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AANS Neurosurgeon | Volume 28, Number 2, 2019

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Neurosurgery Responds to Changes in Quality Reporting, Payment Systems

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The last 12 months has seen seismic changes in how quality mandates impact neurosurgical practices. These changes will have an increasingly greater impact upon physician reimbursement. Paradigms have shifted and initiatives have changed substantially. This article will briefly review where neurosurgery is active in the quality space, what changes have begun in 2015 and how organized neurosurgery is responding to these issues with ongoing advocacy and continuing efforts to champion practicing neurosurgeons in all practice environments.

History
First, some background. Neurosurgery has been represented in the quality realm by the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Joint Quality Improvement Workgroup (QIW). This group was established in 2005 with the QIW growing out of the previous Quality Assessment Committee. The QIW was composed of a chair, vice chair, representatives of each section, NeuroPoint Alliance (NPA), the Joint Guidelines Committee, the American Board of Neurological Surgery (ABNS), the Society of Neurological Surgeons (SNS) and the Washington Committee. While the primary role of the committee was to oversee quality issues in neurosurgery, the QIW had to respond to a variety of quality-focused regulatory changes that had an increasing impact on physician practice and reimbursement.


Value based care graphic 2 


The connection between quality and reimbursement increased in intensity with the 2015 Medicare Physician Fee Schedule. Physicians had been encouraged to report quality metrics through the Physicians Quality Reporting System (PQRS) for a number of years; previously, small bonuses were available for Medicare reimbursement for successful reporting. Starting in 2015, the bonus was eliminated, and the Centers for Medicare & Medicaid Services (CMS) instituted a penalty for non-compliance equal to 2 percent of a physician’s total annual Medicare payments. Due to a two-year gap between reporting and reimbursement, 2015 reporting influences 2017 reimbursement. Quality reporting also influences the Value Based Payment Modifier, a performance-based payment adjustment that evaluates both quality and cost and can impose up to an additional 4 percent in penalties for physicians that do not comply with the program or have poor performance. 

Concurrent with the transition to a penalty system, the 2015 Physician Fee Schedule also eliminated the Perioperative Services Measures Group, a means of PQRS compliance used widely by individual surgical specialists. For employed physicians, there are group reporting options. For physicians in solo or single-group practices, the lack of relevant quality measures makes compliance with the system difficult. For physicians failing to comply with the new targets, 2015 also brought new edicts for maintaining compliance with “Meaningful Use” for electronic health records (EHRs) with further potential penalties (3 percent).

MACRA Changes
The Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) changed this system. While MACRA eliminated the potential risk of a downward adjustment in the Medicare conversion factor that would decrease payments to all physicians via the Sustainable Growth Rate (SGR), the new law also introduced a re-configured system of assessing quality. MACRA introduced a new system called the Merit-based Incentive Payment System (MIPS) that consolidates all of the current Medicare-sponsored quality programs (PQRS, Meaningful Use for EHR implementation and the Value Based Payment Modifier). Starting in 2019, all physicians will receive a score on a 100-point scale based on their composite performance in the four MIPS categories of quality measures, resource use, meaningful use of EHRs and clinical practice improvement activities.

How this will be calculated is still being worked out by Medicare, and neurosurgery is active in making recommendations. The goal of Medicare is to make sure that the majority of fee-for-service reimbursement is tied to quality reporting. The previous system, where PQRS, Meaningful Use and the Value Based Payment Modifier were all individual programs, is set to end in 2018, and the penalties associated with each program will be repealed. While MIPS will include a new structure for penalties, they are capped overtime and put less of a physician’s payment at risk compared to the current penalty structure. 

Nevertheless, MIPS will drive reimbursement for practicing neurosurgeons. In 2019, there will be a maximum 4 percent downwards adjustment and an up to four percent positive adjustment, based on MIPS scoring. This increases to a range of + 9 percent to – 9 percent by 2022. MIPS will be a huge influence on physician reimbursement in the near term.

MACRA also encourages physicians to test innovative alternative payment models (APM) by presenting physicians with the opportunity to receive higher annual base Medicare payment updates — if they receive a significant share of their revenue from an APM that entails nominal risk and some element of quality measurement and meaningful use of EHRs. Again, these details have yet to be determined. 

