It’s the Friday after the election; at the NY Medical Director’s conference this morning, Physicians were asking if the President-elect’s promise to repeal Obamacare will affect their practices.
Predicting what’s going to happen under the Trump Administration is a fool’s errand. However, it is apparent the focus of the Republican Congress over the past 6 years has been aimed toward repealing the mandates for individual insurance, the federal financing of Medicaid Expansion, and the provisions for State and Federal insurance pools, and under Trump’s administration, they may now have the ability to do so.
True, the PPACA also launched a series of sweeping Medicare reforms, but those were all aimed at reducing the spending curve’s rate of increase. That problem isn’t going away as the Baby Boom Generation reaches Medicare eligibility – they have relatively low retirement savings, many chronic problems, and relative longevity. Keeping Medicare solvent, while avoiding angering voters, is a task Congress will probably leave to the CMS – unless there is a politically advantageous legislative alternative.
All of Part B Medicare is now governed by MACRA/MIPS – which passed with broad bipartisan approval, recognizing the inherent flaws with the Sustainable Growth Rate. Some elements of the Medical Community may want parts of MACRA/MIPS rolled back, but to what? Privatizing Medicare may appeal to those with libertarian leaning, but I doubt that will play well with many of the electorate.
Part A Medicare is already moving rapidly to Bundled Payment strategies for most hospital episodes – which hurts hospitals but seems to be a strategy that hasn’t raised problems with the voting public.
Some elements of the PPACA, like the Innovation Center, are probable targets, but the reforms that program launched, e.g. ACOs – are likely to remain after being reassigned to another department within CMS.
Trump’s plan, or lack thereof, has been assumed to be modeled by Paul Ryan’s Patient’s Choice Act. Though Trump is a political outsider with no discernible legislative record for the electorate to gauge his decision-making, it is expected that he will pull his knowledge from already established reform proposals from the Republican Party. So, Trump may be the proverbial ‘political wildcard’, but his actions may be more predictable than previously expected.
While it would be comforting if Congress and the new administration would bring a scalpel to the most onerous parts of MACRA/MIPS Regulations, I think that is wishful at best. There’s not much real choice, so start your MIPS planning for 2017, and expect it to be our companion through all of 2018.
Apologies for describing these two CMS programs by using the words of Charles Dickens – but they fit exactly.
The Best of Times – the CMS’s revisions to MACRA/MIPS regulations suspends the worst aspects of VBP and opens the door to avoiding all penalties for LTPAC Medicine in 2019, based on 2017 behavior.
This is the second, and final installment, of a survey of VBP and MACRA/MIPS. Today we focus on MIPS.
As dismal as our future was under VBP, CMS acknowledged that certain medical groups serve high-cost/high-risk patient populations. Further, they agreed that some of their risk-adjustment methodologies must be corrected. What policy changes does that actually translate into? Here is a high-speed review of the significant changes to MIPS from the draft rule, which we covered in a series of webinars this summer:
Our Key Conclusion:
· The headline for the final rule should read – ‘The Principal [CMS] announces everyone who turns-in any signed/dated homework will automatically earn passing grade for 2017 year – still encouraging everyone to carry 18 semester hour course load and do extra credit during holiday break’.
o Yes, to fully participate in MIPS in hopes of receiving incentives, and possible bonuses – larger medical groups would still have to complete 6 quality measures, up to 4 Clinical Practice Improvement Activities, 5 core EHR activities, and up to 11 advanced EHR performance exercises.
o Alternately, groups can avoid MIPS penalties by documenting participation in a single activity for just 90 days.
§ CMS estimates that 90% of all Practitioners subject to MIPS will successfully meet or exceed the minimum reporting levels, and avoid penalties.
o Lower hurdles reduce the size of performance incentives. Why? MIPS is basically budget neutral – that means the incentives are fueled by the penalties imposed on Practitioners who failed to meet the thresholds for reporting. In the draft rule, 50% of all practitioners were going to receive penalties; those forfeitures would be redistributed to the groups who were in the top 50% of participants. With the losers being reduced from 50% to just 10% of the participants – the available prize money was also cut by 80%. Those funds will be distributed across the 90% of providers who avoided penalties; that distribution is based on a competitive scoring program. To be high performance will require considerable effort, but for a significantly lower possible payoff. The old model – one loser, one winner. The new model – 1 loser, 9 winners.
