AANS Neurosurgeon | Volume 28, Number 4, 2019


The Impact of MIPS on Neurosurgery

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I would like to take a few minutes to review a new payment model that the Centers for Medicare & Medicaid Services (CMS) introduced recently that impacts our orthopaedic colleagues. The new proposed policies for the Merit-based Incentive Payment System (MIPS) have just been made available for public comment. We will review the important content from that document in a future column; it will take some time to digest that 1,000-page tome.

The CCJR Model
CMS recently proposed a new bundled payment system known as the Comprehensive Care for Joint Replacement (CCJR) model. This model covers a variety of charges for patients undergoing total hip and total knee arthroplasty procedures. These bundled payments will cover hospitalization, professional fees and all clinically related Medicare Part A and Part B services for 90 days after discharge. This bundle will also cover both the initial hospitalization, skilled nursing facilities, home care and any hospital readmissions.

How Will it Work?
At the end of the year, a target payment for the relevant procedures will be determined. This target price is determined by blending three years of data using both hospital-specific and regional data for modelling. Each hospital will have its own target price assigned. Facilities will be assessed to see if they are in compliance with quality measures that are assigned to the CCJR model. If facilities spend less than the target price and achieve successful quality reporting, they will receive a bonus payment. If they cost more than the target price, they have to repay CMS up to a cap.

What Quality Measures do They Use?
Risk standardized complication rates, readmission rates and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are used. The over/under is capped at the first year at zero, meaning that there is no downward adjustment at the outset of the program. In the coming years, though, it increases substantially. The program began in 75 metropolitan areas and approximately 750 hospitals in 2016.

Making the Connection 
Why should neurosurgeons care about a new policy that only affects joint replacement? The same basic tenets may be applied to spine, craniotomies, endovascular treatment of stroke or to essentially anything we do. This gives us a window into how CMS will approach developing episodes of care and bundling of payments. The CCJR system is a retrospective approach to bundling payments in that CMS comes around at the end of the calendar year and either pays a bonus or asks for a refund. We may anticipate that the same tenets that dictate the development of the CCJR will be applied to a variety of procedures in the future. What we can learn from this process, and perhaps what we may affect through advocacy, may help improve this process in the future.

Become Part of the Conversation
There are numerous concerns in the approach that CMS is taking. The Washington Committee and your Neurosurgery Quality Council (NQC) have prepared comments that were forwarded to CMS voicing these issues. In the proposed system, the hospital is the primary beneficiary. Hospitals receive the bonus payment or are responsible for the reconciliation if target prices are not met. The system does not provide a platform for engagement of physicians in the process, and the responsibility for dispersing any surplus is that of the hospital. It is our opinion that physicians, not facilities, should be the primary leaders in developing and executing these models. 

The risk-adjustment methodology used in this system, similar to other approaches, does not appropriately capture the impact of patient and procedure factors on complication occurrence. Since readmissions are a primary driver for hospital costs, poor risk-adjustment and lack of risk stratification will unfairly penalize tertiary care facilities that care for sicker patients with more comorbidity burden. Similarly, there are no allowances for pre-operative functional status in the assessment. The additional costs of a post-operative stay in a skilled nursing facility or rehab unit, even when clinically necessary, are noted only as an increased cost and not as an appropriate intervention. 

Perhaps what is most concerning is that the model uses spending as the primary endpoint. None of the quality metrics deal with functional outcomes: Did a patient return to a desired level of activity after a total hip arthroplasty? Did they return to work? Was their pain medication use decreased? None of these functional elements are captured by the system.

Clinical interventions or innovations that provide better outcomes, but cost more, will be discouraged. This approach may also apply a perverse incentive to not provide care to sicker, more debilitated patients who will have greater need for peri-operative and post-operative resources.

Your representatives in the NQC and Coding and Reimbursement teams will continue to monitor CMS’s approaches to bundled payments and to developing episodes of care. Upcoming articles will also provide more information on the new MIPS system.

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