on these various measures, by statute, will be reported to the public through an already existing freely available website called Physician Compare, a CMS website mandated by the ACA that allows patients to compare providers and group practices.26 Practices that do not participate in MIPS reporting will appear deficient compared with their peers with respect to the various final score categories, as made available through Physician Compare. The final rule does provide some respite by publishing historic PQRS data as the quality benchmarks for 2017.16
Conclusion
The MACRA legislation of Spring 2015 demonstrated the ability of the US government to accomplish meaningful healthcare reform. The early headlines focused on the permanent repeal of the Medicare SGR. Since then, medical professionals and many others associated with healthcare delivery have had the opportunity to focus on the implications of the new federal QPP established in MACRA. Most neurointerventional professionals will elect to participate in MIPS, with 2019 serving as the first year of part B bonuses or penalties. It is critical that neurointerventional specialists continue to familiarize themselves with the opportunities and pitfalls associated with QPP.
References
Footnotes
Contributors JAH drafted the original manuscript. All authors reviewed the draft, provided meaningful edits, and contributed to the final version.
Competing interests JAH consults for Medtronic. ABR is supported by a research grant from the Harvey L Neiman Health Policy Institute.
Provenance and peer review Not commissioned; internally peer reviewed.