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Quality & Governance News

CMS Details MACRA Quality Reporting, Payment Reform Proposals

By Jennifer Bresnick

- In the first update to the Medicare physician fee schedule (PFS) since the sustainable growth rate (SGR) formula was repealed in April, CMS has unveiled its proposed rule for implementing some of its major changes to the industry’s clinical quality reporting and value-based reimbursement frameworks. 

SGR repeal quality reporting and value-based reimbursement

The updates, slated to take effect at the beginning of 2016, include modifications to the Physician Quality Reporting System (PQRS), EHR Incentive Programs, and Physician Value-Based Payment Modifier, among other things.

“CMS is building on the important work of Congress to shift the Medicare program toward a system that rewards physicians for providing high quality care,” said Andy Slavitt, Administrator of CMS in a press release.  “Thanks to the recent landmark Medicare and children’s health insurance program legislation, CMS and Congress are working together to achieve a better Medicare payment system for physicians and the American people.”  

The proposed rule, which closely follows provisions previously laid out in the Medicare Access and CHIP Reauthorization Act (MACRA), includes the following notable changes, updates, and adjustments:

Quality data reporting and payment through PQRS and the EHR Incentive Program

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The Physician Quality Reporting System (PQRS) program is coming to an end in 2018 as it completes its transition into the new Merit-Based Incentive Payment System (MIPS).  Negative payment adjustments of up to 2 percent will apply in 2018 to providers who do not satisfactorily report or participate in the program in 2016.

“CMS proposes to make changes to the PQRS measure set to add measures where gaps exist, as well as to eliminate measures that are topped out, duplicative, or are being replaced with a more robust measure,” says the proposed rule’s fact sheet.  “If all measure proposals are finalized, there will be 300 measures in the PQRS measure set for 2016.  Also, as recently authorized under MACRA, CMS proposes to add a reporting option that will allow group practices to report quality measures data using a qualified clinical data registry (QCDR).”

Calendar year 2016 will also be influential for participation in the Physician Value-Based Modifier program, the second initiative that will be rolled into MIPS in 2018.  CY 2016 will determine the Value Modifier for CY 2018, CMS says, based on participation in PQRS by group and solo practitioners.  A tiered methodology based on quality will determine whether a participant receives a neutral, positive, or negative payment adjustment unless they qualify for exceptions included in the 2015 PFS final rule.

Maximum positive and negative payment adjustments will continue to be capped at 4 times the value of the adjustment factor for the largest participating groups.

The third side of the MIPS triangle, the EHR Incentive Programs, will also see reporting changes as the Office of the National Coordinator redefines the scope and meaning of Certified EHR Technology (CEHRT).  Pursuant to a previously released proposed rule, the submission of electronic clinical quality measures (CQMs) will need to meet the new guidelines outlined by the ONC.

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Annual adjustments to incorrectly valued codes

As required by the Affordable Care Act, Medicare will continue to make adjustments to payment structures for codes that may have been misvalued.  For example, lower GI endoscopy services have undergone major changes in application and use over the past few years, with sedation and anesthesia being reported separately more often for these procedures. 

“CMS is seeking recommendations from the RUC and other interested stakeholders for valuation of the work associated with moderate sedation alone before proposing an approach that allows Medicare to make payments based on the resource costs associated with the moderate sedation or anesthesia services that are being furnished.  Additionally, CMS is proposing to identify anesthesia procedure codes 00740 and 00810 as potentially misvalued.”

Adoption of appropriate use criteria for advanced imaging services

The Protecting Access to Medicare Act (PAMA) requires providers who order advanced diagnostic imaging services to consult with “appropriate use criteria” such a clinical decision support system integrated into their EHRs.

READ MORE: Will Big Data Analytics Rescue Lackluster Electronic Health Records?

PAMA also requires CMS to approve clinical decision support mechanisms by April 1, 2016, requires additional information be collected on the Medicare claim form by January 1, 2017, and requires that the claims information be used to develop a prior authorization program by January 1, 2020,” CMS states. 

“CMS is proposing to provide definitions for areas of the statute that require clarification.  For example, a definition is required for “provider-led entity” in order to identify which organizations are eligible to develop or endorse appropriate use criteria.  In addition, CMS proposes to establish a process by which the agency will identify clinical areas of priority, specify appropriate use criteria, and lay out a timeline to accomplish these goals.”

Advanced planning for care coordination and personalized care

In order to ensure that patients have the opportunity to make their end-of-life or emergency wishes known to their providers, CMS proposes to establish payment parameters for physicians who spend time developing advanced directives with their patients.  While Medicare allows for advanced care planning during an enrollee’s initial welcome visit, CMS notes that many patients do not take advantage of this option during that time. 

CMS is asking for public comment on the development of new CPT codes and payment amounts that would best support providers as they undertake this important task for patient engagement and care coordination.

Public data transparency through Physician Compare

CMS will continue to reach out to consumers through its series of Compare websites, and will add additional public data in order to make resource such as Physician Compare a useful destination for patients.  In the proposed rule, CMS notes that it plans to include information on successful PQRS Cardiovascular Prevention measures that support the Million Hearts initiative, as well as practices that receive a positive payment adjustment for the Value Modifier.

CMS also proposes to make individual-level and group-level QCDR measures and utilization data for individual providers available for public reporting.  CMS will also make understanding this information easier for consumers by adding a five-star rating to Physician Compare profile pages, as they have done for other members of the Compare family of websites.

CMS is seeking public comment on all its proposed measures for the Calendar Year 2016 Physician Fee Schedule updates.  Interested stakeholders may submit their reactions for 60 days, with the comment period ending on September 8, 2015.  CMS will publish the final rule on November 1, 2015.

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