Washington Committee Report

Katie O. Orrico
John Ratliff, MD, FACS

On October 14, 2016, the Centers for Medicare and Medicaid Services (CMS) released the final rule describing the new Medicare Quality Payment Program (QPP). This new system was mandated by the Medicare Access and CHIP Reauthorization Act (MACRA). The new QPP rolls many of Medicare’s past quality reporting programs—the Physician Quality Reporting System (PQRS), Electronic Health Records (EHR) Incentive Program and valuebased payment modifier—into a new, integrated system.

The MACRA legislation saved practicing neurosurgeons significant potential revenue—as much as $100,000—by (1) repealing the sustainable growth rate (SGR) and its annual pay cut; (2) preventing the elimination of 10- and 90-day global payments; and (3) streamlining Medicare’s quality programs. This new approach to unified quality reporting is part of CMS’s goal to move away from volume-based, fee-for-service payments to physicians and towards linking reimbursement to the value and quality of care provided.

The QPP offers two pathways for complying with the new quality reporting system. The first option is to participate in an advanced alternative payment model (APM). This option is not widely available, and at the time of this writing, there are only six functioning advanced APMs—the Pioneer Accountable Care Organization being one example. In the future, bundled payments (such as the Comprehensive Care for Joint Replacement (CJR) program for orthopedics) may qualify as an advanced APM. The American College of Surgeons (ACS) is collaborating with many specialty societies, including the CNS, in developing surgical APMs. However, the 2017 advanced APM options for physicians, particularly surgeons and other specialists, are extremely limited.

The vast majority of neurosurgeons will comply with Medicare’s QPP through the Meritbased Incentive Payment System (MIPS). Performance during 2017 will be used to modify 2019 Medicare payments. Physicians who do not participate in the QPP in 2017 will automatically receive the maximum penalty, which for 2019 is a 4 percent Medicare pay cut.

MIPS Reporting
The MIPS system generates a performance score based on 4 different categories:

1. Quality Reporting. This category replaces the former PQRS system, although most of the same quality measures will be used. Initially, this category will account for 60 percent of the 2017 performance score. Ultimately, by 2021, the quality portion of a physician’s MIPS score decreases to 30 percent.

2. Advancing Care Information (ACI). ACI replaces the electronic health record (EHR) meaningful use program and accounts for 25 percent of the 2017 performance score in 2017 and in future years.

3. Clinical Practice Improvement Activities (CPIA). Practice improvement activities, including participating in maintenance of certification (MOC), reporting to clinical data registries and 24/7 access to care, account for 15 percent of the MIPS score in 2017 and beyond.

4. Resource Use/Cost. Initially worth zero percent of the performance score in 2017, this category will compare resources used to treat similar care episodes and clinical condition groups across practices. Over time, this will increase to 30 percent of the MIPS score.

Quality Reporting
Generally speaking, the quality reporting element of MIPS requires physicians to report six quality measures, including one outcome measure (if available), to achieve full performance. This is a substantial improvement from the earlier PQRS system, which required physicians to report a total of nine measures. Measures that are routinely reported by neurosurgeons include:

1. PQRS 021: Perioperative Care: Selection of Prophylactic Antibiotic

2. PQRS 022: Perioperative Care: Discontinuation of Prophylactic Antibiotic

3. PQRS 023: Perioperative Care: Venous Thromboembolism Prophylaxis

4. PQRS 130: Documentation of Current Medications in the Medical Record

5. NQF 1789: All Cause Unplanned Readmissions

6. PQRS 046: Medication Reconciliation Post-discharge

7. PQRS 047: Development of an Advanced Care Plan

8. PQRS 128: Preventative Care and Screening: Body Mass Index Screening and Follow-up

9. PQRS 131: Pain Assessment and Follow-up

10. PQRS 226: Preventative Care: Tobacco Use Screening and Cessation Intervention

11. PQRS 260: Rates of Carotid Endarterectomy (CEA) for Asymptomatic Patients without Major Complications, Discharged to Home by Post-operative Day Two

12. PQRS 344: Rates of Carotid Artery Stenting (CAS) for Asymptomatic Patients, without Major Complications, Discharged to Home by Post-operative Day Two 1

3. PQRS 345: Rates of Post-operative Stroke or Death in Asymptomatic Patients Undergoing CAS

14. PQRS 346: Rates of Post-operative Stroke or Death in Asymptomatic Patients Undergoing CEA

All of the quality measures available for MIPS reporting can be accessed at the CMS QPP Quality Measures website: https://qpp.cms. gov/measures/quality.

