In the first quarter of each year, anesthesiologists and their groups encounter a number of burdens for federal quality reporting. These burdens include choosing quality measures, updating measure specifications, and modifying workflows to accommodate new quality measure data capture. For 2022, ASA was able to work with the Centers for Medicare & Medicaid Services (CMS) to limit the amount of change within the Merit-based Incentive Payment System (MIPS) while also carving out less burdensome reporting options for anesthesiologists and their groups in the future.
Now in its sixth year, the Quality Payment Program (QPP) has reached a level of stability that includes a consistent number of measures and improvement activities to report from year to year. Since 2019, participation requirements have changed slightly, and much of the program remains the same. Physicians and their groups can check the QPP website to understand their reporting requirements, including their designations as non-patient facing or hospital-based status. The number of quality measures and improvement activities to report has remained the same this year as in previous years. Individuals and groups must report at least six quality measures and ensure that they are reporting for at least 70% of the applicable cases to the measure. More information on reporting requirements is available on the ASA website at asahq.org/macra.
Yet changes to the MIPS program, whether through legislation or regulation, will pose additional challenges to anesthesiologists and their groups. Based upon the original Medicare Access and CHIP Reauthorization Act (MACRA), CMS must set the performance threshold at either the mean or median of the final scores for all MIPS-eligible clinicians with respect to a prior performance period. CMS implemented a 75-point threshold for 2022 that is based upon the final mean score from the 2017 performance period (subsequent years resulted in higher mean and median scores). In 2022, those scoring less than 75 points will receive a negative payment adjustment, while those scoring higher than 75 points will receive a modest positive payment adjustment. Payments will be applied in 2024.
ASA is also concerned about recent CMS policies that will limit the ability for individuals and groups to achieve a higher score. Several anesthesia measures are topped out, and – because of their topped-out status – those measures are capped at seven out of 10 possible points. In 2022, CMS will only score the six top-scoring quality measures submitted by an individual or group. This is a significant change, as CMS is discontinuing the process of awarding bonus points for reporting outcome or high-priority measures beyond those initial six measures.
MACRA legislation required that the quality and cost performance categories be equally weighted at 30% each in 2022. For most anesthesiologists and their groups, this change will have no impact, as the cost performance category has rarely been applied to anesthesia groups. However, there may be a couple of ways that an anesthesia group may see a cost performance category score. The first way is if CMS can attribute the Medicare Spending Per Beneficiary (MSPB) measure to the anesthesia group. In some cases, CMS has been able to score a handful of cases by a larger group and assign a cost score. The second process CMS uses to assign a score is via the facility-based reporting option. With this option, CMS will use the hospital’s quality scores and apply them to the anesthesia group. Anesthesia groups have benefited from this option, as CMS will use the higher of the two scores (MSPB versus hospital score) as the group’s final cost performance category score.
The question of how the cost performance category will affect your group rests upon multiple contingencies. The first is to recognize that you have limited control over the cost category. CMS calculates your cost score based upon a convoluted (yet tested) MSPB measure using administrative claims submitted by multiple physicians and providers. Previous CMS feedback reports have given anesthesia groups very limited data on how best to improve their cost scores. As mentioned above, some groups have fared better by receiving their facility-based score as a proxy for their cost performance category.
Generally speaking, however, the cost component may be able to diversify your score and mitigate the limitations of topped-out quality measures. As previously mentioned, most anesthesia groups have their cost (30 points) and promoting interoperability (25 points) reweighted to the quality performance category. For reweighting, the quality category then consists of 85% of the total MIPS score. In an extreme case, if a group reports six topped-out measures, the group can only achieve a 74.5 point MIPS score (Table 1).
Since the cost category does not have topped-out measures, there may be more opportunities to score higher. In the hypothetical situation before, the group reports six topped-out measures (and earns the highest score of 7 of 10 points per measure). The group’s promoting interoperability category is reweighted to the quality category. The group scores an 8 out of 10 on their cost category and attests to the appropriate number of improvement activities. In this scenario, the score would calculate to over the 75 point threshold to avoid a penalty (Table 2). Of course, lower scores on the cost or quality performance category would affect these examples.
For 2022, anesthesiologists and their groups should again review their quality measures for reporting and identify which measures will best meet their MIPS needs and align with their clinical workflows. The Anesthesia Quality Institutes (AQI) is once again a designated Qualified Registry and a Qualified Clinical Data Registry that groups can use to report their data to CMS. MIPS quality measure specifications are available on the QPP website, and AQI QCDR measure specifications are available on the AQI website. Please check to make sure you are accurately collecting and reporting 2022 measures since specifications do change from year to year.
There may be some relief for groups seeking to reduce their reporting burden in 2023 and beyond. CMS has approved the use of MIPS Value Pathways (MVPs) in 2023 and has released some preliminary regulations governing their roll out. ASA is proud that CMS approved the “Patient Safety and Support of Positive Experiences with Anesthesia MVP” for 2023. We believe that reporting an MVP will allow groups to report few measures and participate in improvement activities that closely align with anesthesia workflows. Although the scoring of MVPs will be similar to the traditional MIPS pathway, we nonetheless believe that MVPs may present an initial step to improving access to alternative payment models while reducing the reporting burden that groups face. We expect that CMS will release additional guidance later this year on MVPs. ASA expects, over the course of this year, to prepare our members for MVP participation in 2023.