Looking Ahead: What's in Store For the New Medicare Payment System in 2017

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the broken Sustainable Growth Rate formula and ushered in a new Medicare payment system, the Quality Payment Program (QPP), that rewards clinicians for the value of care delivered versus the volume of services. MACRA also streamlines the current Medicare quality reporting programs: the Physician Quality Reporting System (PQRS), the Value Modifier and the Electronic Health Record (EHR) Incentive Program into a single program. Regardless of whether a clinician participates in the Merit-Based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM), the two pathways under the QPP, clinicians will be measured on four core components: quality, meaningful use of certified EHRs, clinical practice improvement activities (CPIA) and resource use.

The Centers for Medicare and Medicaid Services (CMS) on Oct. 14 released the final rule for the QPP that solidifies policies for MIPS and Advanced APM participation starting with the 2017 performance year (2019 payment year).

Through its advocacy efforts, the College has worked with CMS and other health care organizations since day one to help shape the new Medicare payment system and ensure cardiovascular professionals can succeed in the new program. It is clear that CMS listened to the ACC and other health care stakeholders as key recommendations were included in the final rule to provide increased flexibility in year one of the program. Program flexibility highlights include:

  • The “Pick Your Pace” program will allow clinicians and groups to avoid a penalty under the MIPS program by simply reporting at least one measure. Clinicians and groups that strive to report data across all MIPS categories for at least 90 days, or ideally, the full 2017 calendar year, will be eligible for bonuses.
  • By increasing the low-volume dollar threshold from $10,000 to $30,000, CMS estimates 32 percent of clinicians will be exempt from QPP requirements in the first year of the program.
  • $100 million for technical assistance through contracts with regional organizations will be available to small practices of 15 or fewer MIPS eligible clinicians, rural areas, health professional shortage areas and Indian Health Services clinics, with priority given to rural areas, medically underserved areas and practices with low MIPS scores.

Additionally, the Advancing Care Information (ACI) category of MIPS (formerly the EHR Incentive Program) requirements have been reduced from 11 required measures to five measures for full credit. CMS has also reduced the number of CPIAs that clinicians need to participate in to receive full credit in that category. CMS has lowered the scoring weight for the Resource Use (cost) MIPS category to 0 percent for the first year of the program, recognizing that many of the procedure- and condition-based episode groups used to measure performance in this category have not yet been tested for use at the clinician level. As a result, the 2017 performance year MIPS weight for the Quality category will be increased to 60 percent. As for Advanced APMs, this pathway is being expanded to include more clinicians by recognizing more APMs as Advanced, including simplifying the definition of the financial risk that an APM must assume in order to qualify.

Merit-Based Incentive Payment System Highlights

The primary goal of the QPP is to reward clinicians for quality patient outcomes, rather than paying for the volume of services provided. Under MIPS, clinicians will be assessed based on performance against quality measures developed by the ACC, the American Heart Association and other stakeholders. Most of these measures will be familiar to clinicians as measures currently reported under PQRS.

The structure of the MIPS Quality component and the process of reporting quality measures remains similar to PQRS in many ways, meaning that clinicians who are currently successfully reporting to PQRS should easily transition to reporting under the MIPS Quality component. In 2017, MIPS eligible clinicians or groups attempting full participation will be required to report at least six measures during a continuous 90-day performance period, including at least one outcome measure. Unlike PQRS which was only based on reporting measures, points will be awarded based on performance against prior year benchmarks for each measure.

Quality measure reporting will count toward 60 percent of a clinician’s or group’s MIPS composite performance score for the 2017 performance year/2019 payment year.

Advancing Care Information
Under MIPS, the requirement to meaningfully use certified EHR technology is referred to as ACI, which replaces the Medicare EHR Incentive Program for clinicians. The ACI component of MIPS expands program eligibility beyond physicians to clinical nurse specialists, physician assistants and certified registered nurse anesthesiologists in 2017 and 2018. Additional groups will be added in 2019. All MIPS eligible clinicians can participate as individuals or as members of a group.