Regardless of the reduced incentive for full participation, the 2017 specifications are likely to be relatively unchanged for the 2018 Performance Year. It is critical for your future success to understand the mechanics and use 2017 for planning and testing – in 2018 CMS expects to terminate the lower performance thresholds and raise penalties for nonparticipation from 4% to 5% as previously announced.
· The biggest change – Resource Use in suspended from MIPS entirely for 2017 scoring. The draft rule weighted Resource Use (i.e. Cost) at 10% of our total score. Your protests were heard – CMS is going to re-work its Resource Use Measures to improve their Risk Adjustment for Practitioners who serve very high cost patients (e.g. LTPAC residents). It is incredibly important to devote 2017 to advocating for revisions to CMS Risk Adjustment calculations appropriate to LTPAC residents (this applies to both MIPS and APM programs). In 2018 Resource Use starts @ 15% of total score.
· The Final Rule excludes SNF Encounters from the definition of Primary Care. This was proposed in the draft rule, but it is a big ‘win’ for LTPAC medicine. Those SNF patients have very high costs, and 30-day all cause rehospitalization rates that are significantly above the averages for ambulatory PCP groups – this was a double penalty. These Post-Acute Care (PAC) patients are high cost, and their Rehospitalization Rates are also part of a CMS Quality Measure (calculated from Claims) CMS-3 (30 day all cause rehospitalization rates). This QM was a big factor in low Quality performance scores for LTPAC Medical Groups. Now those SNF patients won’t be counted at all in your rehospitalization scores. Only SNF patients who stay in the building and convert to POS 32 (LTC) are likely to be attributed to you.
o Unless these SNF patients started as a LTC resident in you practice, then go to Acute Care, return to PAC, then get rehospitalized - as a LTC Practitioner you should have significantly improved CMS-3 scores.
· The Final Rule eliminated two additional CMS calculated Quality Measures:
o CMS-1 – Acute Conditions Composite Hospitalization Rate (annual). This calculated the hospital rate of your attributed patients – this included all your POS 31 attributed patients, and any of your LTC residents who required a hospitalization for Bacterial Pneumonia, UTI, or Dehydration.
o CMS-2 – Chronic Conditions Composite Hospitalization Rate (annual). Same as CMS=1 but focused on Diabetes, COPD, and HF.
The elimination of CMS-1 and CMS-2, combined with shedding attribution of SNF patients should materially reduce the quality score penalty we inherit when caring for a LTPAC Population. If you are a gEHRiMed™ user, we’ll cover this in an upcoming webinar giving our recommendations for MIPS 2017 management strategies. Otherwise we recommend practitioners prepare a careful study of the rules – they are typically complex and with more options than ever before.
CMS made other sweeping revisions – the most far reaching was in terms of the number of affected practitioners. They accommodated protests by setting a Low Medicare Volume Exclusion test. Practitioners whose Medicare Part B payments are below $30,000 are exempt from MIPS for 2017. This exemption is unlikely to apply to any LTPAC Medical group where nearly every patient is covered by Medicare B or C.
Within MIPS there were major program adjustments which effectively lowered complexity and difficulty. The Rule offered three possible methods of successful MIPS Participation:
1. Test the Waters – groups that demonstrate the slightest willingness to acknowledge MIPS (earn 3 points out of the 100 available) will avoid any penalty. The Final Rule describes multiple options to satisfy this minimal level of engagement – this means reporting one quality measure, one improvement activity, or only four advancing care information measures.
2. Partial Participation – EC’s or groups who submit 90 days of 2017 data for all three categories (quality, advancing care information and clinical practice improvement activity) to Medicare, may earn a neutral or small positive payment adjustment in 2019.
3. Full Participation - Some well organized groups are likely to have programs in place that will allow complete success under MIPS. Those groups probably earned VBP bonuses for 2015 and 2016, and will have lower incentive payments under the final MIPS rules because only 10% of groups are expected to receive negative payment adjustments. (A $500 Million bonus pool is available for groups that score >70 points which will be an inducement for currently high performing groups to continue their winning strategies). We doubt groups that aren’t already highly organized will find the effort required for a full year’s participation cost to be justified.
Scoring Quality, Advancing Clinical Information, and Clinical Practice Improvement:
· The Three MIPS Categories each became easier to successfully report:
o Quality: In addition to the elimination of the two CMS calculated Quality Measures for Hospitalization Rates, the frequency of patient reporting decreased. In the absence of Resource Use, the Quality domain is increased to 60% of the total MIPS composite score; it drops to 50% in 2018.
§ In the final rule, CMS established that for full performance, clinicians will report on six quality measures, or one specialty-specific or subspecialty-specific measure set. A lower threshold of one measure out of six applies for CY 2017.
