From 1997-2015 Medicare physician payments were determined by the Sustainable Growth Rate (SGR), a formula which tied year-to-year payment updates to economic growth. The formula was widely recognized as deeply flawed, requiring yearly congressional action to stave off physician reimbursement rate cuts. In Spring 2015, Congress overwhelmingly passed the Medicare Access and CHIP Reauthorization Act of 2015 (Pub.L. 114-10), commonly known as MACRA, setting the groundwork for transitioning to a value-based purchasing system beginning in 2017.
The Quality Payment Program (QPP)
The MACRA payment structure applicable to most Medicare clinicians is called the Quality Payment Program (QPP). Please note: this system does not concern ASC facility payments in any way, only those physician services reimbursed by Medicare. The QPP splits Medicare physicians into two payment paths: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). MIPS organizes several previous programs—the Physician Quality Reporting System (PQRS), the Physician Value-Based Payment Modifier and the Medicare EHR Incentive Program (Meaningful Use)—into a single performance scoring schema. Advanced APMs are unique care models such as bundled episodes of care, comprehensive care models and ACOs. Most physicians who practice in ASCs will not be eligible for any of the Advanced APMs, at least for now.
The Merit-based Incentive Payment System (MIPS)
Traditional MIPS is organized into four performance categories: Quality, Cost, Improvement Activities and Promoting Interoperability. The four categories are weighted for scoring in relation to a physician’s total score. Currently, the weights are as follows:
- Quality: 30 percent
- Cost: 30 percent
- Improvement Activities: 15 percent
- Promoting Interoperability: 25 percent
Performance Scoring and Payment Adjustments
Reporting in the various categories translates to points on a scale of 0-100. For the 2022 performance period, an overall performance score of 75 points translates to a neutral adjustment (in 2023). This 75-point demarcation is called the performance threshold; scoring above the threshold translates to positive payment adjustments and vice versa. In 2022, the maximum possible payment adjustment will be 9 percent (up or down). Beginning in 2022, the performance threshold will be determined based on the mean or median scores of MIPS participants. Scoring above 89 points is considered exceptional performance, and those physicians will be eligible for additional positive payment adjustments.
Much of the ASC discussion regarding MIPS occurs around the Promoting Interoperability (PI) performance category. PI is the successor to CMS’ Meaningful Use program, which was designed to stimulate uptake of certified Electronic Health Record (EHR) technology. However, some physicians lack the access to certified EHR technology (CEHRT) to make reporting under this performance category feasible. For example, there exists no ASC-specific certified EHR technology. Thus, ASC-based clinicians that furnish 75% or more of their covered services in ASC are exempt from the PI category. The 25 percent category score is redistributed to the Quality performance category. This issue is an ongoing advocacy priority for ASCA, as the lack of ASC-specific CEHRT hampers the ability of our physicians to be assessed accurately under the MIPS payment adjustment formula.
Transition to MIPS Value Pathways (MVPs)
In the CY 2022 Medicare Physician Fee Schedule (MPFS) Final Rule, CMS finalized a proposal to gradually move away from “traditional MIPS”, the scoring framework described above, to a new MIPS Value Pathways (MVPs). MVPs will bring together measures from each of the traditional MIPS performance categories into defined groups centered around clinical specialties or episodes of care, to provide better feedback on quality and costs of care.
MVPs are scheduled to launch in 2023, with voluntary reporting for seven MVPs:
- Advancing Rheumatology Patient Care
- Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes
- Advancing Care for Heart Disease
- Optimizing Chronic Disease Management
- Adopting Best Practices and Promoting Patient Safety within Emergency Medicine
- Improving Care for Lower Extremity Joint Repair
- Support of Positive Experiences with Anesthesia
Advanced Alternative Payment Models (APMs)
As an alternative to MIPS, physicians also have the option to participate in an Advanced Alternative Payment Model (AAPM). To be exempt from MIPS and qualify for AAPM bonuses and updates, providers must participate in a qualifying program and meet certain participation thresholds (i.e., 50 percent of payments from an APM or 35 percent patient volume from an APM in 2021). Surgeons have a limited number of AAPM participation opportunities, and surgeons practicing in an ASC environment have even fewer options. To date, CMS has not proposed an ASC-based AAPM. CMS is establishing a process whereby physician groups, including specialty societies, can propose qualifying AAPMs, but those programs will not be immediately available as options. In recent comments, ASCA urged CMS to implement a request for proposals process that is flexible enough to address the needs of the wide range of surgical specialties that practice in the ASC environment.
There are a number of resources available to those wishing to learn more about MACRA, QPP or MIPS. For more information, please visit qpp.cms.gov, where CMS has provided the NPI participation tool, fact sheets and other resources. General information about the Medicare program can be found at cms.gov/Medicare. Please also feel free to reach out to Alex Taira at email@example.com with ASC-specific MACRA questions.