Washington Scene: Change Is Coming: Learn What the New Medicare Payment Policies Mean for Your Practice

STS News, Fall 2016 -- A 2015 article in The Annals of Thoracic Surgery by Alan M. Speir, MD cautioned that the devil of post-SGR Medicare physician payment would be in the details.

Those details are now being unveiled, and STS members need to be aware of them. The following information outlines the various payment policies stemming from the Medicare Access and CHIP Reauthorization Act (MACRA) and explains how the Society is working to ensure that cardiothoracic surgeons have the opportunity for success.

Merit-Based Incentive Payment System (MIPS)

The MIPS program will replace the current Medicare fee-for-service infrastructure and consolidate many existing Medicare reporting requirements. Under MIPS, physicians will receive composite scores based on four performance categories. Thresholds will be established annually, with physicians whose scores are in the top tier receiving bonus payments and those in the lowest receiving pay cuts.

The four MIPS performance categories are:

  • Quality: Physicians will be required to provide the Centers for Medicare & Medicaid Services (CMS) with certain quality metrics. Participants in the STS National Database will be able to report through the Database.
  • Resource Use: CMS has released patient attribution criteria and other ways it plans to quantify resource use by Medicare providers. STS is working to ensure that cardiothoracic surgeons are not unfairly assigned costs. However, as currently proposed, CMS will calculate the resource use performance score based on claims data, and there will be no data submission requirements under this category.
  • Clinical Practice Improvement Activities: Physicians will be rewarded for implementing policies and procedures that have been demonstrated to have a positive impact on patient care. Participating in the STS National Database likely will contribute to the score available under this category.
  • Advancing Care Information: This category incentivizes providers to utilize electronic health records.

Under CMS’s proposed implementation, physicians were to be evaluated starting in January 2017, with the first payments under this model coming in 2019. However, after being pressured by STS and others in the medical community, CMS recently announced plans for a modified rollout of the data reporting requirements.

Under the revised schedule, physicians can avoid penalties by submitting minimal amounts of data to CMS in 2017. Those who choose to report more extensive data for some or all of the year will be eligible for bonus payments. While further details will not be available until CMS issues its Final Rule (anticipated in November 2016), 2017 STS National Database participation may help physicians avoid negative payment adjustments in 2019.

Alternative Payment Models (APMs)

MACRA also incentivizes the development of APMs that demonstrate new and innovative ways to provide, coordinate, and pay for quality health care. Providers participating in certain APMs can receive bonus payments of up to 5%.

MACRA sets a pathway for providers and physician organizations to submit their ideas, and STS is developing an APM that uses the STS National Database to demonstrate how quality improvements and cost reductions are related.

STS also is partnering with the American College of Surgeons and other surgical specialty organizations to make an APM available for surgeons in the near future.

Bundled Payments for CABG

In addition to the previously mentioned changes, CMS has published a proposed rule aimed at establishing a mandatory bundled payment for coronary artery bypass grafting (CABG) procedures. It is proposed that this mandatory bundle be piloted in certain regions of the country beginning in July 2017 and that surgeons who participate be eligible to receive the APM bonus payment.

Global Surgical Payments

Despite the current policy focus on bundled payment as a mechanism to incentivize improvements in patient care, CMS continues to undermine global surgical payments.

STS led an aggressive campaign in 2015 to preserve global surgical payments. Because of the Society’s leadership, Congress passed legislation requiring CMS to collect data on global services from a “representative sample” of physicians before any changes could take effect. However, CMS has disregarded congressional direction and recently proposed to collect data from allphysicians who perform these services.

The proposal would require all surgeons to submit data in 10-minute increments for all 10- and 90-day global surgery code services through the use of eight nonpayable G-codes. This would create an undue administrative burden on physician practices, and STS is working with a coalition of surgical subspecialties to prevent this policy from taking effect.

Learn More at the Health Policy Forum

The above programs will be discussed at the Early Riser Health Policy Forum at the STS 53rd Annual Meeting in Houston, Texas, on Tuesday, January 24, 2017. Visit www.sts.org/annualmeeting for registration information.