September Ebrief 2019

The Centers for Medicare and Medicaid Services (CMS) released the 2020 Medicare Physician Fee Schedule Proposed Rule (MPFS NPRM) on Monday, July 29th, 2019. The MPFS NPRM also proposes updates to the Quality Payment Program (QPP) for 2020 which includes the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs). The industry watches for the release of these proposed payment policies every July and this year was no exception. The following is a focus on the proposed changes to the MIPS program.

2020 is the fourth performance year for MIPS and the second year of three where Congress has granted CMS flexibility in implementing MIPS, most notably a) allowing CMS to arbitrarily establish the Performance Threshold for 2019 – 2021 and b) granting discretion in the weighting of the Cost performance category for those same years (H.R. 1892). This continued flexibility in setting the performance threshold causes the creation of significantly fewer penalty dollars, meaning eligible clinicians who excel under the program realize only nominal payment incentives.

Highlights of the proposed updates to MIPS under the Quality Payment Program for 2020 include:

• Performance Category weighting:
  • Quality: 40 percent
  • Cost: 20 percent
  • Improvement Activities: 15 percent
  • Promoting Interoperability: 25 percent

• Performance Threshold: 45 points (increase from 30 points in 2019) and 60 points in 2021.
• Exceptional performance threshold: 80 points (increases from 75 points in 2019) and 85 points in 2021.
• The MIPS payments adjustments increase from up to +/- 7 percent in 2019 to up to +/-9 percent. The 2020 payments adjustments will impact 2022 Medicare payments.
• Data completeness for quality measures increases to 70 percent, up from 60 percent in 2019.
• The low volume threshold remains unchanged from 2019 at </= 7 percent in 2019 to up to +/-9 percent. The 2020 payments adjustments will impact 2022 Medicare payments.
• Data completeness for quality measures increases to 70 percent, up from 60 percent in 2019.
• The low volume threshold remains unchanged from 2019 at </=$90,000 in Part B allowed charges or </=200 Part B beneficiaries or </=covered professional services. Clinicians may opt-in to MIPS if they meet or exceed one or two, but not all three, of the low-volume threshold criteria.
• Small practices may still submit quality data through the Medicare Part B claims submission type for the Quality performance category; however, CMS is proposing only allowing this option to clinicians/groups who submitted data via claims submission in 2017.
• The quality reporting period mirrors 2019 at 12 months and there is no change in the reporting period (90 days) for Promoting Interoperability and Improvement Activities.
• Facility- based groups have the option to use facility-based scoring if 75 percent or more of the MIPS eligible clinicians billing under a group’s TIN are eligible for facility-based measurement as individuals. To be eligible as an individual, 75 percent or more of the individual’s covered professional services must be performed in inpatient hospital (POS 21), on-campus outpatient hospital (POS code 22), off-campus outpatient hospital (POS 19) or emergency room – hospital (POS 23).
• The measure set for the fiscal year Hospital Value-Based Purchasing (VBP) program would be used for facility-based clinicians.
• There are no reporting requirements for clinicians under the facility-based measurement, but the group must submit data in the Improvement Activities and Promoting Interoperability (if applicable) performance categories to be measured as a group.
• CMS is proposing to change the attribution methodology for the Total Per Capita Cost (TPCC) measure to more accurately identify a beneficiary’s primary care relationship. Important to radiologists is CMS’ proposal to add service and specialty category exclusions for clinicians who perform nonprimary care services. These exclusions would include diagnostic and interventional radiology, so the TPCC measure would not be attributed to these specialties.[1]
• CMS is also proposing changes to the Medicare Spending Per Beneficiary (MSPB) measure attribution methodology to differentiate between medical and surgical episodes to better recognize the team-based nature of inpatient care and to ensure attribution to multiple clinicians. Patients will be attributed to any TIN that bills 30 percent or more of E/M services during an inpatient admission and any clinician that bills at least one E/M in that TIN will receive the attribution.

A significant proposal relates to CMS’ acknowledgement of the complexity, burden, lack of performance comparability, questionable meaningfulness and lack of patient focused measurement in the MIPS program. CMS is therefore proposing the MIPS Value Pathways (MVPs), a conceptual participation framework for future proposals beginning with the 2021 performance year. CMS’ goal is to align measures across the “siloed” MIPS performance categories to allow a more meaningful and relevant assessment of a clinician’s practice. The MVP framework would incorporate a combination of administrative claims-based measures and specialty/condition specific measures while leveraging Promoting Interoperability measures. The goal is to have all MIPS eligible clinicians participate in either an MVP or a MIPS APM.[2].

The NPRM is available by clicking here and comments must be received no later than 5 p.m. on September 27th, 2019.

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[1] Wile diagnostic and interventional radiologists may not have any patient attribution, if they employ PAs and/or NPs, there could be patients attributed to their TINs.
[2] The next e-Brief will focus on the specific details of MVPs.
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As I write this Ebrief, Hurricane Dorian has finally moved off Grand Bahama Island and is moving parallel along the Florida coast. The east coast braces to see what damage Dorian leaves in its wake. The effect of Dorian will be seen during this next legislative session which starts in January. Praying for those in the Bahamas, especially the Abacos, the devastation is tough to comprehend.

While folks were making their Hurricane preparations, Speaker Oliva announced committee membership changes.

Chairman Ray Rodrigues’s Health and Human Services Committee saw no change. Chairman Colleen Burton’s Health Quality Committee saw Representatves – Cord Byrd (R), Scott Plakon (R), and Randy Fine (R) leave the committee. In their places, new House Representatives – Jason Shoaf (R) and Randy Maggard (R) were added along with Representative Amber Mariano (R). On the Health Market Reform Committee, Chaired by Representative “Dr.” Pigman (R) – ER doctor, Representative “Dr.” Massulo (R) dermatologist came off the committee and new a House Representative Alex Andrade(R) was put on the committee. In the Health Care Appropriations committee chaired by Representative MaryLynn Magar (R), three members came off the committee – Representatives Grall (R), Plasencia (R), and Toledo (R). In their places, Representatives Burton (R), Ana Maria Rodriguez (R), and Stevenson (R) were added.

Representative Stevenson (R) no longer Chairs the House Insurance Committee and was replaced by Representative Donalds (R).

The first House and Senate Committee week is scheduled to start the week of September 16th. The block calendars are available but the committee agendas are not available yet.

In political news, Representative Travis Cummings (R) announced he was not going to run for Senator Rob Bradley’s seat. Senator Bradley (R) is termed out in 2020. Senator Bradley’s wonderful wife Jennifer Bradley (R) has announced her bid to run for her husband’s Senate seat and has tremendous support. Sam Garrison (R) has announced his intention to run for Representative Travis Cummings’ seat, also termed out in 2029, and he has great support. His brother is a radiologist in Citrus County and trained at the Mayo Clinic. He also has tremendous support.

I hope this email finds all safe as we continue through this Hurricane season.