AANS Neurosurgeon | Volume 28, Number 4, 2019


The Coming of MIPS

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2017 promises to see many changes in neurosurgical coding and quality reporting. New systems will impose fundamental shifts in a variety of Medicare reporting requirements. This article will provide a quick overview of changes in quality, meaningful use, and value reporting. Future educational content developed and provided by the American Association of Neurological Surgeons (AANS) will help members prepare their practices to adapt to these changes.

The greatest potential impact on physician reimbursement from 2001 until 2015 was Medicare’s perpetual sustainable growth rate (SGR) payment cliff — a threat to physician reimbursement that required yearly lobbying from organized medicine to forestall this 20 percent pay cut. Physicians were also subject to a variety of often redundant Centers for Medicare & Medicaid (CMS) quality reporting systems: the Physician Quality Reporting System (PQRS), Electronic Health Record (EHR) Incentive meaningful use (MU) program and the Value-Based Payment Modifier (VM). Noncompliance with these programs could potentially yield more than an 11 percent cut in Medicare payments each year.

This all changed in 2015, with the passage of the Medicare Access and CHIP Reauthorization Act (MACRA). While this legislation eliminated the threat of SGR-related pay cuts, it also generated a new consolidated system of quality reporting. Many of the elements reviewed in this article are potential requirements at this time. However, it can be safely assumed that each part will play a role in the final regulations that the CMS publishes later this year.

MACRA — The Basics
MACRA establishes a unified approach to quality reporting by physicians, incorporating parts of the current disparate quality reporting elements, while at the same time attempting to eliminate the redundancy and separate reporting requirements of the PQRS, VM and MU programs. This new Quality Payment Program is divided into two pathways: Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS).

APMs have a host of requirements, the most notable being that physicians involved in the APM must bear more than “nominal risk” for expenditures. This is similar to Accountable Care Organizations (ACOs), where expenditures are tracked over time. Expenditures for services or a treatment course that come in below benchmark values are financially rewarded; expenditures that are greater than a set benchmark are financially penalized. APMs must also incorporate quality measurement and require the use of EHRs. Finally, to qualify as an advanced APM under the new program, a sufficient number of Medicare patients must be incorporated into the APM. Successful compliance with an APM is great; it provides an automatic 5 percent Medicare payment bonus in addition to any APM-specific rewards.

APMs in neurosurgery are easy to discuss:  There aren’t any. The American College of Surgeons (ACS), working with the AANS and CNS, is developing a surgical APM. CMS is also developing sets of care episodes to be used for bundled payments. Under a bundled payment, CMS would pay a single fee for all the care provided under the bundle, including physician fees, hospital and post-acute care costs and other ancillary services such as imaging. These bundled payment programs require quality reporting and overall cost-reduction. A recent example of such a bundled payment APM is the Comprehensive Care for Joint Replacement (CCJR) system. Future bundled payments involving spine and stroke care are also likely forthcoming and would provide neurosurgeons an avenue for participating in a Medicare APM.

At present, though, APMs appear structured more for primary care physicians participating in “medical home” models and for existing ACOs. Thus, most neurosurgeons will not be eligible for an APM in 2017 and hence will be subject to the requirements of the MIPS system.

The MIPS system ties together four separate elements of quality reporting, with the goal of eliminating redundant reporting and streamlining the overall process for physicians. The four components of MIPS are:
1. Quality Reporting: This element is similar to PQRS. Initially, CMS will require reporting on six quality measures — down from the nine elements required under the current PQRS program. Initially, the quality element will be the highest weighted aspect of MIPS scoring, comprising 50 percent of a provider’s Eventually, quality will count for 30 percent of neurosurgeons’ MIPS scores.

2. Resource Use: This is a claims-based measure that CMS will calculate based upon general measures assessing total expenditure per Medicare beneficiary and a group of 40 clinic episode measures. Lumbar fusion, for example, is one of the episodes used to calculate resource use. Initially, resource use will only provide 10 percent of a clinician’s score. Over time, this will be worth 30 percent of the overall MIPS score.

3. Advancing Care Information (ACI): ACI replaces the EHR MU program. Requirements for reporting are fewer and easier than the old MU system. Interoperability of EHR data is emphasized. The ACI score will count as 25 percent of a physician’s MIPS score.

4. Clinical Practice Improvement Activity (CPIA): This new quality reporting category covers a variety of practice improvement activities, providing physicians credit for participating in maintenance of certification, reporting data to clinical data registries, care coordination and expanded office/practice hours. CPIA accounts for 15 percent of the total MIPS score.

Neurosurgeons will receive a composite score based on his or her performance among the four MIPS components. The composite score will be compared to a baseline and, depending on whether or not a physician’s score is above or below the baseline level, CMS will apply an up or down adjustment to Medicare payments. Initially, the up or down adjustment will be plus or minus 4 percent. Payment adjustments based on data collected in 2017 will be made two years later in 2019. Ultimately, when the program is fully implemented in 2022, payment adjustments will increase to plus or minus 9 percent.

While the new Quality Payment Program is better than the current, fragmented quality reporting system, there remain areas of potential improvement. Some requirements of the new program make successful reporting extremely difficult. For example, neurosurgeons opting for Qualified Clinical Data Registry (QCDR) reporting must report data on 90 percent (up from 50 percent under the current QCDR program) of all patients, whether Medicare beneficiaries or not.

Neurosurgery’s Response
Organized neurosurgery has suggested numerous changes in our comments, including:

  • Applying a phased approach to implementation;
  • Ensuring equal opportunity among different practice sizes to earn a MIPS bonus;
  • Scoring physicians based on participation rather than performance in the initial years;
  • Increasing the variety of activities that may be used to fulfill the CPIA requirements; and
  • Making data completion rates more reasonable.

The AANS and CNS also suggested a set of measures that could comprise a neurosurgery-spine measures set, which might ease the quality reporting requirement.

There is no doubt that MIPS has the potential to have a significant impact upon neurosurgeons in private practice. However, employed neurosurgeons and those practicing in large multi-specialty clinics or group practices (where reporting by primary care or other physicians may cover reporting for their entire group) will also be affected by MIPS. It, therefore, behooves all neurosurgeons to familiarize themselves with MACRA’s requirements.

Hopefully, this brief overview provides a general picture of the MIPS system and how it may affect your practice. Further information and updates may be found on MACRA resource web pages at www.aans.org/MACRA. Additional educational content specific to MIPS and MACRA will be forthcoming from the AANS/CNS Neurosurgery Quality Council (NQC), the AANS/CNS Communications and Public Relations Committee (CPR), the AANS/CNS Washington Committee and the Council of State Neurosurgical Societies (CSNS). Our aim is to make neurosurgeons MACRA-ready in the coming months to ensure successful participation in Medicare’s Quality Payment Program.

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Vikram Prabhu | September 12, 2016 at 9:33 am

Thanks John. This is a great snapshot of a complex issue. Vikram