Understanding the impact of ‘cost’ under MACRA: a neurointerventional imperative!
The cost of providing healthcare in the United States continues to rise. The Affordable Care Act created systems to test value-based alternative payments models. Traditionally, procedure-based specialists such as neurointerventionalists have largely functioned in, and are thus familiar with, the traditional Fee for Service system. Administrative charge data would suggest that neurointerventional surgery is an expensive specialty. The Medicare Access and CHIP Reauthorization Act consolidated pre-existing federal performance programs in the Merit-based Incentive Payments System (MIPS), including a performance category called ‘cost’. Understanding cost as a dimension that contributes to the value of care delivered is critical for succeeding in MIPS and offers a meaningful route for favorably bending the cost curve.
The use of incentives to stimulate high-value care by tying both hospital and physician payments to new value-based payment models.
Increase integration of care delivery, with more efficient teams and care coordination, as well as more awareness by providers to population health.
Use of health information technology to optimize patient care.
The MIPS cost performance category is being calculated starting in performance year (calendar year - CY) 2017. However, it is weighted at 0% in the FS. Even though cost does not require specific reporting at present, the other MIPS data of 2017 CY must be reported by the end of March 2018.33 For CY 2018 (2020 payment year), cost will be weighted at 10% of the FS.34 35 Until the recently dropped congressional budget, for the following CY 2019, FS was expected to increase to 30% wt cost-based. With the Bipartisan Budget Act (BBA) of 2018, CMS has been given greater flexibility in pursuing years for reweighting of cost to 10% through 2021.36 The authors believe it likely that these changes will slow the momentum considerably and that cost will not be weighted to 30% in 2019.
The recently published 2018 MACRA final rule35 provides the following overall FS weights: Performance year 2017: Quality 60%, Cost 0%, Improvement Activities 15%, and Advancing Care Information 25%. Performance year 2018: Quality 50%, Cost 10%, Improvement Activities 15%, and Advancing Care Information 25%.
Define the population of index admissions.
Attribute episodes to a TIN-NPI.
Calculate the MSPB measure for the TIN-NPI or TIN.
Report the MSPB measure for the TIN-NPI or TIN.
MSPB attribution has changed in two fundamental ways.
Under VM, MSPB was first attributed to a TIN with the plurality of part B services on the index patient (it was subsequently assigned to an NPI, but this was an insignificant bookkeeping attribute). Under MIPS, the attribution occurs at the NPI-TIN or TIN level depending on whether you report as an individual, group, or virtual group. This change in methodology has strategic implications as it is harder to get an attribute as an NPI-TIN than it is as a TIN. This strategy did not exist under VM.
The threshold of attributes changed several times during VM but ended up at 125. In MIPS the threshold is 35.
Calculate payment standardized per-capita costs.
Calculate the TPCC measure for the TIN-NPI or TIN.
Report the TPCC measure for the TIN-NPI or TIN.
Both MSPB and TPCC are risk-adjusted metrics, which take into consideration beneficiaries’ age and comorbidities. The risk-adjustment methodology for both is based on the CMS Hierarchical Condition Category (CMS-HCC) model, which is used for the Medicare Advantage program.44 However, there are distinct updates developed for each of the two metrics, beyond the scope of this paper.
Assignment of the cost to the episode group.
Connecting an episode group to specific clinicians.
Risk adjustment of the episode groups.
‘Coupling’ cost and quality (which incorporates outcomes, processes of care, and patient engagement/experience).
For 2018 CY, 10% of the FS will be calculated based on the average of TPCC for all attributed beneficiaries and MSPB. The final rule of the Quality Payment Program35 opted for a 10% weight and is an attempt to soften the transition for the subsequent year when cost will be scored at 30% as has now been actively addressed in the BBA of 2018.36 CMS will grade eligible physicians and groups using administrative claims data if they meet the case minimum for the metric and if a benchmark is available for comparison. If only one criterion can be evaluated, this single number will represent the whole cost score. The10 episode-based cost measures that were assessed during 2017 CY will not be used for the 2018 CY and thus will not be covered here.
For CY 2018, CMS has contracted with Acumen LLC to develop a new episode of care system, currently under testing, to comply with the MACRA rules.35 Acumen LLC is a research and consulting firm which specializes in health policy and traditionally works with government agencies45 46 that CMS contracted to this endeavor. This entity engaged two separate subgroups to help with the process: a conglomerate of seven Clinical Subcommittees (CS) and Technical Expert Panels (TEPs).37 Of note, at least four NI specialists are involved in the Acumen effort.