§ A 50% minimum reporting rate is the new standard. In the draft rule individual or groups had to report on 80 or 90% of all eligible patients. This will give participants significantly more leeway in rolling-out their 2017 Quality Reporting strategies.
§ There is a ‘test the program’ option to avoid penalties – simply report your measures
o Advancing Care Information (the program formerly known as Meaningful Use) reporting is significantly less problematic under the final MIPS rule than the draft’s proposal. The number of specified activities needed to satisfy the base reporting requirements for 50% of the category’s score dropped from 11 to 5 . Other adjustments in scoring increased the possible pathways to achieve a maximum score. The actual burden on LTPAC groups will still be significant, but much lower than under MU.
§ Medicaid MU – despite multiple requests to align Medicaid MU standards with ACI under MIPS, CMS rejected those pleas. LTPAC medical groups that are seeking to receive Medicaid MU payments @ $8,500 for program years 1-5 must report to Medicaid for MU and Medicare for ACI.
§ Medicare ACI Hardship Exemptions – LTPAC medical groups are likely to remain eligible for hardship status under MIPS’ ACI category. Groups should model their expected MIPS scores to evaluate the wisdom of this strategy. If you’ve ever earned Medicaid MU payments, ACI is probably going to seem relatively simple.
o Clinical Practice Improvement (CPI) – the final rule lowered the threshold for successful reporting for groups of all sizes. Small groups (14 or fewer) report one or more activities, and large groups (15+) report four medium-weighted or two high-weighted activities The actual amount of work groups must undertake to satisfy these requirements won’t be known until the CMS publishes specifications for the 90+ CPI activities they name in the regulation. Reporting of certain CPIA’s that are aligned with ACI objectives will award eligible clinicians bonus points in the ACI performance category, thus paving additional pathways for maximization of the ACI score.
Our overall assessment of the revised MIPS final rule is that LTPAC medical groups should be certain to report on several quality measures , at least one CPIA, and test their ability to meet the five basic ACI criteria. We’ve seen multiple failures for groups executing a PQRS strategy – so it is key to be certain you understand these highly complex reporting mechanisms – use this ‘practice & testing’ year wisely.
A significant majority of your practice’s revenue is derived from Medicare beneficiaries., it should be rewarding to get a head start on 2018 while everyone else is taking a MIPS holiday.
[i] The balance of this blog simplifies a 2,398 page rule into a few easier to comprehend thoughts – it is not a substitute for a thoughtful assessment of the entire MACRA/MIPS regulation.
Apologies for describing these two CMS programs by using the words of Charles Dickens – but they fit exactly.
The worst of times – Value Based Purchasing’s teeth bite into LTPAC Physician Groups’ 2017 and 2018 Medicare Pay Rates.
Two weeks ago the CMS began issuing 2015 QRURs (Quality and Resource Use Reports) to all medical groups submitting claims under Medicare Part B. These reports catalogue your performance on quality measures (e.g. PQRS), and resource use (average costs for a panel of Part B patients attributed to the group through a PCP relationship, or via inpatient hospital episodes).
The results were uniformly dismal, and confirmed something we’d predicted. Any LTPAC Medical Group that includes one or more Physicians as group members is going to receive a <2%> downward adjustment in 2017 Part B fees because they are classified as High Cost. That means the average cost of all their attributed patients was more than 1 standard deviation above the mean (e.g. benchmark value) for all PCP groups. Groups that failed to satisfy PQRS participation requirements incurred an additional <2%> downward adjustment – for a total cutback at the group level of <4%>.
Currently, we’ve reviewed QRURs from 10 different groups which served over a dozen geographically separated markets. One of the groups only employed Nurse Practitioners; the others mixed Physicians, NPs, and PAs.
All of those five groups successfully reported for PQRS for more than 50% of their patients, but none were able to completely execute a reporting strategy that satisfied the requirements for being ‘High Quality’. [promisingly, one group did reach a score of 0.92 which placed them in the upper quartile of all groups reporting – so it is possible for highly organized groups to report better than average quality].
It's probably too late for groups to modify their 2016 PQRS reporting strategy in search of a Quality Score >1.0. However, for groups that have been working on that goal all year, we can confirm that the strategies GPM has discussed with Users over the past 12 months do work.
Our second November Blog post will focus on an initial review of the final MACRA/MIPS rule and its effect on LTPAC medical groups.
