January 2017

CMS Proposes Rule for the Establishment of Special Payment Provisions and Requirements for Qualified Practitioners and Qualified Suppliers of Prosthetics and Custom Fabricated Orthotics

CMS proposed rule would implement statutory requirements and specify: the qualifications needed for qualified practitioners to furnish and fabricate prosthetics and custom-fabricated orthotics, and for qualified suppliers to fabricate prosthetics and custom-fabricated orthotics; accreditation requirements that qualified suppliers must meet in order to bill for prosthetics and custom fabricated orthotics; requirements that an organization must meet in order to accredit qualified suppliers to bill for prosthetics and custom-fabricated orthotics; and a timeframe by which qualified practitioners and qualified suppliers must meet the applicable licensure, certification, and accreditation requirements. This rule would also remove the exemption from quality standards and accreditation that is currently in place in accordance with section 1834(a)(20) of the Act for certain practitioners and suppliers who furnish or fabricate prosthetics and custom fabricated orthotics. In addition, this rule also includes authority for the Centers for Medicare & Medicaid Services (CMS) to revoke the Medicare enrollment of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers that submit claims for items that do not meet the requirements of the statute and this proposed rule. A copy of the proposed rule is available here. The Department is accepting comments through March 13, 2017.

EHR Incentive Programs: New Attestation Resources

The Electronic Health Record (EHR) Incentive Programs attestation system is open through February 28. Providers must attest by the deadline to avoid a 2018 payment adjustment. CMS released two attestation worksheets for eligible professionals and eligible hospitals and critical access hospitals. Visit the 2016 Program Requirements webpage for more information.

2017 Medicare Payment Penalties in Effect as of January 1

The Centers for Medicare & Medicaid Services (CMS) released a fact sheet in late December 2016 regarding penalties that are being imposed in 2017 through the Electronic Health Record Incentive Program, also known as meaningful use. Surgeons and other eligible professionals (EPs) who did not meet meaningful use reporting requirements in 2015 are facing a 3 percent Medicare payment penalty in 2017. According to CMS, approximately 171,000 EPs will experience the negative adjustment. To avoid a penalty in 2018, surgeons may attest to 2016 meaningful use through February 28, 2017. More information about attestation is available through the CMS Registration and Attestation System.

CMS Accepting Applications for CPIA Study

The Centers for Medicare & Medicaid Services (CMS) is conducting a Clinical Practice Improvement Activity (CPIA) study to examine clinical workflows and data collection methods that use different submission systems. The goal is to gain an understanding of the challenges that clinicians encounter when collecting and reporting CPIA data. Clinicians and group practices that are eligible for the Merit-based Incentive Payment System (MIPS) and that successfully participate in the study will receive full credit for the Improvement Activities performance category of MIPS. Participants in the 2017 study must meet the following requirements throughout 2017: • Complete at least three survey questionnaires • Participate in at least three focus groups • Submit at least three clinician quality performance measures to CMS For more information and to apply to participate in the study, visit the CMS website. CMS is accepting a limited number of participants into the study, so applications should be completed as early as possible. Completed applications should be submitted to  CMSCPIAStudy@ketchum.com by January 31.

CMS Releases 2017 QPP Quality Measure Benchmarks

If a physician or practice plans to participate in 2017 Quality Payment Program (QPP) (aka MIPS) with the goal of receiving a bonus in 2019 it is highly recommended that they review the recently released 2017 QPP Measure Benchmark information. The 2017 quality benchmark information does not apply to physicians who only plan to participate in 2017 to avoid a 2019 penalty (submit one measure, one time in 2017). The 2017 CMS QPP benchmark information was released late last week and posted to the CMS QPP website. The benchmark calculations for the 2017 performance year use data that was submitted for PQRS in 2015 by clinicians that were a Quality Payment Program provider type eligible for MIPS and were not newly enrolled in 2015, or groups with at least 1 such clinician. When a clinician submits measures for the QPP Quality Performance Category, each measure is assessed against its benchmarks to determine how many points the measure earns. A clinician can receive anywhere from 3 to 10 points for each measure (not including any bonus points). Benchmarks are specific to the type of submission mechanism: EHRs, QCDRs/Registries, CAHPS and claims. For CG-CAHPS, the benchmarks are based on two sets of data, 2015 PQRS CAHPS and 2015 ACO CAHPS data. Submissions via CMS Web Interface will use benchmarks from the Shared Savings Programs. Each benchmark is presented in terms of deciles. Points will be awarded within each decile (see Table 1). Clinicians who receive a score in the first or second decile will receive 3 points. Clinicians who are in the 3rd decile will receive somewhere between 3 and 3.9 points depending on their exact position in the decile, and clinicians in higher deciles will receive a corresponding number of points. For example, if a clinician submits data showing 83% on the measure, and the 5th decile begins at 72% and the 6th decile begins at 85%, then the clinician will receive between 5 and 5.9 points because 83% is in the 5th decile. For measures where a positive performance is seen in a lower score, the scores are reversed in the benchmark deciles.

