From the ASCRS Healthcare Economics Committee
The Medicare Access and CHIPS Reauthorization Act of 2015 (MACRA) repealed the Sustainable Growth Rate (SGR) and established the Quality Payment Plan (QPP), which is intended to promote greater value within the healthcare system. The QPP consists of two distinct programs that will determine physician payments beginning in 2019, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). MIPS will consolidate components of three existing programs—the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program, commonly referred to as “Meaningful Use.” Almost all colorectal surgeons will participate through MIPS.
MIPS is a budget-neutral payment system, meaning that there will be winners and losers starting in 2019. The good news is that CMS estimates that 90% of physicians will have a neutral or positive adjustment in the first year. The bad news is that you need to learn now what to do in 2017 in order to avoid penalties in 2019. Adjustments, up or down, to CMS payments will be made based on your MIPS composite score. The score is based on four domains but only three will be utilized in 2017, which is considered a “transition year.”
- Quality Activities replaces the PQRS and makes up 60% of the MIPS score in 2017. The program is similar to PQRS but the reporting requirements are different.
- Advancing Care Information (ACI) replaces Meaningful Use and will account for 25% of the penalty or reward.
- Clinical Practice Improvement Activities (CPIA), is a menu of activities that are documented by self-attestation. CPIA represents 10% of the MIPS score.
- Resource Utilization, or cost performance, is an adjustment calculated by CMS that will have zero weight in 2017. Starting in 2018, the cost contribution contribution to the final MIPS score will gradually increase to 30% by the third year of QPP payments in 2022.
Why is this important to ALL Colorectal Surgeons?
While 2019 sounds very distant, the MIPS will determine 2019 payment adjustments based on the actions physicians take in 2017. Since the final MACRA rules, all 2400 pages, were finally released on October 14 and the program starts on January 1, 2017, it is time to begin learning about your options under this new payment system. A brief summary of the development of the QPP was published in the October Bulletin of the ACS, prior to the publication of the final rules.
What is at risk?
If a physician reports no MIPS data to Medicare during 2017, all payments from CMS will be decreased by 4% in 2019. The negative adjustment will increase each year to a maximum of 9% of all CMS payments by 2022. You should review your payments from CMS to determine how large the potential reductions might be for your practice.
Is there any chance that my payments will go up?
Realistically, probably not. Since it will be relatively easy to avoid penalties in 2019 and MIPS is a budget-neutral payment system, there probably won’t be much money taken in penalties to reward those who diligently report for the full year. However, MACRA set aside $500 million to reward physicians with exceptional quality performance, so some physicians will be rewarded for their participation.
Do I have to participate?
Physicians who see fewer than 100 Medicare Part B patients in a year, or who have less than $30,000 in allowable Medicare Part B charges in a year, are exempt from participating. Their fees will remain unchanged. Those physicians participating in an advanced APM are also exempt from the MIPS requirements. Medicare Advantage patients are not included in MIPS or APMs.
Do I have to start reporting January 1?
In response to comments from many physician organizations, CMS has adopted a flexible “Pick Your Pace” approach to participation in MIPS. Physicians who do not report any data in 2017 will receive a -4% payment adjustment in 2019. Submitting a minimum amount of 2017 data (for example, one quality measure or one improvement activity for any point in 2017) will avoid a downward adjustment. Physicians who submit data for 90 days in 2017 will remain neutral or receive a small positive payment adjustment. Submitting a full year of data may earn a moderate positive payment adjustment for 2019.
If I am in a solo or small group practice, should I just look for an employed position?
Penalties for not participating in MIPS won’t take effect until 2019 and most surgeons will be able to avoid penalties until 2020. That means you have plenty of time to carefully weigh all of your options regarding the future of your practice.
If I am employed, do I need to do anything?
Healthcare organizations don’t have to report quality metrics on every employed physician. It is important that you know what, if any, quality data is being reported on your behalf. That information could be very important in future contract negotiations and might make you more, or less, desirable if you decide to change jobs. Besides, some physicians will be rewarded for exceptional quality performance. For employed physicians, those rewards will be paid to the employer and may not be shared if you don’t know to ask.
How do I incorporate MACRA into my practice?
There will undoubtedly be consulting services that will offer to help you navigate MIPS in return for a fee. Other resources are readily available at no cost. The American College of Surgeons Division of Health Policy and Advocacy has posted a large quantity of very helpful information on their website and will be updating it as needed. The ACS has generously offered to make this information available to all surgeons, regardless of whether they are Fellows or Members of the College. Links to that information are provided below.
What is ASCRS doing to help me?
Your society has been working with the ACS to educate our members about MACRA. The Healthcare Economics Committee is working with the Website Committee, the Social Media Committee and the Program Committee for the Annual Meeting to disseminate information through a variety of media. Specific questions can be submitted to ascrs@fascrs.org and we will do our best to provide an accurate response.
Where can I learn more?
- The ACS has many resources available. The best place to start is the QPP Resource Center.
- The Bulletin of the ACS had a recent article that provides a brief summary of the QPP.
- CMS has detailed information available about MACRA and QPP but is not geared specifically to surgeons.