In late 2016, the Centers for Medicare & Medicaid Services (CMS) finalized regulations implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and establishing the Medicare Quality Payment Program (QPP). MACRA replaced the flawed Medicare sustainable growth rate (SGR) reimbursement formula with a new approach, intending to pay clinicians for the value of care they provide. MACRA shifts away from fee-for-service volume driven care and focuses on measuring, reporting and paying for the quality and cost efficiency of care. Each physician should begin complying with these new requirements in 2017; MACRA-related pay adjustments take effect in 2019 based on 2017 performance. Reporting on performance in 2017 is possible into the first quarter of 2018. Although there is national conversation about possible repeal of the Affordable Care Act (ACA), MACRA and the ACA are, however, two separate endeavors and given the extensive bipartisan support for the MACRA regulations they are likely here to stay regardless of what may happen with the ACA. Not only does MACRA impact CMS payment adjustments, but it also requires public reporting of clinician performance through the CMS website (Physician Compare); this information may then be made available through other websites such as Yelp and Zocdoc.
This MACRA Primer for Transplant Surgeons offers important information about the program and recommendations to help transplant surgeons and surgical practices adjust to the QPP. The primer will also summarize some of the advocacy activities that ASTS leadership and the ASTS MACRA Task Force have engaged in, responding to MACRA implementation on behalf of transplant surgeons and our institutions and patients. For a more complete overview of QPP and updated educational materials, visit the CMS website.
The QPP has two pathways, the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Almost all transplant surgeons will follow the MIPS pathway for the next few years; APMs may well become more relevant in the future.
Certain clinicians have “special status” and are exempt from the QPP. Clinicians expressly excluded from MIPS include low-volume clinicians, defined for 2017 as group practices and clinicians who bill less than or equal to $30,000 in Medicare Part B allowed charges or have less than or equal to 100 Medicare patients. To learn more about the exemptions, visit qpp.cms.gov/participation-lookup/about.
Under MACRA, CMS is required to evaluate clinician performance based on four categories—Quality, Cost, Advancing Care Information (ACI), and Clinical Practice Improvement Activities (CPIA). MIPS consolidates elements of three prior Medicare physician quality programs, including the Physician Quality Reporting System (now the Quality category), the Value Modifier (now the Cost category), and the Electronic Health Record (EHR) Incentive Program (now the ACI category), and adds the new fourth category of CPIA. MIPS scoring has the potential to yield financial penalties or incentive payments to physicians.
To check whether you must submit data to MIPS, enter your National Provider Identifier number here.
For performance year 2017, eligible clinicians and groups will receive a total MIPS Composite Score for Quality, ACI, and CPIA. Although CMS will calculate cost measures and provide clinicians with confidential feedback on their performance in this category, the agency will not use cost scores to determine payment adjustments for payment year 2019 (based on 2017 performance). MIPS Composite Scores will be based on a scale of 0–100 points. Clinicians and groups will be able to earn up to a certain number of points within each MIPS category, depending on their sliding scale performance. The law requires MIPS to be budget neutral, except that bonus payments totaling $500 million will be made each year for the first several years of implementation. Therefore, clinicians’ MIPS scores would be used to compute a positive, negative, or neutral adjustment to their Medicare Part B payments. CMS has declared 2017 a transition year where clinicians may “pick their pace” for MIPS reporting. Some level of participation ensures that a penalty will be avoided. The MIPS performance threshold in 2017 is 3 points for those who do the bare minimum; they will receive a neutral adjustment. Those with a score of 100 will receive the highest upward adjustment. For performance year 2017, negative adjustments can be no more than 4%. Non-participation results in an automatic 4% penalty in 2019. Positive adjustments will depend on bonus payment distributions and budget neutrality calculations but have the potential to exceed the limits placed on negative adjustments in 2017. Per the law, negative adjustments will increase over time as follows: 5% in 2020, 7% in 2021 and 9% beginning in 2022. For 2017, it is extremely easy to avoid a penalty by reporting just one measure (quality, CPIA or ACI) for only one patient!
