The American College of Cardiology recently held the 65th Annual Scientific Session and Expo, where several sessions focused on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). During the session it was clear that CMS's intention was to only accept ACO's that accept risk in the APM model payments.
Piecing Together the MACRA Puzzle
One session, entitled Piecing Together the MACRA Puzzle, was hosted by Robert Furno, Nancy Foster, and Harold Miller. This session started out with a broad overview of the MACRA program, followed by a presentation on how hospitals are preparing for MACRA, and then a presentation focused on how to implement physician-focused alternative payment models under MACRA. The session ended with a panel discussion with all three presenters.
As an overview, MACRA repeals the Sustainable Growth Rate (SGR) formula and changes the way the Medicare pays clinicians, while also streamlining multiple quality reporting programs into one new program (known as MIPS).
MACRA will affect clinicians who operate under Medicare Part B, and the specific types of Medicare Part B clinicians affected by MIPS could possibly expand after the first two years of implementation. During the first two years, physicians, physician assistants, nurse practitioners, clinical nurse specialists, and nurse anesthetists are affected. However, the Secretary may broaden the eligible professionals group to include others, such as: physical or occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dieticians/nutritional professionals.
As noted above, MACRA changes how Medicare pays clinicians. Previously, a physician provided services, was owed payment according to the Medicare fee schedule, and then adjustments were made through one of three programs (i.e., Physician Quality Reporting Program (PQRS), Value-Based Payment Modifier, or the Medicare EHR Incentive Program), before final payment was made to the clinician. Now, with MACRA, instead of adjustments being made through one of the three aforementioned programs, there is only one program through which adjustments are made: the Merit-Based Incentive Payment System (MIPS).
MIPS adjusts payments based on a composite performance score, while can result in positive or negative, or even neutral, adjustments being made, to the Medicare Part B payment they are owed. The maximum adjustment varies from year to year in the beginning, starting with a maximum of 4% in 2019, maximum of 5% in 2020, a maximum of 7% in 2021, and a maximum of 9% from 2022 into the foreseeable future. The composite performance score will factor in performance in four different weighted categories: quality, resource use, clinical practice improvement activities, and use of certified EHR technology.
There are, however, three groups of clinicians who will not be subject to MIPS: clinicians who are in their first year of Medicare Part B participation, clinicians who are below the low patient volume threshold, and certain participants in eligible Alternative Payment Models (APMs). MIPS also does not apply to hospitals or facilities.
An APM is a new approach to pay for medical care through Medicare that tries to incentivize quality and value. APMs that are eligible under MACRA are the most advanced APMs, or those who meet the following criteria: base payment on quality measures comparable to those in MIPS, require use of certified EHR technology, and either (a) bear more than nominal financial risk for monetary losses or (b) be a medical home model expanded under CMMI authority.
MACRA provides additional rewards for participating in an APM: you will receive the MIPS adjustments as well as APM-specific rewards. However, if you are in an eligible APM (as outlined above), you do not receive MIPS adjustments (because you are excluded from MIPS), but instead, you receive APM-specific rewards as well as a 5% lump sum bonus. APM bonuses are set to expire after 2025.
Nancy Foster spoke on the implications for hospitals, some of which include: the cost of implementation and compliance by employed physicians and the increased pressure on hospitals to participate in risk-bearing arrangements. She suggested hospitals adopt a system that is fair, focused on important issues, and sustainable. She suggested that in order to do so, one should streamline the number of measures that are required and employ the risk adjustment rigorously – including sociodemographic adjustments where appropriate. She also suggested that CMS should allow for a hospital-based physician measure reporting option and to allow flexibility in how group practices identify themselves for the purposes of the MIPS.
Harold Miller spoke about how to achieve better care for patients, savings for payers, and keep physician practices and hospitals financially viable. He spoke of how patient care will not be driven by dozens of narrow quality measures, and that an over-emphasis on narrow quality measures can harm patients. He also suggested that providers will be penalized for having patients with higher needs, as patient characteristics are not taken into account and that hospitals with high readmission rates may be penalized based on the patients they serve.
New Payment Models
Another session of note, entitled New Payment Models: What Does This Mean for Interventional Cardiology, discussed the specialty designation for interventional cardiology, tips on MIPS, ACO versus the traditional fee for service, and bundled payment for PCI.
Benefits of Specialty Designation
James Blankenship presented briefly on what benefits exist for specialty designation, and why such a designation is so important to interventional cardiologists. Some benefits include: increased status of the Specialty, increased recognition on CMS Physician Compare Website, ability to get paid for consultations referred by general cardiologists, and not being compared to general cardiologists on costs or on adverse outcomes.
Dr. Blankenship also noted, interestingly, that you do not need to be Board certified to identify as an Interventional Cardiologist, but that your specialty designation should reflect your clinical practice.
Tips on MIPS
Thomas M. Maddox offered some tips on making the most of MIPS, and how to handle the new process. He suggested that when it comes to expanded practice access, practitioners should allow for same day appointments for urgent needs and occasionally offer after-hours clinician advice. When it comes to population management, physicians should monitor the health conditions of their patients and provide timely intervention, as well as participate in a qualified clinical data registry.
He further suggested that when it comes to beneficiary engagement, clinicians should work to establish care plans for complex patients, to assist in beneficiary self-management assessment and training, and to share decision-making with beneficiaries. Further, as far as care coordination, physicians should timely communicate test results to patients, engage in a timely exchange of clinical information with patients and providers, as well as learn and utilize remote monitoring and telehealth.
William Borden explained the structure, process, and outcomes related to quality improvements, and what takeaways interventional cardiologists should have when it comes to quality improvements. He suggested interventional cardiologists should understand, among other things, that: payments are still currently based on fee for service; quality and cost performance reporting is important; risk-adjustment is crucial, and documentation really matters; that coordination with episode-based payments is important; and innovation can still exist.