Advancing Care Information
The ACI reporting is a substantial improvement versus the previous EHR meaningful use program, only requiring the reporting of five EHR-related measures. Some of these elements merely need attestation and include such things as providing patient access to their medical record, secure messaging, sending care records summaries, e-prescribing, and patient-specific education.

Clinical Practice Improvement Activities
Clinical practice improvement activities (CPIA) includes a variety of options. Most participants in the system will have to report four activities over a 90-day period. For smaller physician groups or rural physicians, the requirement is two activities over a 90-day reporting period. Unfortunately, CPIA options generally focus on primary care, without many options for specialists. Some options that neurosurgeons have for reporting include: Participating in a qualified clinical data registry (QCDR), using Consumer Assessment of Healthcare Providers and Systems (CAHPS®) patient satisfaction questionnaires, participating in MOC Part IV, providing 24/7 access to care, and using patient safety tools. Each of these elements has to be performed for at least 90 consecutive days during the performance period to earn credit. The entire list of CPIA activities is available at the CMS QPP Quality Measures website: https://qpp.cms.gov/measures/ia.

Physician Exemptions
Certain physicians will be exempt from MIPS and any corresponding pay cuts. Thanks to the advocacy of the CNS and others, more physicians will be exempt from the program than was initially proposed by CMS. Three sets of physicians will be exempt from 2017 reporting:

  1. Physicians new to the Medicare program in 2017
  2. Physicians who bill Medicare less than $30,000
  3. Physicians who see fewer than 100 Medicare patients

CMS estimates that approximately 1,500 neurosurgeons will be exempt from the program in 2017.

Pick Your Pace
Organized medicine, including the CNS, pushed CMS to phase-in the new QPP program over a few years, rather than implementing it on January 1, 2017. Responding to these concerns, CMS adopted the “Pick Your Pace” program, which makes 2017 compliance with the system much easier. Under this approach, physicians have three options for 2017 reporting:

1. Report all required elements of MIPS for either 90 days or the full year to qualify for a bonus payment.

2. Report fewer MIPS measures for less than a full year.

3. Report one measure in the quality performance category or required measures in the advancing care information (i.e., electronic health record meaningful use) category.

While 2017 can almost be considered a year-long holiday from quality reporting since the burden to avoid any penalties is minimal, the competition for achieving bonus payments in 2019 will likely be relatively low as well— providing neurosurgeons who do full reporting an opportunity to boost their revenues in two years.

Reporting Options
Reporting options for individual physicians include claims, EHR, qualified registry, or QCDR. Many neurosurgeons will report through a group reporting option, either as part of their practice or through their employer for hospital-based physicians. For 2017, the Group Practice Reporting Option (GPRO) under which most employed neurosurgeons will be scored will be more complicated than GPRO reporting under previous quality reporting programs. As a result, some hospitals are considering using more than one tax identifier and more than one GPRO for their physicians. Employed neurosurgeons should check with their hospital’s quality department to see what option their facility is using and to make sure that their expectations for quality reporting and MIPS compliance are clear.

More Information
Hopefully, this brief overview will provide some background on the MIPS system and how it may affect your practice. Further information and updates may be found on MACRA resource web pages at www.cns.org/MACRA. Additional educational content specific to MIPS and MACRA will be forthcoming from the AANS/CNS Neurosurgery Quality Council, the Communications and Public Relations Committee, and the Council of State Neurosurgical Societies. There are other available resources for MIPS education, including:

This article originally appeared in the AANS Neurosurgeon.

Reporting a single quality measure in 2017 is sufficient to avoid a 4% Medicare pay cut in 2019.