Bundled Payments
In July 2015, the Federal Register brought an entirely new reimbursement system to play with the introduction of the Comprehensive Care for Joint Replacement (CCJR) system. The CCJR is a bundled payment system where orthopaedic surgeons face upwards or downwards payment adjustments based upon whether or not their expenditures on patients are below or above target prices set by Medicare (based on retrospective data).

This new approach was the first time that Medicare imposed a bundled-payment architecture on a wide variety of hospitals. Previously, there were elective options where physicians and facilities could volunteer to participate. This is the first time that bundles have been mandated by Medicare.

We can anticipate that bundled payments will become a greater driver of physician reimbursement in the future. So, while this system is not relevant to neurosurgery today, it may have a huge impact on our specialty in the future. There are problems with the proposal that we have pointed out to CMS — in addition to concerns about the mandatory nature of the program. The approach essentially provides no incentive to improve care, the risk-adjustment system used to identify complex or high-risk cases is not well defined and the entire system relies upon hospitals for execution. Regardless, this system will begin to affect our orthopaedic colleagues starting Jan. 1, 2016.

Change to Neurosurgery Quality Council
Neurosurgery, through the previous QIW, is involved in an “alphabet soup” of quality organizations. We have endeavored to make sure that every significant player in the quality world has a representative from our specialty. The QIW ensured neurosurgeons were directly engaged in the National Quality Forum (NQF), the Physician Consortium for Performance Improvement (PCPI), the Surgical Quality Alliance (SQA) and the Patient Centered Outcomes Research Institute (PCORI). Neurosurgical representatives worked on the Choosing Wisely Campaign, contributed to improving the accuracy of bundled payments in spine surgery through work with the Health Care Incentives Improvement Institute (HCI3), provided annual comments on changes to the Meaningful Use system, loudly voiced our concerns about the Physician Compare website maintained by CMS to publicly report quality data, critiqued the Open Payments program and influenced the development of federal Accountable Care Organizations.

These efforts required the dedicated efforts of countless QIW members. Even with these dedicated efforts, the constant changes in the quality space made it clear that changes were necessary in the QIW structure. Hence, the QIW is changing to become more responsive to the demands of the quality space and be a stronger voice in advocating for practicing neurosurgeons. With approval from the AANS and CNS, the Washington Committee is transforming the QIW into the Neurosurgery Quality Council (NQC). The new council will be composed into a single chair and overseeing four vice chairs who will take responsibility for individual aspects of quality assessment.

The four vice chairs will be:

  • Vice Chair, Data Registries and Performance Measurement
  • Vice Chair, Payment, Delivery Models and Public Reporting
  • Vice Chair, Health Information Technology
  • Vice Chair, Performance Improvement

 

This change will make the NQC better able to complete strategic planning, identify resource needs, foster greater stakeholder relationships and coordinate activities between the variety of involved neurosurgical organizations. The new council will have representation from the joint sections, including the Coding and Reimbursement, Drugs and Devices, Joint Guidelines, CSNS Safety and Washington Committees, in addition to AANS, CNS, NPA, SNS and ABNS.

What We are Doing
Neurosurgery faces wide-ranging challenges, particularly relating to quality improvement and demonstrating the value that neurosurgeons bring to patients. A restructured NQC that is integrated with all elements of organized neurosurgery will help ensure that the AANS and CNS are able to meet these challenges for the benefit of our members and patients alike. 

In addition to the ongoing involvement in the quality groups mentioned above, the NQC is already active on a variety of new fronts. Members of the Neuropoint Alliance (NPA) have achieved recognition of the National Neurosurgery Quality Outcomes Database (N2QOD) as a registry for quality reporting to CMS, meaning N2QOD sites may achieve compliance with PQRS reporting through their ongoing registry reporting and participation.

We are developing measures groups that may be more relevant to neurosurgical practice. We are pointing out the limitations and weakness of the CCJR bundled payments system. We are working with Acumen, the contractor responsible for the CCJR system, to make sure that any spine bundled payments have a logical structure that will not lump disparate cases into ill-defined bundle architectures. We are intimately involved in crafting responses to Medicare that will help define the MIPS system and try to make it relevant and beneficial to practicing surgeons.

Through continued advocacy by our Washington Committee team and the tireless efforts of the NQC volunteers, we will continue to advocate for our patients and our specialty.

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Camille Devaux | November 6, 2018 at 4:54 pm

It I helpful to know what a neurosurgeon does since my uncle was looking into it. He wants to know how they handle the issues people suffer from. My uncle would love knowing that improvement in quality is making outcomes for patients better.