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Preparing for Quality Payment Program Year Four

(NOTE: This is a longer version of an article that appeared in the May 2020 issue of Vascular Specialist.) 

Congress passed the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) by a bipartisan vote in 2015. MACRA repealed the sustainable growth rate that threatened to reduce Medicare physician payments by more than 20% yearly. At the same time, MACRA created the Quality Payment Program (QPP), which requires that most physicians who submit claims to the Centers for Medicare and Medicaid Services (CMS) participate in one of two programs to avoid a reimbursement penalty. These are the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM).

Physicians who do not participate adequately in the QPP in 2020 will face a 9% penalty in their 2022 Medicare reimbursements. There is currently no approved vascular condition-specific APM, so many vascular surgeons will participate in MIPS if they are not part of a multispecialty APM. Vascular surgeons in independent practices can consider exploring joining a multispecialty APM as a way of satisfying QPP participation requirements.

Calendar year 2020 is year four of the QPP. Year one was 2017, in which MIPS clinicians had flexible participation options to help ease transition into the program. CMS has gradually increased the minimum performance requirements yearly to allow for a gradual shift to the full program requirements by year five. The Society for Vascular Surgery (SVS) annually takes advantage of the opportunity to submit comments regarding the proposed rule for how the QPP will be implemented in the coming year. Based on feedback from the SVS and other professional societies, some of the latest changes for performance year 2020 aim to reduce complexity, choice and “paperwork” and remove unnecessary elements. CMS also has placed high priority on activities that improve care and experience for patients. 

For MIPS year four, there are four performance categories with weights that each contribute to the final score remaining unchanged from Year three: Quality (45%), Cost (15%), Promoting Interoperability (25%), and Improvement Activities (15%). In the Quality category, data on 70% (up from 60 percent in year three) of eligible patients for any given measure must be reported for the measure to be considered complete. Quality measures eligible for use in MIPS are available in the QPP Resource Library available at https://qpp.cms.gov/mips/quality-measures. Topped-out measures that CMS considers to be maximized out on their potential for quality improvement may now be removed from MIPS eligibility in the future, and these are published on the website along with their historical quality benchmarks for all measures. In general, for all measures, historical quality benchmarks are used for scoring performance.

Improvement Activities are those meant to improve clinical practice. In this category, two new activities are available, seven were modified and 15 were removed. These activities also can be viewed in the QPP Resource Library. The Promoting Interoperability category refers to the requirements for the electronic health record. The requirements in this category remain unchanged from year three with one set of required objectives and measures based on the 2015 Edition Certified Electronic Health Record Technology. The four required objectives are e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. 

The final category is Cost, which is calculated from claims and requires no reporting by providers. There are specific cost measures which are relevant to vascular surgeons: Revascularization for Lower Extremity Chronic Critical Limb Ischemia and Hemodialysis Access Creation. Providers who perform the minimum threshold number of procedures that fit the inclusion criteria for each cost measure will automatically be assessed using claims. For providers who do not meet the inclusion criteria for the specific cost measures, two general cost measures will be used: “Medicare spending per beneficiary” and “total per capita cost for all attributed beneficiaries.”

Clinicians are required to report certain measures from each of the four objectives unless a valid exclusion is claimed. The minimum performance threshold for the 2020 performance period to avoid the 2022 payment penalty is 45 points (increased from 30 in year 3). There is a $500 million pool for exceptional performers. The threshold for exceptional performance in year 4 is 85 points (increased from 70 in year 3). The performance threshold and performance category weights will continue to be incrementally adjusted to meet the requirements established by Congress. Beginning with the sixth year of the program (2022 performance period) the performance threshold is required by law to be set at the mean or median of the final scores for all MIPS eligible clinicians for a prior period, and the Quality and Cost performance categories must be equally weighted at 30% each. 

One private practice vascular surgery provider in Tennessee, the Nashville Vascular and Vein Institute (NVAVI), shared their experience with meeting QPP requirements. The practice initially used its participation in the Vascular Quality Initiative (VQI) to satisfy many of the reporting requirements for MIPS but when the VQI ceased to be a Qualified Clinical Data Registry in 2018, this was no longer possible. NVAVI’s then planned for reporting each year to be done through attestation and utilization of built-in electronic health record functionality. However, without the practice’s knowledge, NVAVI has been included each year in a local, hospital- associated APM. This emphasizes the importance of checking your QPP participation status here. Nevertheless, NVAVI’s experience is that it is not difficult to participate adequately in MIPS. 

The MIPS changes outlined here will have a significant impact on vascular surgery and should be considered in a surgeon’s strategy for participating in QPP in 2020.