Additional details about the four categories are as follows:
The quality category accounts for the largest proportion of the MIPS score, 60% for performance in 2017. To receive a full quality score, physicians must report on at least six quality measures from the MIPS inventory. However, none of the current measures are transplant-specific and there is a paucity that are relevant to transplant surgeons. Further complicating implementation by transplant surgeons is that some of the measures relevant to transplant surgeons are “topped out,” meaning they garner such a high performance rate among providers that they effectively do not yield any net positive scoring (at least for 2017); topped out measures include the perioperative measures of cephalosporin use and of VTE prophylaxis. Transplant surgeons may be spared the above barriers to quality reporting if they are at institutions that report to CMS under the Group Performance Reporting Option (GPRO; see further below).
For those interested, the MIPS measure search tool links to detailed measure specifications and may be used to determine which measures might be relevant to a specific transplant surgeon’s practice. Failing to submit on six measures does not automatically result in a final score below the threshold because each reported measure will be translated to a number of points. Reported measures must include one outcomes measure or, if an outcomes measure is not available, another high-priority measure (appropriate use, patient safety, efficiency, patient experience, or care coordination). SRTR-based outcomes in the PSRs are not accepted as MIPS quality measures.
There are several mechanisms for quality measures data submission. Individuals, but not groups, may use claims reporting. Individuals and groups may report through a qualified registry, Qualified Clinical Data Registry (QCDR), or EHR. Groups with over 24 clinicians may use a CMS Web interface to report. To receive a performance score on a reported measure for 2017, clinicians must report on each measure for 50% of applicable patients (Medicare-only for claims reporting; all-payer data for qualified registry, Qualified Clinical Data Registry, and EHR reporting) over at least a 90-day period and have at least 20 applicable patients for a given measure.
Some measures that transplant surgeons may consider reporting include:
- Care Plan: % of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
- Documentation of Current Medications in the Medical Record: % of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.
- Tobacco Screening and Cessation Intervention: % of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
- Patient-Centered Surgical Risk Assessment and Communication: % of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.
Qualified Clinical Data Registry (QCDR): Of note, a QCDR is a CMS-approved entity that collects clinical data for tracking quality of care. A QCDR can collect and submit quality measures data on behalf of clinicians. A critical advantage of QCDR-based MIPS reporting is the option to use not only MIPS measures listed in the proposed rule but also specialty-specific measures developed by the entity sponsoring the QCDR; such measures do not need to undergo CMS’s usual rule-making process. QCDR-based reporting can be used in the quality, ACI, and CPIA categories. To be considered a QCDR, an entity must self-nominate and successfully complete a very robust qualification process.
The SRTR does not meet the specifications of a QCDR, one reason being that it doesn’t incorporate MACRA specific quality measures. It is counterintuitive that SRTR isn’t approved as a QCDR even though this Federally supported and mandated registry is one of the very finest available, with high quality long-term data that is audited, validated, risk adjusted, outcomes focused, team oriented, publicly reported, and utilized by patients and provides a basis for accountability and powerful QI capabilities shown to steadily improve care.
ASTS is advocating with CMS to approve the SRTR as a QCDR to facilitate quality measure reporting, to accept PSR outcomes reporting for the purposes of MIPS quality measures, and to accept compliance with CMS CoPs in lieu of MIPS process measures. ASTS is also introducing TransQIP, which will meet QCDR standards for MIPS measures reporting, and considering transplant-specific measure development, although this is a challenging task given the complex technical specifications for CMS approval (numerator/denominator delineation, inclusions/exclusions, data source requirements, etc.). One area of particular interest involves creation of a transplant relevant patient satisfaction tool for purposes of patient reported outcomes measures (PROMs), increasingly important under MACRA, since S-CAHPS is not geared toward transplant surgeons.
Although cost performance doesn’t count toward the MIPS score in 2017, CMS will automatically calculate episode-based cost measures, including total per capita cost and Medicare spending per beneficiary. The calculations will be based on claims; there is no physician reporting responsibility or mechanism. CMS will then provide confidential feedback to clinicians on their performance through the Quality and Resource Use Reports (QRUR) portal.
ASTS will monitor the cost reporting regulations and implementation time-frame, especially transplant-specific concerns such as risk adjustment for cost benchmarking.
