Medicare Compliance & Reimbursement

Brace yourself for CMS to rate you on these six quality domains.

You know that audacious idea about moving Medicare payments from a volume- to value-based reimbursement structure? That wasn’t just a fleeting notion — the Centers for Medicare & Medicaid Services (CMS) has taken its first big step in making it a reality.

Prepare for the New MIPS & APMs

CMS intends to move at least 50 percent of Medicare payments from fee-for-service (FFS) to alternative payment systems based on quality and/or value by 2018, notes Todd Rodriguez, partner and co-chair of Fox Rothschild LLP’s Health Law Practice.

And on Dec. 18, 2015, CMS published a draft Quality Measure Development Plan (MDP), which creates a framework for the development of quality measures under the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

As early as the end of 2016, the Obama administration “has set an aggressive goal of linking 30 percent of Medicare payments to quality or value,” said partner attorney Laurie Cohen in a Jan. 7 analysis for Nixon Peabody LLP. “The quality measure development process is a critical foundation to achieving such goals.”

Will MDP Become More Painful than SGR?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) specifically mandated that CMS post a draft plan for developing quality measures by Jan. 1, 2016, Cohen noted.

Many physicians celebrated MACRA’s passage, mostly because the law brought an end to the “much despised” Sustainable Growth Rate (SGR) method of adjusting Medicare payment rates, wrote Don McCanne, MD in a Dec. 29, 2015 blog posting for the Physicians for a National Health Program (PNHP). And essentially the trade-off was the requirement to establish the MIPS and APMs.

The newly released MDP outlines how CMS will build a quality measure portfolio for MIPS and APMs based on prior quality-measure development strategies, policies, and principles. The MDP focuses on the gaps CMS identified in the quality measure sets that it currently uses for the:

• Physician Quality Reporting System (PQRS)
• Value-Based Payment Modifier (VM)
• Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs), also known as Meaningful Use.

The plan offers recommendations for filling these gaps. Future quality-measure development will prioritize person- and caregiver-centered care experience, patient-reported outcomes and patient health outcomes, communication and care coordination, and appropriate use of resources across the following six quality domains:

1.  Clinical Care;
2.  Safety;
3.  Care Coordination;
4.  Patient and Caregiver Experience;
5.  Population Health and Prevention; and
6.  Efficiency and Cost Reduction.

No More Payment Updates

MACRA effectively sunsets payment adjustments for the three existing clinician reporting and incentive programs — the PQRS, VM, and Meaningful Use. Ending these payment adjustments will “accelerate the alignment of quality measurement and program policies,” CMS says.

“Perhaps the main reason that physicians, who happened to be aware of MIPS and APMs, were not concerned is that they replaced” the PQRS, VM, and Meaningful Use programs, McCanne posited. “Many thought that this would bring efficiency to existing programs by coordinating them under MIPS.”

Still, the quality measures that these three programs utilize will initially form the foundation for the MDP, Cohen pointed out.

Expect 13 Types of Measures

How it works: “The draft MDP sets forth the process for the annual solicitation, validation, and approval of quality measures that will be utilized in the MIPS,” Cohen explained. “CMS will annually solicit professional organizations and other stakeholders for new or updated quality measures through an annual Call for Measure.”

Then, CMS will establish an annual list of quality measures for MIPS through the rulemaking process, Cohen stated. In selecting a quality measure for inclusion in the annual rulemaking, a consensus-based organization — such as the Measure Applications Partnership of the National Quality Forum (NQF) — must endorse the measure. Otherwise, the measure must be evidence-based, likely determined by the rating criteria that NQF uses.

According to a recent summary by the American Academy of Orthopaedic Surgeons (AAOS), CMS expects the portfolio of quality measures to continuously evolve to include measures that:

1.  Follow the patient across the continuum of care for those populations with one or more chronic conditions;
2.  Emphasize patient outcomes balanced with process measures;
3.  Address patient experience, care coordination, and appropriate care use;
4.  Promote multiple levels of accountability;
5.  Apply to multiple types of providers;
6.  Are appropriate for low-volume, particularly rural, providers;
7.  Are adopted from other payment systems and applicable to physicians and other professionals;
8.  Align with other models and reporting systems (including Medicaid, other federal partners, and the private sector) and are specified for multi-payer applicability;
9.  Account for variation and diversity in payment models;
10.    Use EHR-generated data, based on existing provider workflows and created as a byproduct of clinical care provision;
11.    Incorporate broader use of qualified clinical data registries (QCDRs);
12.    Yield results stratified by race, ethnicity, gender, and other demographic variables available to enable providers to identify and reduce disparities among vulnerable populations; and
13.    Are suitable for public reporting on CMS’ Physician Compare website.

Offer Up Your 2 Cents

Bottom line: “Although the plan is only in draft, it sheds important light on what Medicare payment systems are likely to look like commencing in 2019 and beyond,” Rodriguez says. “Physicians and other providers who rely upon Medicare reimbursement for their livelihood should review the draft plan and keep a close eye on future developments in this area as changes will likely be sweeping.”

CMS expects to finalize the MDP by May 1, 2016. You can view the draft MDP at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html.

Also, CMS wants your feedback on the MDP, which you can provide by March 1, 2016. You can send your comments, questions, or thoughts on the MDP via:

• Online at www.surveymonkey.com/r/26NYQRB;
• Email to MACRA-MDP@hsag.com; or
• U.S. mail to Attn: Eric Gilbertson, CMS MACRA Team; Health Services Advisory Group Inc.; 3133 East Camelback Road, Suite 240; Phoenix, AZ 85016-4545.