The Future of Medicare: The New Alphabet Soup
Bye-bye SGR; say hello to MIPS and APMs
By Todd V. Cartee, MD
On April 16, the house of medicine scored a major victory with the repeal of the Sustainable Growth Rate (SGR) formula. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 also restored surgical global periods which were due to be eliminated by prior Centers for Medicare & Medicaid Services (CMS) mandates. MACRA, however, contains numerous additional policy initiatives that further the long-term goal of shifting from a fee-for-service to a value-driven reimbursement system. To help our membership understand and negotiate these unchartered waters, the ACMS works with Hart Health Strategies (HHS), a boutique healthcare lobbying and consulting firm in Washington, DC, with offices on Capitol Hill. Emily Graham from Hart Health Strategies spoke at our 2015 business meeting to introduce us to the new payment system delineated in MACRA. I interviewed her to expound on these issues and what steps she thinks Mohs surgeons need to be taking:
Hi Emily, could you please tell us about Hart Health Strategies and what services it provides the ACMS?
We have nine members on our team and represent close to 30 different health care organizations, most of which are medical specialty societies. Our primary focus is helping our clients engage in the federal legislative and regulatory process, but we also assist with other quasi-governmental entities that may influence federal initiatives, such as the National Quality Forum and the National Association of Insurance Commissioners. For the ACMS, we provide legislative support on issues that impact the practice of Mohs surgery, and medicine in general. For example, we monitor all newly introduced legislation and provide detailed analysis of relevant bills. We also follow all relevant proposed and final regulations, and provide detailed summaries that help the ACMS understand and respond to the changes. We assist the ACMS with its engagement on federal issues, whether through drafting written correspondence to or direct “shoe-leather” lobbying of Congressional offices and staff. Of course, our engagement is not limited to the above; we are a full-service firm, so we do everything we can to assist the ACMS, and its volunteers, with all aspects of government relations, public policy, and even private payer issues, both at the state and federal level, as requested.
Can you provide a few specific examples of recent activities HHS has conducted for the College?
On June 3-4, the ACMS hosted its third annual legislative conference, or “fly-in,” here in Washington, DC. HHS has continued to help organize the conference. This year, our firm secured a robust lineup which featured speakers from Capitol Hill, including Congressman Phil Roe (R-TN-1), senior Congressional staff from the Senate Finance and House Ways and Means Committees, as well as federal agencies, including CMS. We also coordinated Hill visits for each attendee and put together talking points for the attending members.
We have been investing a lot of effort in combating the narrow network/network adequacy issue with Medicare Advantage (MA) plans, drafting numerous letters to regulatory agencies and other influential bodies that focus on insurer issues, as well as helping design innovative strategies to persuade the MA plans themselves of the importance of keeping Mohs surgeons in their networks.
We have also been actively working with the ACMS to craft responses to problematic Local Coverage Determinations (LCDs), such as the one recently put forth by Novitas Solutions, a Medicare Contractor that covers 12 states. According to Medicare regulations, Novitas is required to contact the relevant specialty society before proceeding with a new or revised LCD, which in this case would be the ACMS, but instead drafted a completely new policy on Mohs surgery without input from the College.
At the business meeting this Spring, you relayed the good news regarding the SGR repeal but also detailed important Medicare payment system changes that were included in that recent legislation. Would you mind summarizing some of the key points we should be aware of?
There will be a transition to the new payment system in 2019. Providers will have a choice between two tracks: 1) the newly defined merit-based incentive payment system (MIPS) or 2) participate in an alternative payment model (APM). MIPS consolidates and replaces the separate existing Medicare value programs; the Electronic Health Record (EHR) Incentive program, also referred to as “meaningful use”, the Physician Quality Reporting System (PQRS), and the value-based payment modifier (VM), all three of which are now in effect and potentially affecting your Medicare reimbursement. CMS will generate a composite performance score under MIPS which includes these three arms and also assesses clinicians’ involvement in clinical practice improvement activities (CPIA). CPIA may include quality improvement programs such as Maintenance of Certification (MOC) and participation in a clinical data registry. Many other programs will likely be designated by the secretary in the future, but the work already done by ACMS in establishing a registry positions you ahead of the curve.
The MIPS track will be the most similar to traditional fee-for-service Medicare, whereas APMs, such as accountable care organizations, patient-centered medical homes, and bundled payments, represent a shift to a value-based model of payment and care delivery. The Secretary of Health and Human Services will tell us what else may qualify as an APM moving forward. For those who chose to participate in an APM, a percentage of their Part B services will need to be attributable to that APM, and that threshold will increase over time.
What can the ACMS do to prepare for this changing Medicare reimbursement landscape?
An APM for diagnosis and treatment of skin cancer would be ideal though not necessary. If the ACMS could develop an APM and get it approved by CMS, that would provide a straightforward mechanism for compliance for the foreseeable future. Regardless, I do not worry that ACMS members would not be successful in compliance. You’ve done an amazing job so far. You are taking on the skin cancer epidemic with a procedure that is 99% effective and overall cost effective. You are functioning in multiple roles: cutaneous oncologist, skin cancer surgeon, pathologist, and reconstructionist. It is unfortunate that some payers do not appreciate the value of this service, but overall, the ACMS is well-positioned to thrive in a value-based reimbursement scheme. The fact that you are already well underway in developing a clinical data registry is a prime example of how you are doing an excellent job staying ahead of the game relative to other sub-specialties.
What should the individual Mohs surgeon be doing to prepare for MIPS?
Right now Mohs surgeons need to make sure they are participating in meaningful use and reporting through the PQRS. They should also get a handle on the value-based payment modifier (VM). The VM will adjust Medicare reimbursements, taking into account both quality and cost. The quality component is derived from PQRS; the current cost measures are not optimal and are based on a physician’s individual impact on a beneficiary’s cost of care relative to his/her total cost of care for the year. Furthermore, Mohs surgeons will likely be compared on cost metrics to all dermatologists. The VM will impact all physicians in 2017 based on this year’s performance [2015].
CMS has been developing a set of reports known as Quality and Resource Use Reports (QRURs) to provide comparative performance information to physicians. Each physician or physician group [defined by TIN] has a confidential QRUR which can be downloaded from the CMS website. I recommend you access your report* and begin to understand it.
*Author’s note: Instructions for obtaining your QRUR (through a predictably convoluted process) can be found at this website: Obtain your 2013 QRUR
For interest’s sake, I have provided a link to a sample QRUR similar to my group’s QRUR: Sample QRUR