Clemens M. Schirmer, MD, PhD, FAANS, FACS, FAHA
Vice-Chair, AANS/CNS Communications and Public Relations Committee
Geisinger
Wilkes Barre, PA
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a law that reformed the Medicare payment system by repealing the sustainable growth rate formula (SGR), which calculated payment cuts for physicians. It also created a new framework for rewarding physicians who provide higher-value care by combining three former Medicare programs — the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM) and Electronic Health Record (EHR) Incentive Program — into a single payment program called the Merit-based Incentive Payment System, or MIPS. On the surface, the switch from multiple regulatory programs to a single one holds the potential for reducing the regulatory burden for physicians, but challenges are still abundant:
- Most practices invested resources in meeting the prior requirements, and these are not directly transferable to MIPS;
- The MIPS program continues to evolve, making it difficult for physicians to adopt compliant systems in their practices;
- Inclusion of certified registries remains amorphous; and
- Individual and small practice implementation remains challenging.
As a result, many practicing physicians see MACRA as a bundle of regulatory red tape that impedes daily practice. Most agree that the status quo is not sustainable and innovation is needed to ensure a high-quality health care system. This innovation can take many forms. Currently, under MIPS, providers can qualify for either bonus payments or be subject to penalties based on their performance metrics, including evidence of:
- Quality improvement;
- Cost reduction or maintaining current levels of spending;
- Efficient use of electronic medical records; and
- Clinical improvement activities such as care coordination.
Two years into the implementation of the law, CMS still hasn’t charted precisely how providers will be judged under the cost metric. The law allowed CMS to waive any penalties under the cost measure for two years, but not for year three, which ultimately will account for 30 percent of MIPS quality-based payments. This is difficult to fathom since we are still don’t have sound cost assessment metrics and physicians are unsure how they will be measured.
Meanwhile, the Centers for Medicare & Medicaid Services (CMS) is already testing the hypothesis that MACRA and its provisions will lead to a reduction in health care costs. Specifically, CMS contracted with Acumen to develop a number of disease-specific cost measures to serve as a litmus test to assess whether physicians who participate with MIPS, are actually reducing the cost of care.
Even though work has been going on in the background for most of the year, CMS rolled out the initiative just two weeks after the Medicare Payment Advisory Commission (MedPAC) suggested repealing MIPS based on concerns it wouldn’t lead to better quality of care for patients or lower costs. Organized neurosurgery joined a chorus of other physician groups opposing MedPAC’s policy option aimed at eliminating the MIPS program and replacing it with a brand new program, citing that physicians have been working to improve MIPS and MedPAC’s proposal would be a significant step backward.
CMS, together with Acumen, selected eight clinical measures after extensive input from Clinical Subcommittees, through a Technical Expert Panel and public comment. The Clinical Subcommittees were composed of 147 members affiliated with 98 professional societies including organized neurosurgery providing detailed clinical input on preliminary measure specifications during in-person and webinar meetings during May and August of this year.
CMS and Acumen, LLC, field-tested eight episode-based cost measures in October 2017, before considering their potential use in the cost performance category of MIPS. One measure selected is of great importance to neurosurgeons: “Intracranial Hemorrhage or Cerebral Infarction.” Neurosurgeons (and other physicians) who treat Medicare inpatients for Intracranial Hemorrhage or Cerebral Infarction will be evaluated for their risk-adjusted cost of their care.
Now that the field testing period has concluded, a National Summary Data Report for the eight episode-based cost measures is available online and will serve as the “baseline.” Some notable findings include:
- 118,573 episodes captured;
- Mean age 77, slight female predominance;
- Numbers of patients for most providers is low; and
- High volume providers were slightly more costly.
After substantial work, the question remains, will this program just create a significant regulatory burden or deliver true cost reduction? Unfortunately, to date, MIPS-related efforts have proven both vague and cumbersome. Neurosurgeons are committed to providing the right care to the right patient at the right time through a variety of longitudinal efforts:
- NeuroPoint Alliance’s Quality Outcomes Database (QOD) assesses true neurosurgical quality measures in spine, stereotactic radiosurgery, and cerebrovascular interventions;
- Neurosurgical graduate medical education (GME) Milestone and Curriculum Establishment, and
- Appropriate Maintenance of Certification (MOC) for neurosurgeons.
Although we remain concerned about the potential for regulatory hurdles to prevent this, neurosurgery will continue to work with CMS and Congress to improve MIPS and to allow for more meaningful and robust engagement.
Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #RegRelief.
