Quality Queries and Quandaries:
By Emil Engels, MD, MBA, CPC
Congress has finally repealed the Sustainable Growth Rate (SGR) formula with a law titled the Medicare Access and Chip Reauthorization Act of 2015 (MACRA). In addition to repealing the SGR formula, MACRA continued the Centers for Medicare & Medicaid Services (CMS) shift away from fee-for-service toward paying for quality. Providers can choose to participate through one of two pathways: the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).
CMS released the final rule. The 2,000-plus pages of regulations will dramatically change the landscape of health care delivery in the United States.
The final rule provides clarity about how anesthesia providers can participate in 2017 and beyond. Here are 12 things you should know from the final rule:
1.Regarding participation in 2017, anesthesia providers can “pick your pace.” CMS listened to comments during the rulemaking process and provided flexibility for 2017. MIPS-eligible clinicians have five options (excerpts from the quality payment program website):
First option: Don’t participate. If you don’t send in any 2017 data, then you receive a negative 4% payment adjustment.
Second option: Test the quality payment program. If you submit a minimum amount of 2017 data to Medicare (e.g., one quality measure or one improvement activity for any point in 2017), you can avoid a downward payment adjustment.
Third option: Participate for part of the calendar year (CY). If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small positive payment adjustment.
Fourth option: Participate for the full CY. If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment.
Fifth option: Participate in an APM in 2017. This will not be an option for most anesthesia providers in 2017.
2.Once again, CMS listened to comments from interested parties and modified the definition of a MIPS-eligible professional. Those who fall below the requirements of at least $30,000 Medicare Part B charges or 100 Medicare patients are exempt from participating in 2017. In addition, if you are a new enrollee in Medicare or participate in an APM, you will be exempt as well. CMS estimates this represents 32.5% of clinicians, but accounts for only 5% of Medicare spending.
The MIPS quality measures
for anesthesia include:
4.In the final rule, CMS confirmed that eligible professionals must report on six quality measures, including one outcome measure. Unlike the Physician Quality Reporting System (PQRS), the National Quality Strategy (NQS) domain of the measure is not relevant. This is in contrast to the current PQRS requirements to report nine measures across three NQS domains. CMS also has waived the requirement to report a cross-cutting measure in 2017.
5.In the proposed rule, CMS set the reporting threshold at 90%. The threshold was lowered in the final rule to 50% in 2017, and will be 60% in 2018. This is good news for anesthesia providers. To be successful with quality reporting in 2017, one must report on 50% of all patients (both Medicare and commercial).
6.If an anesthesia provider chooses to report via claims, he or she would only be responsible for reporting measures #76, #130 and #317: “Finally, we would like to explain that if an MIPS eligible clinician or group reports via a data submission method that only has one applicable measure reportable via that method, the MIPS eligible clinician or group is only responsible for the measure that is applicable via that method.”
But CMS also states: “Given the potential for gaming in this situation, we will monitor whether MIPS eligible clinicians appear to be actively selecting submission mechanisms and measures sets with few applicable measures; we will address any changes to policies based on these monitoring activities through future rulemaking.”
7.Recall that MIPS-eligible clinicians must perform and report on Clinical Practice Improvement Activities (CPIA). These are activities that focus on projects and programs that improve patient care. The final rule confirmed that the activity must span at least a 90-day period of activity, documentation, discussion and review. The final list of CPIA appears in Table H, and includes processes such as using a qualified clinical data registry to generate performance feedback that improves care and to participate in Maintenance of Certification Part IV.
Once again, CMS listened to the concerns of clinicians and reduced the requirement in the final rule to four medium-weighted activities or two high-weighted activities. For non–patient-facing providers (see below), the requirement is reduced even further to one high-weighted or two medium-weighted activities.
8.Advancing Care Information:
CMS reduced the total number of required measures from 11 in the proposed rule to five in the final rule. These are:
- Security risk analysis;
- Providing patient access;
- Sending summary of care; and
- Requesting/accepting summary of care.
However, it is likely that most anesthesiologists will be exempt from this requirement, because they will either be classified as “non–patient-facing clinicians” (see below) or hospital-based physicians. Hospital-based physicians are defined as those who provide 75% of their services at Place of Service locations 21 (hospital inpatient), 22 (hospital outpatient) and 23 (emergency department). Note: The original requirement to be hospital-based required 90% of services to be provided in these settings. CMS lowered the requirement in response to comments.
9.Non–patient-facing clinicians: CMS acknowledges in the final rule that there is weakness in this terminology. The phrase “non-patient facing” is another way to describe hospital-based physicians. Of course, anesthesiologists “face” the patient, and professional groups are suggesting alternative wording to CMS.
Non–patient-facing clinicians are treated favorably under MIPS in two ways: They are exempt from the Advancing Care Information category, and they have a reduced requirement to report clinical practice improvement activities. CMS defines non–patient-facing clinicians as those who report 100 or fewer patient-facing Current Procedural Terminology (CPT) codes. The list of patient-facing CPT codes has not been released by CMS, but it will likely include pain procedures and not anesthesia CPT codes.
If you report as a group, and more than 75% of the National Provider Identifiers billing under the group’s Tax Identification Number meet the CMS definition of non-patient facing, the group is considered non-patient facing.
10.CMS assigned the cost category a weight of zero for 2017. This means that anesthesia providers will not be held accountable for cost in the first reporting year.
11.Final weighting: The MIPS final score for anesthesia providers in 2017 will most likely be determined by only quality and CPIA. The cost category will be assigned a weight of zero in 2017, and most anesthesia providers will be exempt from the Advancing Care Information category. In the final rule, quality will contribute 85% and CPIA 15% of the final score.
If you believe that you’ll be able to fully participate in 2017, and you achieve a final score of 70 or higher, you will be eligible for the exceptional performance adjustment funded from a pool of $500 million!
12.CMS makes it clear for the first time that anesthesiologist assistants are participating providers: “Note that section 1861(bb)(2) of the Act specifies that the term ‘certified registered nurse anesthetist’ includes an anesthesiologist assistant. Thus, anesthesiologist assistants are considered eligible for MIPS beginning with the CY 2017 performance period.”
MACRA accelerates the shift by CMS from paying for volume to paying for value. The overwhelming majority of anesthesia providers will participate in the MIPS pathway in year 1. CMS listened to the comments it received during the rulemaking process and created additional flexibility for 2017. All anesthesia providers should report some quality data in 2017 to avoid a negative adjustment in 2019 payments. In addition, clinicians and groups need to understand the rule and position themselves to participate fully in 2018.
Look for future columns on other quality reporting topics.
Dr. Engels is an anesthesiologist with MEDNAX and can be reached at EmilEngelsMD@gmail.com.
This column includes information from the Centers for Medicare & Medicaid Services (CMS) and represents the author’s best interpretation of available resources. The author is not recommending specific methods for participating in MACRA.