Authors: Richard P. Dutton, M.D., M.B.A.; Teodora Orhideea Nicolescu, M.D., M.B.A.-H.C.M.
ASA Monitor 06 2017, Vol.81, 12-15.
The Medicare Access and CHIP Reauthorization Act (MACRA) was passed in April 2015 with the bipartisan support of Congress.MACRA replaces the unpopular Sustainable Growth Rate formula for adjustment of Medicare payments to physicians. MACRA is intended to accelerate the transition from volume to value-based payments. MACRA outlines two pathways in its Quality Payment Program.
The first pathway, known as Alternative Payment Models (APMs), may apply to some practices participating in arrangements that include, but are not limited to, Accountable Care Organizations. Advanced APMs, a subset of this first pathway, applies to groups with greater than 25 percent of their payments coming through certain payment models featuring two-way risk sharing. This is something few, if any, anesthesia groups will achieve in the near future.
The second pathway is the Merit-Based Incentive Payment System (MIPS). MIPS applies positive incentive payments or negative payment withholds in a budget-neutral fashion (i.e., the losers pay for the winners) based on the provider’s or group’s score across four components of performance: quality, advancing care information (ACI – the former meaningful use program), cost, and improvement activities (IA). 2017 performance data will affect payments for 2019, and scores will be given as follows: 60 percent for quality (achieving threshold performance on at least six measures, including one outcome measure), 25 percent for ACI and 15 percent for IA. The cost component will not be scored in 2017. Anesthesia providers and groups who are designated as non-patient-facing or who have more than 75 percent of their patient encounters “hospital-based” are exempt from ACI requirements. For those anesthesiologists (most of us!), the MIPS score in 2019 will be composed of 85 percent quality and 15 percent IA.
Individuals and groups must decide both which IA activities to attest to and how to submit this information to the Centers for Medicare & Medicaid Services (CMS). In most cases, IA requires completing a minimum of two high-weighted activities or four medium-weighted activities in 2017. For small practices, rural practices or practices located in geographic health professional shortage areas (HPSAs), and for non-patient facing clinicians, the requirement is two medium-weighted activities or just one high-weighted activity.
Attestation of IAs can be completed through qualified registry (QR), Qualified Clinical Data Registry (QCDR), electronic health record interface or CMS web interface. For groups participating in ASA quality reporting services, the ASA® QCDR will collect attestations on specific IAs related to ASA membership needs. It is likely that other QCDRs will do the same.
After reviewing the 92 CMS-specified IA activities, we believe those most suitable for anesthesia practices include:
- ■ Use of QCDR for feedback reports that incorporate population health.
- ■ Collection and follow-up on patient experience and satisfaction data on beneficiary engagement.
- ■ Provide 24/7 access to eligible clinicians or groups who have real-time access to patients’ medical record.
- ■ Participation in a QCDR, which promotes interactive collaborative learning network opportunities.
- ■ Use of QCDR data for ongoing practice assessment and improvements.
- ■ Use of QCDR data for quality improvement such as comparative analysis reports across patient populations.
- ■ Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination.
- ■ Participation in Maintenance of Certification (MOCA®) in Anesthesiology Part IV.
- ■ Participation in Joint Commission Evaluation Initiative (e.g., Participation in Ongoing Professional Practice Evaluation).
- ■ Implementation of formal quality improvement methods, practice changes or other practice improvement processes.
The question of which improvement activities to select is important for stakeholders. The answer lies mostly at the local level, with the nature of the practice and its infrastructure being the main determinants. Appended to this article are suggested IAs for a variety of group size and structure combinations, as well as some IAs specifically for pain practices and those with a single electronic medical record. Care coordination through documentation of transition of care (medium-weight activity), collection of patient satisfaction and experience data (high weight), participation in Ongoing Professional Practice Evaluation (OPPE) and participation in MOCA IV activities may likely be popular choices. While the current IAs seem easy to fulfill – requiring little more than attestation to activities the group is likely already doing –CMS has indicated that acceptable activities will become more stringent in future years. CMS has also indicated that any reported IA may be audited at the group or individual level; it is therefore important to report honestly and to maintain documentation.
Of course, the most useful IAs are those that further other goals for the group. There is some crossover between quality activities and IAs around topics such as population health management. Efforts to encourage smoking abstinence, for example, might include reporting a quality measure for the MIPS Quality Component while participating in local population management activities under the MIPS IA component. It appears that groups which measure anesthesia patient satisfaction and use this information to improve care and educate providers can easily attest to the appropriate IA. Those that maintain preoperative assessment centers may gain credit for coordination of care. And most obviously, reporting quality metrics through a QCDR, then sharing data reports and benchmarks with members of the group, will most likely meet IA requirements as well.
Lastly, MIPS improvement activities may be chosen to benefit groups and individuals in meeting CMS requirements but also to meet larger community needs. Examples are participation in emergency preparedness activities as well as humanitarian work. This may include registration of MIPS Eligible Clinicians in the Emergency System for Advance Registration of Volunteer Health Professionals or measuring MIPS Eligible Clinicians’ voluntary participation in domestic or international humanitarian medical relief work.
CMS has stated that MIPS will evolve in the future. The roster of activities is expected to change each year, with some activities being retired, new ones being added and high- and medium-weight status changing. Mechanisms of reporting will evolve as well, likely placing greater emphasis on group reporting and registry participation. A majority of anesthesiologists already report quality metrics through a group mechanism, quality registry or qualified clinical data registry, often facilitated by a private vendor. As requirements continue to change, engagement of outside expertise will become a necessity for most practitioners. Beginning the process of adaptation now will benefit individuals and groups in the future as federal quality programs become steadily more complex.
Improvement Activity Vignettes: Any given practice will have its own unique circumstances, so the quality officer should review all of the available improvement activities. The following lists are recommendations only.
Centers for Medicare & Medicaid Services. The Medicare Accessed & Chip Reauthorization Act of 2015. Merit-Based Incentive Payment System: Clinical Practice Improvement Activities Performance Category. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/CPIA-Performance-Category-slide-deck.pdf. Last accessed April 18, 2017.
Improvement Activities. American Society of Anesthesiologists website. http://www.asahq.org/quality-and-practice-management/macra/asa-macra-resources/Improvement-Activities. Last accessed April 18, 2017.