CMS Releases Patient Facing Encounter Codes

CMS released and posted to the QPP website the list of patient-facing encounter codes. The list is used to determine the non-patient facing status of MIPS eligible clinicians. Given the flexibility in program requirements for non-patient facing clinicians, the encounter codes are critical for CMS to identify MIPS eligible clinicians. A non-patient facing MIPS eligible clinician is: • An individual MIPS eligible clinician that bills 100 or fewer patient-facing encounters (including Medicare telehealth services defined in section 1834(m) of the Act) during the non-patient facing determination period, and • A group provided that more than 75 percent of the clinicians billing under the group’s TIN meet the definition of a non-patient facing individual MIPS eligible clinician during the non-patient facing determination period. The list of patient-facing encounter codes are categorized into three overarching groups of codes (Evaluation and Management Codes; Surgical and Procedural Codes, and Visit Codes). The utilization of Evaluation and Management Codes, Surgical and Procedural Codes, and Visit Codes classifies MIPS eligible clinicians as non-patient facing and patient-facing.

Health Industry Calls for Stabilization

Executives from major insurance and pharmaceutical companies and hospitals are pressing the incoming Trump administration to shore up the health insurance marketplaces. Companies like Aetna, Blue Cross Blue Shield of Tennessee, Johnson and Johnson and Novartis, who are members of the Healthcare Leadership Council, outlined policy proposals that the group agrees “should be taken immediately to stabilize the health insurance marketplace,” according to a release. They asked Congress to pour more federal money toward the sickest consumers, to provide refundable tax credits to help people afford coverage, to repeal the health law’s health insurance tax and to reduce federal oversight of the insurance marketplaces. The companies’ requests come just as Republicans on Capitol Hill and in the administration are ramping up for an aggressive effort to repeal the law. Vice President-elect Mike Pence met with Republicans to discuss the administration’s plans to repeal parts of the law through executive action, and to press lawmakers to get a repeal bill to the new president’s desk before Feb. 20, according to members who attended the meeting. Lawmakers have suggested they will include a transition period in their repeal plans, in order to ensure people who currently have coverage under the health law are not kicked off their plans immediately. That also will give Republicans some time to come up with a replacement plan. The threat of repeal has worried nearly every sector of the health care industry. Hospitals argue they stand to lose hundreds of billions of dollars if the law is annulled. Insurers have long decried the current marketplaces as unstable. They caution that repeal and replacement efforts must be measured and deliberate to minimize disruption.

Health Law Repeal Could Spur Job Losses, Report Says

Repealing provisions of the health care law, such as the Medicaid expansion and the tax subsidies that help those in lower income brackets purchase individual plans, could result in millions of jobs lost over the next few years. The analysis, by the Commonwealth Fund and researchers at George Washington University’s Milken Institute School of Public Health, predicts a $140 billion federal cut in health spending in 2019, resulting in 2.6 million jobs lost. The authors acknowledge that they cannot yet incorporate other policies, such as an anticipated Republican plan to replace the health law into their analysis. The health care sector makes up about one-fifth of the economy, but the researchers say the jobs will not just be lost in health and insurance: the loss of federal funding could have a cascading impact on the construction, real estate and retail industries as well, including in states that have not pursued a Medicaid expansion. “Because economic benefits and losses flow across state lines, even states that did not expand Medicaid would experience losses if Medicaid expansions were canceled,” the report says. President-elect Donald Trump and has proposed Medicaid block grants, and the researchers note that if the grant levels incorporate the expansion, that could help blunt the economic impact. Overall, by 2023, the researchers predict $2.6 trillion could be lost in business output and $48 billion lost for state treasuries due to revenue decreases and the increasing cost of uncompensated care.

