Close this search box.

October 2016

New Quality Payment Program Announced

The Department of Health and Human Services (HHS) finalized its policy implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively referred to as the Quality Payment Program. The new Quality Payment Program will gradually transform Medicare payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care system. The rule is informed by a months-long listening tour with nearly 100,000 attendees and nearly 4,000 public comments. A common theme in the input HHS received was the need for flexibility, simplicity, and support for small practices. And that’s what this final policy aims to provide. First, the new payment system creates two pathways. These paths let clinicians pick the right pace for them to participate in the transition from a fee-for-service health care system to one that uses alternative payment models that reward quality of care over quantity of services. Clinicians will choose between two options:

  • The first path gives clinicians the opportunity to be paid more for better care and investments that support patients. It reduces existing requirements, while still emphasizing and rewarding quality care. In the first year, it also provides a flexible performance period, so that those who are ready can dive in immediately, but those who need more time can prepare for participation later in the year.
  • The second path helps clinicians go further by participating in organizations that get paid primarily for keeping people healthy.

For example, they could be part of an Accountable Care Organization where clinicians come together to coordinate high-quality care for the patients they serve. When they get better health results and reduce costs for the care of their patients, the clinicians receive a portion of the savings. Other parts of the final rule reveal that CMS listened to physician concerns and modified portions of the proposed rule to help physicians participate in the QPP. For example:

  • Details are provided about the 2017 transition period announced in September. The only physicians who will experience payment penalties in 2019 are those who choose to report no performance data next year, and those who report for at least 90-days will be eligible for positive payment adjustments.
  • The low-volume threshold that exempts physicians from all performance reporting has been increased from $10,000 in annual Medicare revenue and less than 100 Medicare patients to $30,000 in revenue or 100 patients. CMS estimates that this change will exempt 32.5 percent of physicians and other clinicians from the program.
  • Performance reporting requirements have been further reduced, and the resource use component of the Merit-based Incentive Payment System (MIPS) has been reweighted to zero for 2017. Accompanying today’s announcement is a new Quality Payment Program website, which will explain the new program and help clinicians easily identify the measures most meaningful to their practice or specialty. The website includes fact sheets and educational material for all types of practices including small, rural, and specialty based.

CMS Indicates Flexibility for Physician Participation in Quality Payment Program

In a September 8 blog post, Andy Slavitt, the Centers for Medicare & Medicaid Services (CMS) Administrator, indicated a willingness to provide flexibility for physicians participating in the new Quality Payment Program (QPP). Physicians will have four options for participation. For example, one option indicates that if a physician provides “some data” to the QPP in 2017, the physician will avoid a negative payment adjustment in 2019.

Check Your Performance in 2015 CMS Quality Programs

The Centers for Medicare & Medicaid Services (CMS) recently released the 2015 Annual Quality and Resource Use Reports (QRURs) and Physician Quality Reporting System (PQRS) Feedback Reports for all group practices and solo practitioners. The 2015 QRURs show how groups and individual practitioners performed in 2015 with respect to the quality and cost measures used to calculate the 2017 Value Modifier (VM) and how the VM will apply to physician payments. The 2015 PQRS Feedback Report will show how groups and solo practitioners reported PQRS and whether they will receive a payment adjustment. Reviewing QRURs and feedback reports is especially important as CMS quality programs will soon transition into the Merit-based Incentive Payment System (MIPS). The MIPS reporting year will begin in 2017, and the QRURs and feedback reports will give providers an opportunity to see how they are performing in terms of the Quality and Resource Use components of MIPS before payment adjustments occur in 2019. Groups and solo practitioners are identified in the QRURs by their Taxpayer Identification Number (TIN) and their PQRS Feedback Reports by a combination of their TIN and National Provider Identifier (NPI). The CMS website provides instructions about how to access your QRUR, as well as a reference guide to obtain your PQRS Feedback Report.

Smart Cards to Block Medicare Fraud

Representative Peter Roskam pressed for a test of using so-called smart cards to prevent Medicare fraud. He’s seeking to mimic for the giant federal health program the success that private businesses have had in combating theft and fraud. Federal estimates peg the rate of improper payments, including fraud, at 3.6 percent for Medicare’s Part D drug plans to 9.5 percent for the insurer-run Advantage program and 12.1 percent for the traditional fee-for-service program. Roskam noted that an official of Visa Inc. last year told his subcommittee that its fraud rate is far less than 1 percent. At the Wednesday hearing, Roskam stressed that the harms extend beyond the roughly $60 billion squandered in improper payments. Medicare smart cards would provide for something akin to “point-of-sale authenticity” from doctors’ offices instead of Medicare contractors reviewing the charges later in the billing process, Roskam said. Such rapid communication helps credit card companies now quickly spot suspicious trends in billing that tip them off to fraud and theft. A smart card could give Medicare the same advantage, according to Roskam. However, Roskam faces two significant hurdles to his bid to kick off a pilot program for Medicare cards with an integrated circuit chip that would allow more rapid and secure connection to billing systems. Congress’ abbreviated schedule due to the election may give Roskam few chances to move his bill (HR 3220), either as an attachment to another bill or as a stand-alone measure. His bill was not in a House-passed Ways and Means package (HR 5273) of small Medicare changes, a measure that trade associations are pressing Congress to clear in the lame-duck session.

Possible Medicare Cost Increases for Seniors

A coalition of advocacy groups, unions and insurers asked lawmakers to commit to stop potential 2017 increases in the tab that many seniors citizens and people with disabilities pay for Medicare’s outpatient coverage. The abbreviated election-year schedule will leave Congress little time to react to changes in premiums and deductibles, which may be announced next month. The potential increases would be tied to the amount of the annual cost-of-living adjustment that Social Security is expected to announce around Oct. 18. Congress will be on recess at that time ahead of the November election. If the Social Security COLA triggers an increase in Medicare premiums and deductibles for 2017, as is expected, lawmakers would face pressure to address that during the lame-duck session after the election. The letter was sent to the leaders of the Senate Finance Committee, the House Ways and Means Committee and the House Energy and Commerce panel, as well as Republican and Democratic leaders in both chambers. Signers include Aetna Inc. and America’s Health Insurance Plans, as well as medical advocacy groups such as the American Academy of Nursing. About 30 percent of people enrolled in the federal health program will likely see a bump, according to Medicare’s board of trustees. This group includes people already paying higher premiums due to their high incomes, new enrollees and people who don’t collect Social Security benefits. The Part B outpatient deductible for all Medicare enrollees also could rise, depending on what the final COLA figure is for Social Security payments for next year. In their letter to lawmakers, the groups asked Congress to repeat the steps that they took last year to head off scheduled 2016 Medicare cost increases if seniors face them for next year. The November 2015 budget agreement (PL 114-74) included a provision blocking increases in premiums and deductibles for Medicare Part B, which covers services provided in doctors’ offices. Given the abbreviated congressional schedule after the election, any similar fix for Medicare Part B premiums would likely have to be tucked into a fiscal 2017 spending package because Congress will clear few other measures in the lame-duck session.

112 House Members Sign Letter Panning Global Payment Proposal

Representative Joe Heck, D.O. (R-NV), along with 111 bipartisan congressional cosigners, sent a letter to the Centers for Medicare & Medicaid Services (CMS) September 16 opposing a global payments provision in the 2017 Medicare Physician Fee Schedule proposed rule. The proposed rule would require all surgeons to submit data for all 10- and 90-day global surgery code services in 10-minute increments using eight non-payable G-codes for all patients. The letter notes that the proposed rule does not comply with the congressional mandate in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 that calls for the collection of global payment data from a representative sample of surgeons.