Today’s blog is focused on the inconsistent regulatory environment faced by LTPAC Medicine in the 2017 draft CMS rules in MACRA/MIPS and the Physician Fee Schedule.
These inconsistencies create economic challenges for the Medical professionals serving populations dwelling in LTC settings; equally important is the missed opportunity to incent a model of care that promotes primary care in these settings.
The Draft MACRA/MIPS regulations, for the first time, embody a clear statement from CMS which differentiates a Physician’s role in caring for a patient in a Skilled Nursing Facility (Place of Service 31), versus a LTC Nursing Facility resident (POS 32). (Copied from pg. 142 of the rule)
Patients in SNFs (POS 31) are generally shorter stay patients who are receiving continued acute medical care and rehabilitative services. While their care may be coordinated during their time in the SNF, they are then transitioned back to the community. Patients in a SNF (POS 31) require more frequent practitioner visits—often from 1 to 3 times a week. In contrast, patients in nursing facilities (NFs) (POS 32) are almost always permanent residents and generally receive their primary care services in the facility for the duration of their life. Patients in the NF (POS 32) are usually seen every 30 to 60 days unless medical necessity dictates otherwise. We believe that it would be appropriate to follow a similar policy in MIPS; therefore, we propose to exclude services billed under CPT codes 99304 through 99318 when the claim includes the POS 31 modifier from the definition of primary care services.
For readers who aren’t immersed in deciphering CMS’s unique language, the draft policy creates a clear distinction in the nature of the doctor:patient relationship in the two settings:
This policy distinction doesn’t correct other long standing errors in the resource use benchmarking process (LTC residents have significantly higher annual costs than their ambulatory counterparts). However, it relies on an objective measure (the presence of a Medicare Part A payment to the SNF) as a marker to distinguish between the two populations treated by the medical professionals under Medicare Part B. This lays the foundation for future methodology with a refined acuity adjustment.
Would it be too much to hope that the draft Part B Fee Schedule would align the concepts of primary care with these MIPS proposals? Apparently so.
The draft fee schedule devotes pages 143-198 to a section titled Improving Payment Accuracy for Primary Care, Care Management, and Patient-Centered Services. In my opinion, this is the clearest policy statement CMS has ever made, via the fee schedule, of its intention to transition from encounter based care to a population management model. What it fails to do is codify that LTC Nursing Facilities are locations where residents may receive these population management services.
In the fee schedule, CMS proposes to improve, and extend, the principals of Care Management via CPT® codes. In the draft 2014 Fee Schedule, CMS introduced the concept of Chronic Care Management (CCM). This was incorporated in the 2015 fee schedule as CPT® 99490 (paid at approximately $41/month for 20 or more minutes of care). When the 2015 draft schedule was published, and again in 2016, AMDA and many LTPAC Medical Groups asked if CCM applied to residents in POS 32? It wasn’t until the March of 2016 that CMS resolved this issue by issuing a FAQ (frequently asked question).
7. Can I bill CPT 99490 for CCM services provided to beneficiaries in skilled nursing facilities, nursing facilities or assisted living facilities?
If all the CCM billing requirements are met and the facility is not receiving payment for care management services (for example, the beneficiary is not in a Medicare Part A covered stay), practitioners may bill CPT 99490 for CCM services furnished to beneficiaries in skilled nursing facilities, nursing facilities or assisted living facilities. The place of service (POS) on the claim should be the billing location (i.e., where the billing practitioner would furnish a face-to-face office visit with the patient) as per #5 above.
That policy clarification opened a safe pathway for LTPAC medical groups and facilities to begin implementing population management strategies for the residents in all LTC settings.
This clarification about the applicability of CCM to POS 32 was forgotten when the draft 2017 fee schedule was published. This doesn’t mean that the principal of using Care Management in POS 32 is lost, it simply is overlooked as a Primary Care site.
The fee schedule proposed adopting a family of care management and care coordination codes from the AMA’s CPT® panel. In several cases, the codes were still under review, and CMS elected to implement those draft definitions as HCPCS codes. To summarize the codes in the draft rule:
Changes in Codes Available for CCM
|99487||Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, establishment or substantial revision of a comprehensive care plan, moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care
Professional, per calendar month.