December 2016

Senate Committee on Finance Issues Final Report on Concurrent Surgery The United States Senate Committee on Finance began an investigation of concurrent surgery and released its findings in a report. The report is available here.   In early 2016, the Committee sent a letter to 20 teaching hospitals querying them about the practice in their institutions. The letter generated strong interest from hospitals, individual physicians, patient advocates, and others who reached out to the Committee to share their experiences, insights, and knowledge about these issues. Additionally, Committee staff examined guidance issued by the Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), and the American College of Surgeons (ACS), policies and other information provided to the. The report is a summary of the Committee’s staff’s findings to date and an overview of key issues and areas of Congressional concern.   The report outlined two areas that troubled the Committee most, patient safety and improper payments. The patient safety concerns focused on whether patients are giving consent to have these types of surgeries performed and whether they are safe to perform. The Committee is asking for further guidance and an examination on how best to proceed from CMS and the ACS. The Committee is asking for particular procedures that could be allowed to have concurrent surgeries performed and to further define the “critical parts” of the surgery. The second area of concern is the improper payments from Medicare and Medicaid. CMS has not taken any steps to determine whether the existing billing requirements applicable to teaching physicians in hospitals are or are not being followed despite a history of problems in this area. Second, CMS’s billing requirements are applicable only to teaching physicians operating in hospitals. There are no billing requirements in place that would prevent a surgeon from billing for two or more concurrent surgeries in hospitals outside of a teaching scenario, such as when a physician is assisted by a technician, or in nonhospital settings, such as in ambulatory surgery centers. The Committee is asking for further investigations into billing practices of teaching physicians and whether additional similar measures are needed for other surgical scenarios and facilities.   FIRST Trial: Residents with More Patient Responsibility Prefer Flexible Work Hours U.S. general surgery residents prefer work hour policies that allow them the flexibility to put in more time in the hospital when needed to provide patient care over more restrictive work schedules, according to results from a national survey conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial. The new analysis—which is derived from a survey of more than 95 percent of the 3,700 surgeons in training who participated in the FIRST Trial—found that 86 percent of surgical residents preferred flexible duty-hour policies over regulated duty hours or had no preference.   The FIRST Trial was the first national randomized trial to compare standard surgical resident duty-hour requirements with more flexible policies. During the FIRST Trial, 59 general surgery residency programs adhered to standard duty hour policies, which the Accreditation Council for Graduate Medical Education (ACGME) established in 2003 and 2011. The other 58 programs tested a flexible policy that waived certain ACGME rules on maximum shift lengths and mandatory time off between shifts to allow the residents some flexibility.   Findings from the FIRST Trial published earlier this year in the New England Journal of Medicine demonstrated that easing current restrictions on surgical residents’ schedules to allow for some flexibility did not have an adverse effect on general surgery patient outcomes or on overall resident well-being. In fact, residents in the flexible arm of the study noted several benefits with respect to patient care, continuity of care, and resident training.   MedPAC Meets to Discuss Provider Consolidation, Open Payments   During the meeting in Washington, DC, the commission reviewed the role of CMS in provider consolidation and the implications of different types of consolidation for the Medicare program and private payors. MedPAC staff indicated that vertical financial integration, through which hospital systems acquire physician practices, has caused an increase in Medicare spending due to the higher costs associated with providing services typically furnished in physician offices in hospital outpatient settings. Commissioners reiterated their standing recommendation to limit Medicare facility fees and equalize rates for certain services across all sites of care.   MedPAC commissioners also discussed findings from the Open Payments program, through which CMS collects data from drug and device manufacturers and group purchasing organizations (GPOs) on their financial relationships with physicians and teaching hospitals. MedPAC staff provided an analysis of Open Payments data that CMS released from August 2013 to December 2015. In 2015, manufacturers and GPOs made nearly $7.5 billion in payments for research, royalties, consulting, promotional speeches, and other activities to more than 610,000 physicians and 1,100 teaching hospitals. Open Payments data suggested that these payments are skewed toward the top 5 percent of physicians, who accounted for 86 percent of all general payments made by manufacturers and GPOs. MedPAC recommended that research be conducted to examine the relationship between payments from manufacturers and physicians’ use of certain drugs and devices.   Health Policy Issues in the 115th Congress:     A quick look at major health issues facing the Congress.  FDA User Fees   The issue: Congress in 1992 enacted the prescription drug user fee system. Under the program, the pharmaceutical industry and the Food and Drug Administration negotiate an agreement which sets a certain amount that pharmaceutical companies pay each year, known as a user fee, to fund certain initiatives at the agency. That agreement typically is reauthorized every five years and has grown to include the medical device and generic drug industries, among others. User fees now account for almost half of the FDA’s total budget. Next year, Congress will be tasked with reauthorizing the agreements before the current legislation expires at the end of September 2017.   What to expect: House Energy and Commerce Chairman Fred Upton hopes that his legacy legislation, a package of biomedical innovation bills known as 21st Century Cures, will be signed into law in 2016. If the Michigan Republican is unable to make that happen, many of the provisions included in that package are expected to be considered for possible inclusion in the pending user fee reauthorization. The Cures bill included several changes to the pre-market review process for drugs and medical devices. Those measures have bipartisan support and could be included in the user fee reauthorizations next year.   