This category accounts for 25% of the MIPS composite score and evaluates whether a clinician is a meaningful user of certified electronic health record technology (CEHRT). Since most transplant surgeons are part of large medical centers, they already have CEHRT infrastructure in place and institutional administrators overseeing the capture of information for ACI reporting on their behalf, so they don’t have to focus on this category. Additionally, hospital-based clinicians reporting individually are not required to comply with the ACI portion of MIPS and can instead increase the weight of their quality category. Hospital-based clinicians include those who furnish 75% or more of their covered professional services at an inpatient hospital, on-campus outpatient hospital, or emergency room.
For those interested, CMS has more information about how the agency will score this category. The ACI score is a composite of scores from three categories—base, performance, and bonus—and addresses required measures (Security Risk Analysis, e-Prescribing, Provide Patient Access, Send a Summary of Care, Request/Accept Summary Care) and optional measures (Patient Specific Education, View/Download or Transmit, Secure Messaging, Patient-Generated Health Data, Immunization Registry Reporting, Clinical Information Reconciliation, certain Registry Reporting, certain Improvement Activities using CEHRT).
This category accounts for 15% of the MIPS composite score and offers a new, very easy to achieve opportunity for transplant surgeons to receive MIPS points and be recognized for activities that contribute to higher quality health care. MIPS participants may select from more than 90 possible IAs. Eligible activities focus on beneficiary engagement, care coordination, patient safety, population management, practice assessment, expanded practice access, and more.
To receive the maximum score for this category, clinicians must perform a CPIA for a minimum of 90 days during the performance period. In general, clinicians must attest to performing either two 20-point, high-weighted activities, or four 10-point, medium-weighted activities, or a combination of high- and medium-weighted activities equaling 40 points. Individuals and groups with fewer than 16 clinicians are only required to attest to one high-weighted or two medium-weighted activities to receive the full performance score in this category.
ASTS has identified improvement activities that seem particularly relevant to transplant surgery practice and are already being performed. In January 2018 CMS will open a portal for clinicians to self-attest on CPIAs done in 2017. ASTS will disseminate instructions on the specific measures and how to attest to them, a very easy option for transplant surgeons to gain MIPS points. Meantime, some surgeons may wish to review the entire list of CMS approved CPIAs to choose activities appropriate for their specific practices.
CMS, on November 2, 2017, posted updated MACRA requirements through the CY 2018 QPP Final Rule, with public comments due to CMS by January 1, 2018. Details are available at the CY 2018 QPP Final Rule and the CMS Fact Sheet. Key provisions include:
Low-Volume Threshold: Increases the threshold exclusion to $90,000 in Medicare Part B allowed charges or 200 Medicare Part B patients. In 2017, the thresholds were $30,000 and 100 patients, so some clinicians and groups reporting in 2017 will not need to report in 2018. It is anticipated that about 60% of otherwise eligible physicians are likely to qualify as low volume in future years.
Performance Threshold: Physicians will need to earn 15 points in 2018 to avoid a 2020 payment cut (up from three points in 2017). This means that in 2018, submitting data for just one measure will no longer enable you to avoid the penalty.
- Quality: Quadruples the performance period to 12-month calendar year (instead of 90 days minimum).
- Cost: 12-month calendar year performance period.
- Advancing Care Information: 90 days minimum performance period.
- Improvement Activities: 90 days minimum performance period.
Cost: Weight to final score - 10% (instead of 0% in 2017). CMS is including the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures to calculate your Cost performance category score for the 2018 MIPS performance period. CMS will calculate cost measure performance; no action is required from clinicians.
Quality: Weight to final score - 50% (instead of 60% in 2017). CMS proposes increasing the data completeness threshold to 60% instead of 50%. This is an increase in the percentage of eligible patients required to be reported for each quality measure. Measures that do not meet data completeness criteria will get 1 point instead of 3 points.
Topped out measures: For 2018, the 2 perioperative measures of cephalosporin use and of VTE prophylaxis are among 6 topped out measures that be will scored with a maximum of 7 points instead of the standard 10 points.
Improvement Activities: Weight to final score remains 15%.
Advancing Care Information:Weight to final score remains 25%.
