Tuesday, March 24, 2015

More on the SGR bill: beyond repeal, what else is in it?

As I mentioned in my most recent blog post, only 5 of the 158 pages in the bill being voted on by  the House of Representatives later this week has to do with repealing the SGR and providing positive fee-for-service (FFS) updates to physicians.  The rest has to do with creating a framework for Medicare to encourage physicians to participate in quality improvement activities and in alternative payment models.  This has resulted in some physicians asking, with skepticism, what else is in the bill?  Why should doctors support it?

Last year, my colleague Shari Erickson and I came up with a list of 12 reasons why last year’s bicameral and bipartisan SGR bill, which in almost all respects is the same as this year’s House bill, deserved physicians’ support.  Here is the list, reprised and updated:

1. After 11 years, 17 patches, and more than $154 billion wasted.  It is time to pass SGR-repeal now!
2. The bill establishes stable positive updates during a transition period: annual updates of 0.5 percent starting on July 1, 2015 through the end of 2019.  The rates in 2019 will be maintained through 2025 while providing professionals with the opportunity to receive additional payment adjustments through a new Merit-Based Incentive Payment System (MIPS), as discussed below. While the half percent annual update admittedly should have been higher (ACP urged more, but this is the most Congress would agree to spend), it’s much better than a 24% SGR cut on April 1—which all in probability would have been followed by more patches with rates frozen indefinitely, year after year, as far as the eye could see.

3. Starting in 2019, the existing Medicare quality reporting/incentive programs (PQRS, Value Based Modifier, and Meaningful Use) — which vary significantly in terms of measures, data submission options, and payment timelines — would be consolidated into one single quality improvement program, the Merit-Based Incentive Payment System (MIPS), reducing the significant confusion and hassles now associated with the current three separate reporting programs. Under MIPS, physicians would get a single annual composite score, with an established range of positive or negative updates based on their score, derived from performance in four domains: clinical performance, meaningful use, practice improvement, and efficiency/effectiveness of care, both in terms of their performance compared to their peers and their own relative improvement compared to their own previous year’s score.

4. The new MIPS composite score would allow physicians to more clearly determine their eligibility for incentive payments.  In essence, it empowers physicians to set their own individual conversion factor, rather than having it determined by a flawed formula or other external approach.  Physicians will be able to proactively review their data in order to set their performance goals.  The current Medicare reporting programs are not at all clear, transparent, or aligned in terms of performance thresholds that must be met.

5. Under current law, in 2019, physicians are faced with:
•    2 percent penalty for failure to report PQRS quality measures;
•    5 percent penalty for failure to meet EHR MU requirements; and
•    Additional negative adjustments under the Value-based Modifier (VBM) program

All of which could add up to 7-10 percent cuts in 2019.  However, the new MIPS program aligns all of those incentive payments and caps them at more reasonable limits in the early years (no more than 4% in 2019), which gradually increase over time to no more than 9% in 2022.

6. This legislation keeps the money from the existing PQRS and Meaningful Use incentive program penalties (in 2019 and beyond) in the physician payment pool; therefore, significantly increasing the total funds available to pay physicians.  This is because, starting in 2019, the bill eliminates the two percent penalty for failure to report PQRS quality measures and the 5 percent penalty for failure to meet EHR meaningful use requirements.  Instead, the money CMS would have collected from these penalties would remain in the physician fee schedule, significantly increasing total payments compared to the current law baseline.  This money would be lost to physicians if the current system remains in place.

7. In the current Medicare reporting/incentive programs, physicians receive little to no incentive payment for engaging in clinical improvement activities.  And there is currently no ability for physicians to get credit for transforming to a PCMH under the current programs.  The MIPS program would change that and give credit for overall improvement from year to year, as well as for engaging in specific clinical improvement activities.  In particular, physicians in certified Patient-Centered Medical Homes would automatically get the highest clinical improvement score, which would be 15% of the total MIPS composite score.

8. On top of the base positive incentive payments that high performing physicians would receive in the MIPS program, they can also receive additional payment.  In aggregate, this additional payment would be up to $500 million per year from 2018 to 2023.  This new money does not exist within the current Medicare reporting/incentive programs.

9. Additional new money is also allocated specifically to help small practices ($20 million).  There is currently no funding assistance available for the Medicare reporting programs and very limited assistance available for Alternative Payment Model (APM) transition (mostly limited to practices participating in CMS Innovation Center projects).

10. Those physicians participating in APMs would also receive a 5 percent bonus each year from 2018 through 2023—this is entirely new funding and is on top of any current payment structures that are part of their APM (e.g., prospective care coordination fees, shared savings, etc.).

11. Through its incentives for APMs, this bill would allow for a more rapid and robust expansion of the PCMH and PCMH specialty practices (and other evidence-based models) throughout all of Medicare.  Physicians would have the opportunity to propose additional APMs suitable for their specialties, states, and patient care characteristics and mix.

12. Additionally, current law does not require payment for the management of individuals with chronic conditions.  CMS recently finalized via rulemaking payment for chronic care management that began in 2015.  This bill would put the weight of law behind paying for a chronic care management code (or codes) rather than leaving it to agency discretion.

So to recap: the House bill repeals the SGR and replaces its 24% SGR cut with positive updates, putting hundreds of billions back into the physician payment system above the current baseline.  It simplifies and consolidates existing reporting programs into one program.  It gives physicians more control over their annual updates.  It puts additional money, beyond SGR repeal, into the physician payment system by canceling 2019 PQRS and Meaningful Use penalties and by allocating $500 million to the top quality performers. It creates multiple opportunities for physicians to qualify for higher payments for successfully reporting on quality measures or by participating in alternative payment models like PCMHs.   For all of these reasons, and others, it has earned the support of ACP—and more than 750 physician membership organizations.

Now, let’s close the deal by urging Congress to pass the SGR Repeal and Medicare Provider Modernization Act, this week, without delay, before the 21% SGR cut occurs on April 1.

Today’s question: What have you done to urge your Representative to pass this bill?


Jay Larson MD said...

After all the hoops are jumped through, in the end, will Medicare reimbursement for a primary care provider be enough to cover the cost of running an office practice and still have some money leftover for a reasonable income. If not then it’s just shuffling the deck chairs on the Titanic.

PCP said...

Rest assured if the ACP is trying so hard to sell it to you, then it is like shuffling deck chairs on the titanic.
This seems like a whole lot more paperwork and bureaucracy disguised as patient centric care.
I wonder what happens when they realise that these so called metrics and reporting is not cutting costs?
All of this non sense to fix a system broken by the straight jacket created 18yrs ago by the political establishment.
Paying people fairly and letting their professionalism take the responsibility works best.

southern doc said...

The primary goal of this bill is to completely destroy all solo, small, and independent practices, with the SGR repeal just being the bait on the hook to get the medical societies to bite. It's working.

ryanjo said...

The Merit-Based Incentive Payment System is merely an American version of the UK NHS GP contract. The English GPs have rapidly learned to "game" the system: part of the strategy by the most successful of them is to clean out sicker or less compliant patients from their panel, thereby improving the "quality" stats.

Another poorly thought out plan favored by ACP which hurts not only doctors but the most needly of patients.