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Neurosurgeons Express Serious Concerns with Medicare Physician Payment Rules

ko headGuest post from Katie O. Orrico, Esq.
Director, Washington Office
American Association of Neurological Surgeons (AANS)
Congress of Neurological Surgeons (CNS)

On April 27, 2016, the Centers for Medicare & Medicaid Services issued a proposal to overhaul the way Medicare pays physicians. The proposed rule implements key elements of the Medicare Access and CHIP Reauthorization Act (MACRA). This legislation repealed Medicare’s sustainable growth rate (SGR) formula and replaced it with a new payment system. Through a single framework called the “Quality Payment Program,” the new payment paradigm has two paths — the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). The new program consolidates components of three existing Medicare penalty programs — Physician Quality Reporting System (PQRS)Electronic Health Record (EHR) and Value-Based Payment Modifier (VM) — and creates an qualityopportunity for neurosurgeons to earn quality improvement bonus payments.

Responding to the proposal, on June 27, 2016, the AANS and CNS submitted comments to CMS. In the letter, organized neurosurgery expressed serious concerns with the new proposed payment rules and urged CMS to make substantial change before finalizing the payment overhaul. Key topics addressed in the AANS/CNS letter include:

  • Phased Approach and Reasonable Transition Period. The proposed timeline for implementing this major physician payment overhaul is overly ambitious, and the AANS and CNS strongly recommend that CMS adopt a phased approach that includes sufficient time for both clinician education, as well as the collection of updated data on which to set benchmarks. At a minimum, the initial performance period should begin no earlier than July 1, 2017, but ideally not until Jan. 1, 2018.
  • Minimize Reporting Burden. The intent of MACRA was to consolidate and streamline current reporting mandates, yet the CMS proposal continues to perpetuate the flaws of the existing Medicare quality reporting programs. CMS needs to take a more holistic approach than that which is reflected in the proposed rule. For example, participation in a qualified clinical data registry (QCDR) should automatically satisfy multiple MIPS categories, including quality, advancing care information (ACI) and clinical practice improvement activities (CPIA). Additionally, CMS should require reporting on no more than 50 percent of applicable Medicare patients across all measures and reporting mechanisms.
  • Small and Solo Practices Disadvantaged. The majority of physician practices with fewer than 25 clinicians — which reflects most neurosurgical practices — will receive negative payment adjustments under the proposed rule. CMS must take steps to ensure that all physicians, regardless of their specialty or practice, have an equal opportunity to succeed in this new quality payment program. A positive step in this direction would be for CMS to raise the MIPS low-volume exclusion threshold to $30,000 in Medicare allowed charges or fewer than 100 Medicare patients seen by the physician.

In a release coinciding with the submission of comments, AANS president, Frederick A. Boop, MD, FAANS, chair of the department of neurosurgery at the University of Tennessee remarked, “MACRA presents an unprecedented opportunity to fix the currently broken and burdensome Medicare quality programs, which have little meaningful impact on quality and have been extremely disruptive to physician practices.”

CNS president, Russell R. Lonser, MD, FAANS, chair of the department of neurosurgery at The Ohio State University, stated, “CMS should seize this moment and make substantial changes to the proposed rule to ensure that the new quality payment program is patient-centered, flexible and meaningful for physicians and patients alike.” Dr. Lonser added, “The AANS and CNS recognize the enormity of the task to overhaul the Medicare physician payment system. Nevertheless, it is essential that CMS establish the programmatic building blocks that will ensure the quality payment program’s success into the future.”

Copies of the press release and letters neurosurgery-supported are available below:

In the coming weeks and months, the AANS and CNS will be publishing a variety of educational materials to ensure that neurosurgeons are “MACRA ready” and can thrive under the new quality payment program.


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