Complex Patients Bonus: Apply an adjustment of up to 5 bonus points by adding the average Hierarchical Conditions Category (HCC) risk score to the final score. Generally, this will award from 1 to 5 points to clinicians based on the medical complexity of the patients they see.
Small Practice Bonus: Adjust the final score of any eligible clinician or group who’s in a small practice (defined in the regulations as 15 or fewer clinicians) by adding 5 points to the final score, if the eligible clinician or group submits data on at least 1 performance category in a performance period.
Payment adjustment: Potential 2020 payment adjustments under MIPS will be on a sliding scale from +/- 5 percent (up from +/- 4 percent in 2017), based on 2018 performance. MIPS scoring will become more competitive because of increasing numbers of clinicians exempt from QPP or participating in an APM track.
One way that clinicians can participate in MACRA is through an APM. Clinicians in Advanced APMs will be eligible for the 5% Medicare incentive payment offered under the APM track and will be exempt from MIPS scoring. Advanced APMs must bear financial risk and participants must receive 25% of their Medicare Part B payments or see 20% of their Medicare patients through the Advanced APM; the thresholds will change in later years. CMS has identified certain Advanced APMs for 2017, none of which apply to transplant surgeons.
Importantly, MACRA provides the opportunity for physicians to develop their own APMs for potential approval and implementation by CMS. ASTS is in early discussions with the American College of Surgeons on the potential for a transplant APM that would incorporate shared savings based on optimizing resource use and differentiated target pricing for high and low-risk patients. Transplant surgeons, in particular, are a natural fit for an APM because they are focused on multidisciplinary care, outcomes and quality improvement anchored to a mandated and publicly reported registry, and are cost-conscious. That said, in order for an APM to be attractive to transplant teams, it should take into account the increasing financial risks associated with the evolving donor pool and waitlist candidates and to consider other transplant specifics. APMs will continue to increase in importance over time, and ASTS will continue to explore various paths forward on behalf of transplant surgeons and teams.
ASTS leadership and the ASTS MACRA Task Force have been responding to MACRA implementation on behalf of transplant surgeons. Efforts have focused on transplant-specific advocacy aimed at maximizing reimbursement, easing reporting burdens, garnering recognition for meaningful quality activities transplant surgeons already engage in, and improving performance. To further our interests with CMS, ASTS has collaborated with ACS, AMA, UNOS, SRTR, and other organizations, and has engaged with congressional leadership as well. Additional efforts have included educational offerings for membership. A summary of some relevant activities follows:
- Engaging CMS as the details of MACRA and MIPS implementation continue to evolve, advocating ASTS specific concerns (comment letters to CMS, meetings with CMS).
- Meetings with CMS to gain SRTR approval for MACRA.
- Advocacy for CMS to accept SRTR PSR outcomes reporting for the purposes of MIPS quality measures and to accept compliance with CMS CoPs in lieu of MIPS process measures.
- Advocacy regarding transplant being a ‘team sport’ whereby many results ought to be attributed to the center rather than the individual surgeon.
- Implementing TransQIP in collaboration with ACS (transplant specific NSQIP spin-off); will meet QCDR standards for MIPS measures.
- Developing patient reported outcomes measures (PROMs).
- Considering transplant-specific measure development.
- Transplant program leadership survey (Are members reporting? How? What proportion of transplant surgeons report using GPRO?).
- Working with ACS to potentially develop a transplant APM, incorporating donor and recipient risk adjusted payment.
- Advocacy regarding the Comprehensive ESRD Care (CEC) initiative for ESRD Comprehensive Care Organizations (ESCOs); meetings with CMS on monitoring for potential negative impact on referrals for transplant.
- Member education on strategies that will enhance the likelihood of success under MACRA (ASTS/Kellogg LDPs, ASTS Winter Meeting/BP Seminars, ASTS Webinars and written materials).
- As the MIPS regulations continue to roll out, ASTS will also address facility-based reporting, group reporting, virtual groups, MIPS APMs, Hierarchical Conditions Category (HCC) complex patients bonus, and other relevant topics; keep your eyes open for additional information from ASTS.
Transplant surgeons and centers can be pleased that they are a model of quality care and are well positioned to evolve as providers adapt to the emerging QPP regulations under MACRA.