MACRA: Watchful Waiting is Not an Option; An Interventionalist's Perspective

The interventional cardiology community has been a consistent leader in the delivery of high-quality chronic and acute care. Based on the provision of evidence-based practices and information acquired from registries such as the National Cardiovascular Data Registry®, we have led process improvements at a local level and system improvements at a regional level to improve care. One example is the regional approach to the delivery of care to patients with ST-segment elevation myocardial infarctions, which has resulted in the earlier identification of patients, more rapid transport to percutaneous coronary intervention hospitals, and a consistent improvement in time to reperfusion, which has translated into improved patient outcomes including a reduction in mortality.

The primary method of payment for our providers has been fee for service. Unless one has a portion of time funded to support quality improvement, these efforts have not been financially rewarded. In addition, the Sustainable Growth Rate (SGR), which was linked to inflation, did not keep pace with the rate of cost increases confronting physicians. As a consequence, each year the US Congress has been required to pass a "patch" so that physician reimbursements would not be decreased, relative to the gap between overall inflation and healthcare inflation. In an effort to emphasize quality and to avoid the annual SGR crisis, the Department of Health and Human Services issued rules on April 27, 2016, to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which was approved with bipartisan support. MACRA is budget neutral and will provide reimbursement based on Merit-Based Incentive Payment Systems (MIPS) scores. Therefore, some clinicians will benefit, others will lose, and others will be neutral. Despite this revolution in methodology, approximately two-thirds of the ACC membership is not knowledgeable about the program's details.

The Centers for Medicare & Medicaid Services (CMS) will begin reimbursement based on MIPS or Alternative Payment Models (APMs) in 2019 based on 2017 performance activities. Payments based on MIPS with be adjusted (positively or negatively) at up to 4% in 2019 and up to 9% in 2022. Four primary components will determine the impact score:

  1. Quality. Physicians will select 6 measures that replace the current Physician Quality Reporting System (50% of composite score in 2019 decreasing to 30% by 2021)
  2. Resource Use. CMS will calculate based on claims data (10% of composite score in 2019 increasing to 30% by 2021)
  3. Advancing Care Information. Replaces meaningful use measures (25% of composite score)
  4. Clinical Practice Improvement Activity. Practice activities that increase patient access and support registry participation (15% of composite score)

Initially, the majority of providers will be participating in MIPS, although the CMS expects this to transition toward APMs by 2021 with up to 75% of payments channeled via APMs by 2023. These models are based on the CMS Innovation Center models, Shared Savings Programs tracks, or approved demonstration projects in which providers accept risk and reward for coordinated, efficient, high-quality care. The list of APMs will be updated annually. As interventional cardiologists, we must understand and engage in this new system. Engagement requires understanding the elements for each of the four primary components that determine the MIPS score and developing formalized partnerships with primary care providers, hospital systems, and administrators in preparation for alternative payment models, including bundled payments for acute myocardial infarction patients and coronary artery bypass graft patients. For each of our practices, we should identify an administrator and lead physician to lead the efforts regarding MIPS and APMs, educate others about the rapidly approaching timeline, select the measures to report, and develop the competencies and relationships to be successful. Although payment reform commences in 2019, it actually begins in 2017 because this is the base year of MIPS data that will determine our payments in 2019. The CMS provides four options for 2017 that can be summarized as testing the quality program to confirm functional systems, partial participation, full participation, or participation in alternative payment models. To be successful, we must evolve from individual metrics focused on the cardiac catheterization laboratories to influencing the process of care from clinics, to procedural areas, to the hospital, and transitions back to the ambulatory environment, including cardiac rehabilitation. At the Knight Cardiovascular Institute, we have reorganized our quality structure to represent all portals where patients access different facets of our services. Our quality structure is not simply a catheterization quality unit; rather, we have committees with administrators and clinicians grouped by disease states such as ischemic heart disease, valvular heart disease, arrhythmias, vascular disease, and heart failure. Despite the use of an electronic medical record, we have audited our records and found errors in documentation that impede the reporting of accurate performance metrics. In response, we have developed new documentation tools to improve the delivery of care as well as the ability to accurately measure performance metrics. We have worked with our electronic health infrastructure to develop documentation tools that improve the accuracy of American College of Cardiology (ACC) and American Heart Association (AHA) disease state performance metrics that are in turn reported to our individual practitioners and quality committees in an effort to improve the delivery of evidence-based care and the accuracy and reliability of our reporting tools and disease-based registries. We are currently leveraging our competencies in medical informatics to improve the accuracy and reliability of our reporting systems for the ACC/AHA ischemic heart performance metrics. In concert with the Action Registry, NCDR-PCI registry, and our ischemic heart disease performance metrics dashboard, we will be positioned for the necessary process improvement activities to effectively compete in both MIPS and APMs, including acute myocardial infarction bundled payments. These collective activities are essential for improving coding, documentation, and performance measures that collectively affect reported quality measures; coding that affects adjustment for comorbidities; and claims data that affect resource utilization. Value-based care is dependent upon individual-based care provided within a system of care that provides and measures outcomes that are relevant to the patient, the provider, and now the payer.

Success will be measured on broader patient outcomes, which in turn will determine how individual providers, practices, and health systems are compensated.

Keywords: Arrhythmias, Cardiac, Cardiac Catheterization, Cardiology, Comorbidity, Coronary Artery Bypass, Coronary Artery Disease, Heart Failure, Heart Valve Diseases, Myocardial Infarction, Percutaneous Coronary Intervention, Medicare Access and CHIP Reauthorization Act of 2015

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