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Highlighting Key MACRA Changes for 2021
(A shorter version of this article can be found in the March 2021 Vascular Specialist.)
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is beginning its fifth year of activity in 2021. MACRA established the Quality Payment Program (QPP), which requires clinicians who bill Medicare to participate at a certain level or face a financial penalty. As part of the legislation, the Centers for Medicare & Medicaid Services (CMS) implemented an incentive program aimed at improving the value and quality of patient care, shifting reimbursement from fee-for-service to value-based. CMS continues to publish rule changes annually and 2020 was no exception despite the strains placed on the healthcare system by the global pandemic. COVID-19 has caused an increased burden which has limited the ability of physicians to respond to the proposed rule changes, so CMS tried to limit the changes for 2021. Some of the major changes are highlighted below.
The CMS web Interface will end in 2022. A new reporting pathway (Merit-based Incentive Payment System (MIPS) Value Pathways, or MVPs) will be adopted in 2022. Originally MVPs were to consist of measures that would allow for comparative performance data to be available to patients to make choices about care. All MVPs need approval by a rule change through CMS, and CMS has added several clarifications to the MVP framework, placing more emphasis on patient-centered quality measures.
The major change for 2021 reporting is related to the weights attributed to the traditional MIPS performance categories. The four main categories are Quality, Cost, Promoting Interoperability (PI) and Improvement Activities (IA). The main shift is additional weighting given to Cost measures over Quality with each of these contributing 40% (from 45%) and 20% (from15%) respectively. These two measures will be equally weighted at 30% for 2022. No changes to the weighting of the other two categories will occur. This gradual increase in the weighting of Cost over Quality does not apply to the APM Performance Pathway (APP). Along with the changes to the performance category weighting, the minimal threshold to avoid MIPS penalties also increases to 60 points (from 45), despite efforts from professional societies, including the SVS, to limit it to 50 because of the burdens of caring for COVD-19 patients
The threshold for the exceptional performance category will remain at 85 points and the range for penalties and bonuses will remain at up to +/- 9%. For MIPS APM entities that are reporting traditional MIPS measures, these weighting are Quality, 50%; Cost, 0%; PI, 30%; and IA, 20%, with a minimum threshold of 60 points as well. Of note, by law the weighing of Quality and Cost performance categories must be equally weighted at 30%.
Additionally, CMS introduced the new reporting framework, the Alternative Payment Model (APM) Performance Pathway (APP) for 2021. This pathway is intended to complement MVPs. APP was developed with the goal of reducing reporting burden on clinicians and stakeholders. Since all APM participants are already responsible for cost containment, the Cost performance category weighting is set to 0%. The APP reporting also includes jjust six required quality measures focused mainly on population health.
Within the four Performance categories, several revisions to the specific measures have also occurred, most of which are in the Quality category. Eleven Quality measures were removed, including “All-Cause Hospital Readmission.” Changes to more than 100 existing measures and the addition of two new administrative claims measures were implemented. One of these new measures is directed towards orthopedic surgery and hip replacement; however, the second is a measure of hospital–wide 30-day, all-cause, unplanned readmission. In the Cost category, no major changes occurred other than the inclusion of telehealth services to existing episode-based cost measures and the Total Per Capital Cost measure (TPCC), and the 0% weighing of the Cost category for APM entities reporting in traditional MIPS.
The most important update to the PI category is the retention of the “Query of Prescription Drug Monitoring Program (PDMP),” which can be worth 10 points or one-sixth of the minimal points needed to avoid penalties in the MIPS program. Lastly, in the IA category, CMS will continue to give credit for COVID-19-related data reporting. Whether the treatment is provided through a research trial or routine patient care, the results must be entered into a clinical data registry to be eligible.
Additional COVID-19-specific rule changes led to a finalization of the proposal to double the number of points available for the complex patient bonus. This allows for individuals, groups, virtual groups and APMs to earn up to 10 points for the 2021 year and also to petition for reweighting of the performance categories due to the pandemic. CMS waived the requirement that Accountable Care Organizations (ACOs) perform “Consumer Assessment of Healthcare Providers and Systems” (CAHPS) surveysand still receive full credit. CMS also finalized its plan for phasing in quality reporting for ACOs to meet the Shared Savings Program quality performance standards. The expectation is that by the 2023 performance year, ACOs achieve a quality performance score that is greater than or equal to the 40thpercentile across all MIPS Quality performance category scores.
(The authors are all members of the SVS Performance Measures Committee.)