In 2017, clinicians have several options to report the ACI base score for 50 points on 5 measures in this transition year:

  • Use 2014 edition certified technology and report on the 2017 ACI Transition objectives and measures
  • Use a combination of 2014 and 2015 edition certified technology and report on a combination of the 2017 ACI Transition objectives and measures, and ACI objectives and measures (if their technology permits)
  • Use 2015 edition certified technology and report on the ACI objectives and measures

In addition to the base score, clinicians can earn performance score credit on nine additional objectives and measures. Clinicians have the opportunity to earn bonus points through participation in public health and clinical data registries, as well as through selected CPIAs.

Clinicians must also cooperate with the government’s health IT surveillance activities and certify that they are not engaged in information blocking. ACI will count toward 25 percent of a clinician’s MIPS composite score for the 2017 performance year/2019 payment year.

Clinical Practice Improvement Activities
As part of CPIA, the one new component of MIPS, clinicians can select the activities they participate in. To receive full credit, clinicians or groups must participate in four medium-weighted activities or two high-weighted activities. 90-day participation is required in each activity.

Activities in this category include participation in the Million Hearts Cardiovascular Risk Reduction Model, participation in Maintenance of Certification Part IV, or use of a patient safety tool. Several activities are also linked to the use of a Qualified Clinical Data Registry such as ACC’s PINNACLE Registry, Diabetes Collaborative Registry and CathPCI Registry to support patient care and quality improvement. Clinicians or groups can report participation in activities through attestation or by reporting through a mechanism such as a registry, EHR or third party.

CPIA will count toward 15 percent of a clinician’s or group’s MIPS composite score for the 2017 performance year/2019 payment year. Clinicians or groups who are part of an APM but fall under the MIPS pathway may be eligible to have their APM involvement count toward their CPIA requirements.

Resource Use
Under MIPS, clinicians or groups will be assessed based on their use of resources, or cost of care, provided to patients based on certain conditions, treatments or clinical episodes. The Resource Use category continues elements of the current Value-Based Payment Modifier.

Reference scores will be calculated for two measures from the current Value-Based Payment Modifier: total costs per capita for all attributed beneficiaries and the Medicare Spending per Beneficiary measure, with adjustments. In addition, clinicians and groups will receive information on their performance in 10 clinical episode based measures including Aortic/Mitral Valve Surgery and Coronary Artery Bypass Graft. Resource Use data will be pulled from Medicare claims data and require no reporting by clinicians or groups.

Resource Use will not count toward a clinician’s or group’s MIPS composite score for the 2017 performance year/2019 payment year, but clinicians and groups will receive data on their Resource Use performance in 2017.

How This All Adds Up
Performance on the MIPS components in 2017 will be used to determine whether a clinician or group receives an upward or downward payment adjustment of up to +/-4 percent on their Medicare Part B payments in 2019. The MIPS “Pick Your Pace” program finalized by CMS allows participants to avoid the 2019 penalty by reporting at least one measure in any of the categories, while rewarding those who report for at least 90 days or ideally, a full calendar year.

Visit the MACRA Hub on ACC.org for the latest information and resources.

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Keywords: ACC Publications, Cardiology Magazine, American Heart Association, Benchmarking, Cardiovascular Diseases, Centers for Medicare and Medicaid Services, U.S., Certification, Coronary Artery Bypass, Diabetes Mellitus, Electronic Health Records, Heart Valve Diseases, Meaningful Use, Medicaid, Medically Underserved Area, Medicare Part B, Mitral Valve, Motivation, Nurse Clinicians, Outcome Assessment, Health Care, Patient Care, Patient Safety, Physician Assistants, Physicians, Public Health, Quality Improvement, Registries, Risk Factors, Medicare Access and CHIP Reauthorization Act of 2015

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