Another issue that potentially could be addressed in next year’s legislation is the rising cost of prescription drugs. The issue was discussed widely on the presidential campaign trail by candidates from both parties and the controversy grew in recent months after Mylan N.V. increased the cost of its EpiPen device, which provides emergency medication for severe allergic reactions. Health Care Law The issue: Republicans are likely to make an effort to repeal President Barack Obama’s signature domestic achievement. The marketplace coverage created by the law already was facing mounting challenges. Premiums for people who buy their health insurance on HealthCare.gov are ratcheting up by an average 25 percent for benchmark plans. Some insurance companies, citing financial losses, are backing out of the marketplaces. Some are even going bankrupt. However, the law has provided coverage through the exchanges, Medicaid and other programs to roughly 20 million people, according to the Obama administration.   What to expect: The politics surrounding the 2010 health law run deep. President-elect Donald J. Trump earlier this month called for Republicans to act and pledged to call a “special session” to push repeal. If Republicans pass a budget resolution, they can use special procedures to repeal parts of the law through the so-called reconciliation process, which only requires 51 Senate votes rather than 60. Earlier this year, Republicans used reconciliation to clear a measure that would have removed the penalties used to enforce the mandates that most individuals have health coverage and large employers offer it to their workers. It also would have repealed in 2018 the law’s Medicaid expansion and its subsidies to help low- and middle-income individuals buy health coverage through the new insurance exchanges. Obama vetoed it. Children’s Health Insurance The issue: Funding for the popular Children’s Health Insurance Program will expire at the end of September 2017, making a reauthorization bill a must-pass agenda item for the 115th Congress. Lawmakers could pass a simple two-year extension, although advocates and Democrats would prefer a longer approval for the bipartisan program. That will complicate the debate: the program’s entire legislative authority will run out in 2019, as will requirements that prevent states from making it harder for people to enroll in the program. The levels at which it is funded will also be a hot-button issue because the 2010 health law provided states with a 23 percentage point boost. Some fiscal conservatives would like to lower spending, but states that rely on the funds will push to keep them. As they have in years past, advocates are pushing for Congress to extend that funding in the spring to give state legislatures that adjourn early in the year time to set their health budgets.   What to expect: The CHIP program is extremely popular politically, but that hasn’t stopped it from becoming controversial in recent years. Congress may try to begin debate on the program early in the year in an effort to help state officials plan ahead. But the fight is likely to be partisan. In 2015, the last time the program needed to be authorized, Republicans sought a reduction in the funding levels and a repeal of the provisions related to state eligibility requirements. Democrats, meanwhile, held hostage a separate bipartisan measure on Medicare reimbursements in an unsuccessful attempt to force Republicans to fund the program for four years instead of two. Staffing, IT Systems Top Concerns for Medicaid Directors:     A majority of the country’s Medicaid directors said their biggest challenges are related to staffing and technology infrastructure, according to a survey by an advocacy group for the officials. It is a shift from the past several years, when directors were more likely to cite the implementation of the 2010 health overhaul a top challenge.   The results also underscore other ongoing changes in the Medicaid program, which has grown to cover 73.1 million Americans. More Medicaid directors said their priority is so-called payment reform, an industry-wide focus on transitioning health care away from fee-for-service payments, than any other topic. Directors also highlighted a new focus on IT systems and on behavioral health. About half of the directors, meanwhile, cited their administrative budget as a key challenge. Seniors Opt Out of Full Coverage, Lower Medicare Plans’ Profits:   Medicare may be shortchanging insurers because its calculations ignore the growing number of wealthy and working senior citizens who chose not to fully enroll in the giant health program. They estimated that insurers would gain $20 billion over a decade if Medicare rules were to better reflect the number of people opting out.   MedPAC is working on its 2017 suggestions to Congress regarding the continual financial battles between the insurance industry and Medicare. MedPAC also revisited concerns that some insurers may be identifying customers in their Medicare Advantage plans as sicker than they are to secure extra pay. Medicare sets payments for the Advantage plans by looking at how much the traditional fee-for-service program spends. These calculations factor in spending in both major components of Medicare: the Part A section that covers hospital care and Part B that covers more routine care such as visits to doctors.   A small but growing number of people opt out of Medicare Part B while remaining in Part A, MedPAC staff said Friday. This group grew to 12.4 percent of Medicare’s population in 2015 from 10.2 percent in 2009. People who opt out of Part B also appear to be in better general health, reducing the hospital bills for Part A as well. This may cause further distortion in setting reimbursements for Advantage plans. Sticker shock about Medicare Part B premiums appears to be driving the decision to opt out in many cases. Some people do decline Part B because they continue working and thus have health insurance provided by their insurers. More often, though, people might make this call because they cannot afford Part B premiums or decide that that are a bad deal. CMS Timelime for Off-Campus Doctor Pay Rule Raises Alarms:     The Centers for Medicare and Medicaid Services said it will create special rates for newer hospital-owned practices by Jan. 1 through an administrative fast-track proposal, known as an interim final rule. This is intended to help hospitals determine how to bill for these kinds of services, which they previously billed under the more lucrative hospital outpatient rule. In many cases, the pay for newer hospital services would be set under these transition rates at about half of the former outpatient reimbursement, CMS said. CMS attached the interim rule to the final rule on 2017 outpatient payment.   The budget law mandate does not apply to hospital-owned practices already in operation at the time the measure took effect in November 2015. They can continue to bill at the higher outpatient rates rather than the lower reimbursements set in the physician fee rule.