|99489||Each additional 30 minutes of clinical staff time per month||0.50|
|Behavioral Health Management Codes (billed by PCP)|
|GPP1||Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements…………||1.59|
|GPPP2||Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following….||1.42|
|GPPP3||Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities…||0.71|
|GPPPX||Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional time, per calendar month.||0.61|
|Care Planning for the Cognitively Impaired Patient|
|GPPP6||Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, by the physician or other qualified health care professional in office or other outpatient setting or home or domiciliary or rest home.||3.30|
|Add-on Code for initiation of CCM Care Planning|
|GPPP7||Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of a face-to-face service (billed separately from monthly care management services) (Add-on code, list separately in addition to primary service).||0.87|
|Add-on Code to recognize extra burden of office-based care for mobility impaired|
|GDDD1||Resource-intensive services for patients for whom the use of specialized mobility-assistive technology (such as adjustable height chairs or tables, patient lifts, and adjustable padded leg supports) is medically necessary and used during the provision of an office/outpatient evaluation and management visit (Add-on code, list separately in addition to primary procedure). (limited to office CPT® codes 99201-215)||0.48|
|Non-Face-To-Face Prolonged Evaluation & Management (E/M) Services|
|99358||Prolonged evaluation and management service before and/or after
direct patient care, first hour
|99359||Prolonged evaluation and management service before and/or after
direct patient care, each additional 30 minutes
This blog has consistently argued that the publically insured population with the highest manageable costs are those individuals who reside in long term Nursing Facilities. These are the individuals who, under current policies, are no longer able to live independently. The nursing facility is where they live, and die, unless their death occurs during one of their frequent hospital stays. The vast majority of these individuals enter LTC nursing facility beds (Place of Service – POS32) following a Skilled Nursing Facility episode of care (POS 31).
The definitions CMS uses for these CPT® or HCPCS Codes come directly from the AMA current or proposed narrative CPT® descriptions. The AMA evaluates draft copies of CPT® codes proposed by its members – and these codes were created for Office based medicine. This isn’t to blame the AMA, their objective is to represent the interests of Physician Members – not CMS. Nowhere else but in nursing homes can the same individual, in the same physical location (room & bed) be:
· in a Part A post-acute episode of care during the day, and
· become a LTC outpatient with the updated midnight Census report.
This illogical dual identity for nursing homes didn’t exist in the earliest days of Medicare. We had separate Skilled (SNF), and Intermediate Care (ICF) nursing facilities. The Part B payment rates were lower because the SNF was cost reimbursed, which could include services to support the attending Physicians. The ICF had higher Part B Physician fees in the absence of the CMS facility payments.
When a patient exhausted their Medicare Part A coverage, they either went home or moved to an ICF Bed. This physical relocation was often disruptive and caused unnecessary suffering for the most vulnerable individuals. However, it was simple to keep track of the type of bed the individual occupied.
Patient Advocates successfully lobbied for the right of a patient to remain in familiar surroundings, and the concept of ‘dually licensed’ beds arose, this was in the 1980s. Physician CPT® coding, and reimbursement didn’t get corrected until 2006.
That’s the year when AMDA’s efforts to petition to the AMA and CMS for a new payment model bore fruit. The AMA approved new CPT® codes (99304-99318), and the CMS adopted a single uniform payment rate for those codes in POS 31 and POS 32. The logic that supported the unified payment rates for POS 31 and POS 32 was based on the elimination any extra services for physicians when SNF Part A moved from a Reasonable Cost Reimbursement payment scheme to the Prospective Payment System (RUGS rates).
It is possible to use the AMA as a vehicle to create a POS 32 specific payment model for Primary Care.
Developing a LTC Nursing Facility Care Management family of CPT® codes through the AMA would require a member organization (i.e. AMDA) to submit a validated study of the work physicians are performing that is not covered by existing CPT® codes. That is the best long-term solution, but doesn’t solve the problems LTPAC Medical Groups face today trying to implement population management. CMS also has a problem – it wants to support a switch to these new payment models for Primary Care.
Primary Care Physicians, and Nurse Practitioners, serving LTC Nursing Facility residents are the best available clinicians to operate a ‘treat in place’ model. Those models of care can minimize avoidable hospitalizations, improve the individual’s quality of life, and conserve resources. There are nearly $2 Billion of savings (in 2005 $s) available through improving the hospitalization rates of the Medicare-Medicaid population residing in LTC nursing facilities.
Anyone interested in address this problem should register a public comment on the draft rule asking CMS to extend its policy of covering CPT® 99490 in POS 32 to the new Care Management Codes (99487, 99489, and GPPP1-GPPP7).
If LTPAC Medical Groups are financially responsible for the Resource Use of this population as Primary Care Providers, they need a full set of management tools. The opportunity to achieve the goals of the CMS triple aim far outweighs the importance of the AMA’s CPT® development process.