Just six months before the Merit-based Incentive Payment System (MIPS) is set to debut, CMS released a proposed rule with guidance on what value-based payment will look like. Before you panic, know that it’s less about new rules and more about streamlining existing quality programs. Whether it is an exercise in rearranging the deck chairs on the Titanic or a step in the right direction will not be immediately understood. Storm clouds gathering in the insurance exchange market where payors threaten premium increases of up to 36% suggest that resource use is destined to play an increasingly important role. Let’s take a quick look.
Expect new terminology and a new unique identifier that would be used by physicians who successfully jump through the newly arranged series of hoops that comprise the MIPS: the pre-existing Physician Quality Reporting System (PQRS), the value modifier (VM) and the federal meaningful use (MU) of health IT programs.
MIPS will assess physicians in four performance categories: quality (PQRS redux), worth 50 points in year 1, and 30 in year 3; resource use (retooled VM), 10 points in year one, 30 at year 3; clinical practice improvement (CPI) activities (new, redundant of or synergistic with American Board of Radiology’s Practice Quality Improvement projects?), worth 15 points; and advancing care information (MU program participation), worth 25 points.
Radiologists and other specialists will be encouraged to know that MIPS does not assume that one set of quality measures will be relevant to all physicians. Qualified Patient Data Registries (QPDRs) as designated by CMS can be used to submit data toward the quality performance category.
CMS proposes selecting quality measures each year based on criteria that align with its priorities. Physicians will be required to meet a minimum of six measures, including one outcome measure. In the absence of a relevant outcome measure, physicians can substitute a measure based on appropriate use, patient safety, patient experience or care coordination.
The ACR’s National Radiology Data Registry™ was designated again in 2016 as a QPDR, and some radiologists are already using it to submit PQRS data for specialty-relevant quality measures (see article, page 28). Assuming the college is able to synchronize its measures with the annual priorities of CMS, radiologists are well positioned to participate in MIPS moving forward.
The not-so-good news is that CMS intends to publish the final list of quality measures for the following year in the Federal Register before November 1. Even presuming that the proposed list will be published in June in the proposed Physician Fee Schedule, that gives physician practices and registry operators scant time to prepare for compliance and synchronization.
Winners and losers
The Medicare Access and CHIP Reauthorization Act requires the MIPS to distribute payment adjustments to between 687,000 and 746,000 eligible clinicians (new term for eligible providers) in 2019 based on 2017 data, distributed equally between negative adjustments ($833 million) and positive adjustments ($833 million), ensuring that there will be both winners and losers in the new payment game.
An additional $500 million will be distributed to high achievers called qualified alternative payment model participants (QPs) participating in advanced alternative payment models (APMs). Advanced APMs must require participants to use certified EHR technology, base payment on quality measures comparable to MIPS measures and be a medical home model or bear comparable risk for monetary loss.
Further evidence that the CMS is attempting to avoid past missteps and be more inclusive of specialties (especially hospital-based ones) is by providing eligible clinicians who participate in multiple Advanced APMs an opportunity to apply to be considered for QP status if they don’t achieve it through their participation in just one Advanced APM. Also, professional services provided at certain critical access hospitals, rural health clinics and federal qualified health centers that meet certain criteria will be counted toward QP determination.
If you are pulling your hair out about now, it may be helpful to recall that MIPS is successor to the sustainable growth-rate (SGR) for which many of the reimbursement cuts to radiology in the past ten years were pay-fors. MIPS at least leaves the door ajar for specialties that want to get into the game.
What is the game? Here’s what the rule says: “As we drive change through this proposed rule, we will begin by laying the groundwork for expansion towards an innovative, outcome-focused, patient-centered, resource-effective health system.”
I don’t know about you, but I would very much like to obtain my healthcare in an innovative, outcome-focused, patient-centered, resource-effective health system. How does radiology contribute to that? Think of value-based payment as Claude Monet’s The Portal of Rouen Cathedral in Morning Light, vague, but emerging from the darkness. As MIPS slowly comes into focus over the next few years, don’t wait for the answers to that question to be foisted upon you. Be proactive. This issue of Radiology Business Journal describes how many are doing precisely that.