November 2016

Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program Final Rule

On October 14, 2016, the Centers for Medicare & Medicaid Services (CMS) released the final rule with comment period to implement MACRA’s Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). Collectively, these programs are part of what CMS now calls the Quality Payment Program (QPP). CMS has also issued a fact sheet, an executive summary, and an online toolkit on the payment program.

Quality Payment Program Overview

CMS finalized a transition year for the 2017 performance period, during which the only physicians who will experience a -4 percent payment penalty in 2019 are those who choose not to report any performance data. Physicians can avoid the payment penalty in 2019 by reporting for one patient on one quality measure, one improvement activity, or the 4 required Advancing Care Information (ACI) measures in 2017. Physicians who wish to possibly qualify for a positive payment adjustment must report more than the minimum one patient for one quality measure, improvement activity or the 4 required ACI measures.

Merit-Based Incentive Payment System (MIPS)

Overarching Issues

• Shortens performance period: Physicians who report for at least 90 continuous days in any of the three categories that will be included in the 2017 score will be eligible for positive payment adjustments. • Increases low-volume threshold: CMS raised the low-volume threshold in the proposed rule to exempt physicians from all performance reporting to $30,000 in annual Medicare revenue or 100 or fewer Part B-enrolled Medicare beneficiaries. CMS estimates that this change will exempt 32.5 percent of eligible clinicians from the program. • Increases non-patient facing eligible clinicians encounter threshold: CMS expanded the definition of a non-patient facing physician as an individual clinician that bills 100 or fewer patient-facing encounters during the non-patient facing determination period. • Provides for individual or group reporting: The final rule retains a provision allowing data submission and performance assessment to be done at either the individual or group level. Physicians must choose to report as an individual or group consistently across all MIPS categories. CMS also plans to allow physicians to participate in virtual groups beginning in 2018.


• Reduces reporting burden: Physicians are required to report on 6 measures or a specialty measure set, one of which must be an outcome measure or, if no outcome measures are available, a high priority measure. • Reduces administrative claims measures: An all-cause hospital readmissions measure was finalized for groups of 15 (up from 10 in the proposed rule) or more physicians and with 200 attributed cases. The measure will be calculated based off of administrative claims data. • Reduces data completeness criteria: In 2017, any physician who reports on one quality measure for at least one patient will receive at least 3 points on the measure, thereby avoiding a payment adjustment in 2019. • Reduces reporting thresholds: In 2017, physicians have to report on a measure successfully on 50 percent of patients, and in 2018, physicians have to report on a measure successfully on 60 percent of patients. CMS intends to increase the measure thresholds over time. If a physician is only avoiding a penalty and not attempting to earn an incentive, they are only required to report on one patient in 2017. • Increases quality percent of composite performance score: 60 percent of the composite performance score will be based on the quality performance category in 2017, due to the reduction of the cost performance category weight to zero percent. 50 percent of the composite performance score will be based on the quality performance category in 2018. In 2019 and beyond, 30 percent of the composite performance score will be based on the quality performance category. • Encourages the use of QCDRs and electronic sources: CMS provides preferential scoring for physicians who report quality measures through an EHR, qualified registry, QCDR, or web-interface.


• Reduces weight of composite performance 2: In 2017, the cost performance category is reduced to zero percent of the composite performance score. In 2018, the cost performance category is reduced to 10 percent of the composite performance score. In 2019 and beyond, the cost performance category will make up 30 percent of the composite performance score as required by MACRA. Although this category will not count in the composite performance score, CMS will calculate scores on the cost measures and provide them as informational to physicians in 2017. • Phases in episode-based measures: CMS finalized 10 episode based measures in 2017, and plans to finalize additional episode-based measures in future years. • Retains two problematic cost measures currently used in the value modifier: CMS finalized the total per capita cost and Medicare Spending Per Beneficiary (MSPB) administrative claims cost measures. The minimum number of cases required to count the total cost measure is 20. The minimum case threshold for the MSPB measure is 35. • Tools to improve cost measurement are under development: CMS is developing patient condition groups and patient relationship codes to assist with attribution beginning in 2018, as well as working for future years to refine its risk-adjustment methodologies.

Improvement Activities

• Reduces reporting burden: Physicians must attest to two 20-point high weighted activities, four 10-point medium-weighted activities, or another combination of high and medium weighted activities equaling 40 points or more to achieve full credit in the CPIA category. • Provides accommodations for small, rural, health professional shortage areas (HPSAs) and non-patient facing physicians: A lower reporting threshold of two medium-weighted or one high-weighted improvement activities are required for small, rural, HPSA and non-patient facing physicians to receive full credit. • Finalizes 90-day reporting period: CMS finalized its proposal to only require a 90-day performance period for Improvement Activities. • Increases number of highly-weighted activities: The final rule increases the number of highly-weighted activities available to physicians, including participation in rural health clinics. • Expands definition of medical homes eligible for full Improvement Activity credit: Participants that have received certification or accreditation as a Patient Centered Medical Homes (PCMH), or comparable specialty practices, including those certified by a national, regional or state program, private payer or other body that administers PCMH accreditation and certifies 500 or more practices for PCMH accreditation or comparable specialty practice certification will receive full credit in the CPIA performance category. • Provides full credit for MIPS APMs: APM Entities participating in the 2017 MIPS APMs receive a full score for the Improvement Activities in 2017. The eligible MIPS APMs are subject to change in future years. Other APMs are eligible for at least half-credit. • Incentivizes use of certified electronic health record technology (CEHRT): Physicians may receive preferential scoring in the ACI category by using CEHRT to perform one or more of 18 designated improvement activities.

Advancing Care Information

• Reduces reporting burden: Physicians must report on all required ACI measures in the Base Score (4 in 2017 and 5 thereafter), with up to an additional 9 optional measures in the Performance Score, for which physicians may receive additional percentage points. The Base Score measures are met via one unique patient or attestation to a “yes” option. The Performance Score measures are eligible for partial credit. • Temporarily shortens reporting period: In 2017 and 2018, physicians must report the ACI measures for a minimum of 90-days. • Promotes coordination between performance categories: Physicians can earn preferential scoring in the ACI performance category by reporting to public health and clinical data registries, and by using CEHRT to complete certain activities in the improvement activities performance category. • Eliminates measures: CMS finalized its proposal to eliminate the Clinical Decision Support (CDS) and Computerized Physician Order Entry (CPOE) measures from the Advancing Care Information measures. • Retains a pass-fail element: CMS finalized a pass-fail element in the base performance score, as physicians must report on all measures in the base score in order to earn a score in the ACI performance category.

Alternative Payment Models (APM)

Advanced APMs • Reduces the amount of losses defined as “more than nominal” in Advanced APMs: An APM will qualify as an Advanced APM in 2019 and 2020 if the APM Entity is either (1) at risk of losing 8 percent of its own revenues when Medicare expenditures are higher than expected, or (2) at risk of repaying CMS up to 3 percent of total Medicare expenditures, whichever is lower. CMS states that it plans to increase the risk standard to 10 or 15 percent of revenues in future years. • Simplifies the definition of “more than nominal financial risk”: To qualify as a Medicare Advanced APM, the APM must only meet the requirement for total risk. • Adopts flexible CEHRT and quality requirements: In 2017, 50 percent of participants in Advanced APMs would need to use CEHRT. To satisfy quality measure requirements, Advanced APM participants would be required to report quality measures similar to those used in the MIPS quality performance category. • Indicates future APM expansion: CMS acknowledged the need to expand the number of APMs quickly in the final rule. CMS indicates that it plans to modify existing programs, such as the Bundled Payments for Care Improvement initiative, so they meet the Advanced APM requirements. It also plans to develop a new MSSP ACO Track 1+ that requires less downside risk than current Track 2 and Track 3 ACOs, but sufficient risk to meet the Advanced APM standards. MIPS APMs MIPS APM requirements: MIPS APM participants can improve their MIPS scores in APMs that do not meet criteria to be Advanced APMs or if the physicians are participating in Advanced APMs but do not meet the revenue or patient thresholds to be exempt from MIPS. • Medicare Shared Savings Program and Next Generation ACOs would report quality for participants and the CPIA and ACI performance categories will be reweighted to 20 percent and 80 percent respectively. • Non-ACO MIPS APM participants will have their quality score reweighted to zero for the 2017 performance period and the CPIA and ACI performance categories will be reweighted to 25 percent and 75 percent respectively. • Each year, CMS will compare the requirements of the APM with the list of Improvement Activities and score those measures in the same manner they are otherwise scored for MIPS eligible clinicians. Prior to the start of each performance period, CMS will publish a list of the pre-assigned Improvement Activities score for each MIPS APM. If the assigned score does not represent the maximum Improvement Activities score, APM Entities will have the opportunity to report additional Improvement Activities. Patient-Centered Medical Homes definition: Medical homes that have received certification or accreditation as a patient-centered medical home (PCMH) or comparable specialty practices, including those certified by a national program, regional or state program, private payer, or other body that administers PCMH accreditation and certifies 500 or more practices, will receive full credit in the CPIA performance category.

Physician-Focused Payment Models (PFPMs)

PFPMs: The final rule expanded the definition of PFPM to include practitioners other than physicians. Payment models can target the quality and costs of services that other practitioners provide, order, or significantly influence, rather than just physician services. Physician Attestation Requirements The Office of the National Coordinator for Health Information Technology (ONC) Direct Review: • Physicians must attest that they engaged in good faith in “Supporting Providers with the Performance of Certified Electronic Health Record (EHR) technology” (SPPC) activities related to ONC’s direct in-the-field review of EHRs. • Physicians must attest to their acknowledgment of the requirement to cooperate in good faith with ONC’s direct review of EHRs if a request to assist in ONC direct review is received. • A physician who receives a request must also attest that they cooperated in good faith with ONC’s direct review of EHRs. Prevention of Information Blocking: To be a meaningful EHR user, a physician must demonstrate that they have not knowingly and willfully taken action (such as to disable functionality) to limit or restrict the interoperability of their EHR. Including attestation that they: • did not knowingly and willfully take to limit or restrict the interoperability of their EHR; • implemented technologies, standards, policies, practices, and agreements to ensure—and did not limit restrict—the exchange of electronic patient data in their EHR; and • responded in good faith and in a timely manner to requests to retrieve or exchange electronic patient information—including from patients, health care providers and other persons regardless of the requestor’s affiliation or EHR vendor. Current CMS Resources CMS’ Quality Payment Program Website CMS’ Small Practice Fact Sheet CMS’ Comprehensive List of APMs

CMS Finalizes Overhauled Policy on Global Codes Data Collection

The Centers for Medicare & Medicaid Services (CMS) released an improved policy November 2 on the collection of data that will eventually be used to revalue global codes. Under the final rule, physicians in large practices who perform 10- and 90-day global services in a representative sample of nine states will be required to report Current Procedural Terminology (CPT) code 99024 to report data on the number of postoperative visits they provide. CMS is limiting reporting to codes that the agency has determined are high-volume or high-expenditure Medicare services. This reporting requirement is scheduled to take effect July 1, 2017. CMS is implementing a requirement for reporting on services that are furnished by more than 100 practitioners and are either furnished more than 10,000 times or have allowed charges of more than $10 million annually as recommended by the RUC and many other commenters. Under this policy, CMS would collect data on about 260 codes that describe approximately 87 percent of all furnished 10- and 90-day global services and about 77 percent of all Medicare expenditures for 10- and 90-day global services under the PFS. Given that this data would provide information on the codes describing the vast majority of 10- and 90-day global services and expenditures, it will provide significant data for valuation. CMS will require reporting that only applies to practitioners in selected states. In addition, those practicing only in small practices are excluded from required reporting. Those not required to report can do so voluntarily and we encourage them to do so.  Those states are Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island. CMS is not implementing the statutory provision that authorizes a 5 percent withhold of payment for the global services until claims are filed for the post-operative care, if required. This final policy is a complete overhaul of the proposed rule released in July, which would have required that all physicians in all states report data on all 10- and 90-day services that they provide. Physicians would have been required to report their pre- and postoperative care in 10-minute increments—an untenable requirement that is not aligned with clinician workflow—beginning January 1. The final rule is available online; the section related to global codes begins on page 149.

October 2016

New Quality Payment Program Announced

The Department of Health and Human Services (HHS) finalized its policy implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively referred to as the Quality Payment Program. The new Quality Payment Program will gradually transform Medicare payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care system. The rule is informed by a months-long listening tour with nearly 100,000 attendees and nearly 4,000 public comments. A common theme in the input HHS received was the need for flexibility, simplicity, and support for small practices. And that’s what this final policy aims to provide. First, the new payment system creates two pathways. These paths let clinicians pick the right pace for them to participate in the transition from a fee-for-service health care system to one that uses alternative payment models that reward quality of care over quantity of services. Clinicians will choose between two options:

  • The first path gives clinicians the opportunity to be paid more for better care and investments that support patients. It reduces existing requirements, while still emphasizing and rewarding quality care. In the first year, it also provides a flexible performance period, so that those who are ready can dive in immediately, but those who need more time can prepare for participation later in the year.
  • The second path helps clinicians go further by participating in organizations that get paid primarily for keeping people healthy.

For example, they could be part of an Accountable Care Organization where clinicians come together to coordinate high-quality care for the patients they serve. When they get better health results and reduce costs for the care of their patients, the clinicians receive a portion of the savings. Other parts of the final rule reveal that CMS listened to physician concerns and modified portions of the proposed rule to help physicians participate in the QPP.  For example:

  • Details are provided about the 2017 transition period announced in September. The only physicians who will experience payment penalties in 2019 are those who choose to report no performance data next year, and those who report for at least 90-days will be eligible for positive payment adjustments.
  • The low-volume threshold that exempts physicians from all performance reporting has been increased from $10,000 in annual Medicare revenue and less than 100 Medicare patients to $30,000 in revenue or 100 patients. CMS estimates that this change will exempt 32.5 percent of physicians and other clinicians from the program.
  • Performance reporting requirements have been further reduced, and the resource use component of the Merit-based Incentive Payment System (MIPS) has been reweighted to zero for 2017. Accompanying today’s announcement is a new Quality Payment Program website http://qpp.cms.gov, which will explain the new program and help clinicians easily identify the measures most meaningful to their practice or specialty. The website includes fact sheets and educational material for all types of practices including small, rural, and specialty based.

CMS Indicates Flexibility for Physician Participation in Quality Payment Program

In a September 8 blog post, Andy Slavitt, the Centers for Medicare & Medicaid Services (CMS) Administrator, indicated a willingness to provide flexibility for physicians participating in the new Quality Payment Program (QPP). Physicians will have four options for participation. For example, one option indicates that if a physician provides “some data” to the QPP in 2017, the physician will avoid a negative payment adjustment in 2019.

Check Your Performance in 2015 CMS Quality Programs

The Centers for Medicare & Medicaid Services (CMS) recently released the 2015 Annual Quality and Resource Use Reports (QRURs) and Physician Quality Reporting System (PQRS) Feedback Reports for all group practices and solo practitioners. The 2015 QRURs show how groups and individual practitioners performed in 2015 with respect to the quality and cost measures used to calculate the 2017 Value Modifier (VM) and how the VM will apply to physician payments. The 2015 PQRS Feedback Report will show how groups and solo practitioners reported PQRS and whether they will receive a payment adjustment. Reviewing QRURs and feedback reports is especially important as CMS quality programs will soon transition into the Merit-based Incentive Payment System (MIPS). The MIPS reporting year will begin in 2017, and the QRURs and feedback reports will give providers an opportunity to see how they are performing in terms of the Quality and Resource Use components of MIPS before payment adjustments occur in 2019. Groups and solo practitioners are identified in the QRURs by their Taxpayer Identification Number (TIN) and their PQRS Feedback Reports by a combination of their TIN and National Provider Identifier (NPI). The CMS website provides instructions about how to access your QRUR, as well as a reference guide to obtain your PQRS Feedback Report.

Smart Cards to Block Medicare Fraud

Representative Peter Roskam pressed for a test of using so-called smart cards to prevent Medicare fraud. He’s seeking to mimic for the giant federal health program the success that private businesses have had in combating theft and fraud. Federal estimates peg the rate of improper payments, including fraud, at 3.6 percent for Medicare’s Part D drug plans to 9.5 percent for the insurer-run Advantage program and 12.1 percent for the traditional fee-for-service program. Roskam noted that an official of Visa Inc. last year told his subcommittee that its fraud rate is far less than 1 percent. At the Wednesday hearing, Roskam stressed that the harms extend beyond the roughly $60 billion squandered in improper payments. Medicare smart cards would provide for something akin to “point-of-sale authenticity” from doctors’ offices instead of Medicare contractors reviewing the charges later in the billing process, Roskam said. Such rapid communication helps credit card companies now quickly spot suspicious trends in billing that tip them off to fraud and theft. A smart card could give Medicare the same advantage, according to Roskam. However, Roskam faces two significant hurdles to his bid to kick off a pilot program for Medicare cards with an integrated circuit chip that would allow more rapid and secure connection to billing systems. Congress’ abbreviated schedule due to the election may give Roskam few chances to move his bill (HR 3220), either as an attachment to another bill or as a stand-alone measure. His bill was not in a House-passed Ways and Means package (HR 5273) of small Medicare changes, a measure that trade associations are pressing Congress to clear in the lame-duck session.

Possible Medicare Cost Increases for Seniors

A coalition of advocacy groups, unions and insurers asked lawmakers to commit to stop potential 2017 increases in the tab that many seniors citizens and people with disabilities pay for Medicare’s outpatient coverage. The abbreviated election-year schedule will leave Congress little time to react to changes in premiums and deductibles, which may be announced next month. The potential increases would be tied to the amount of the annual cost-of-living adjustment that Social Security is expected to announce around Oct. 18. Congress will be on recess at that time ahead of the November election. If the Social Security COLA triggers an increase in Medicare premiums and deductibles for 2017, as is expected, lawmakers would face pressure to address that during the lame-duck session after the election. The letter was sent to the leaders of the Senate Finance Committee, the House Ways and Means Committee and the House Energy and Commerce panel, as well as Republican and Democratic leaders in both chambers. Signers include Aetna Inc. and America’s Health Insurance Plans, as well as medical advocacy groups such as the American Academy of Nursing. About 30 percent of people enrolled in the federal health program will likely see a bump, according to Medicare’s board of trustees. This group includes people already paying higher premiums due to their high incomes, new enrollees and people who don’t collect Social Security benefits. The Part B outpatient deductible for all Medicare enrollees also could rise, depending on what the final COLA figure is for Social Security payments for next year. In their letter to lawmakers, the groups asked Congress to repeat the steps that they took last year to head off scheduled 2016 Medicare cost increases if seniors face them for next year. The November 2015 budget agreement (PL 114-74) included a provision blocking increases in premiums and deductibles for Medicare Part B, which covers services provided in doctors’ offices. Given the abbreviated congressional schedule after the election, any similar fix for Medicare Part B premiums would likely have to be tucked into a fiscal 2017 spending package because Congress will clear few other measures in the lame-duck session.

112 House Members Sign Letter Panning Global Payment Proposal

Representative Joe Heck, D.O. (R-NV), along with 111 bipartisan congressional cosigners, sent a letter to the Centers for Medicare & Medicaid Services (CMS) September 16 opposing a global payments provision in the 2017 Medicare Physician Fee Schedule proposed rule. The proposed rule would require all surgeons to submit data for all 10- and 90-day global surgery code services in 10-minute increments using eight non-payable G-codes for all patients. The letter notes that the proposed rule does not comply with the congressional mandate in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 that calls for the collection of global payment data from a representative sample of surgeons.