Elective outpatient percutaneous coronary intervention (PCI).
Revascularization for lower extremity chronic critical limb ischemia.
Routine cataract removal with intraocular lens (IOL) implantation.
Intracranial hemorrhage or cerebral infarction.
ST-elevation myocardial infarction (STEMI) with PCI.
When episodes are initiated, clinicians will be assigned through the TIN-NPI documented in the NPI field on the Physician/Supplier Part B. It is desirable that clinicians are aware at the time of services if they will be associated with the specific episode of care. For procedural episodes, the episode is linked to the physician executing the trigger service (CPT/HCPCS procedure codes). For acute inpatient medical condition episodes, the assignment is related to the professional responsible for billing the minimum of 30% of the inpatient evaluation and management (E&M) services during an inpatient admission with the medical Medicare Severity Diagnosis-Related Groups (MS-DRGs).37 The concept is to ensure that episodes are assigned to professionals who can meaningfully impact episode spending. Patient Relationship Codes (PRCs) are designed to more precisely detail the level of clinical engagement in the episode.47 The codes are currently in a voluntary reporting period and whether and how the codes are reported will not affect Medicare payment. During the voluntary period, CMS will be collecting data for validity and reliability testing of the codes before their potential use in the attribution methodology for cost measures. More than one physician can be responsible for the episode of the same patient, varying with their role.31 While the general concept is intuitive the precise threshold of assessing which clinician has significant influence over the medical expenditures is less clear and may be subject to further refinement based on feedback from real-world testing. It remains uncertain whether measures will be optimally assessed by enumerating encounters or evaluation and management claims.
Episode costs are standardized and risk-adjusted.37 The standardization method is used to facilitate comparison and correct for differences related to choices related to a healthcare facility. Different costs related to geographic variations are also eliminated with standardization. Risk adjustment aims to balance factors outside of the clinician’s control that can influence spending, for example, variance associated with patient’s previous health conditions, illness severity, ages, and comorbidities which are not under a physician’s control (eg, in an elective outpatient PCI episode-based cost measure, risk adjustment model would account for a patient’s previous history of heart failure). Two different types of risk adjustment are used: standard for all of the episode-based cost measures, the CMS Hierarchical Condition Category Version 22 (CMS-HCC V22) 2016 Risk Adjustment Model; and specific risk adjustors recommended by the Clinical Subcommittees31 43 during cost measure development. By way of example, the Neuropsychiatric Subcommittee recommended the concurrent diagnosis of aphasia and dysphagia as independent risk variables for intracranial hemorrhage and cerebral infarction.
Nonetheless, while cost and resource utilization are covered in this manuscript as a specific component of MIPS scoring, it is straightforward to imagine many scenarios where having a better handle on resource utilization could have a meaningful impact on performance metrics of neurointerventionalists. Thus, it is necessary for NI specialists to focus energy on these components as a discipline of practice.
Beyond MIPS and QPP, there are other opportunities for cost to impact on episodes. An example comes from the American Medical Association, which has considered expanding the current procedural terminology (CPT) code sets to include alternative payment models and/or episodes. Neurointerventionalists are familiar with the complex interplay of the CPT system, the Specialty Society RVS Update Committee (RUC), and CMS for determining specific fees for service. How that traditional FFS system might look if expanded to include APMs remains unclear.53 54 In such a circumstance, cost could be expected to be a vital factor in achieving success.
As systems of care continue to expand, it is likely that NI groups will increasingly co-exist within a single clinically integrated and/or health network. Resource utilization coupled with quality could be used to reward or penalize different members of the system. Decision-making within episodes of care could all come under the rubric of efficient utilization of resources. Examples of these types of decisions exist throughout the NI landscape and include the use of diagnostic arteriography when cheaper non-invasive options are available, use of anesthesia when moderate sedation might be appropriate, or even selecting six vessels selected in a diagnostic study when one might answer the question. Further, as episodes consider both Part A and B costs, operators who might have previously chosen interventional devices based on preference, might recognize a higher value in considering per unit or per treatment cost in the decision-making process. Moreover, as private payers adopt progressive elements of value-based methodology, understanding of costs will inure to the benefit of providers.
Neurointerventional specialists will predominantly participate in the MIPS payment pathway in the present, near, and intermediate term future. Understanding the cost performance category of MIPS is vital to succeeding in this environment. The current round of cost measures included a particular set of trigger episodes of some, but perhaps not crucial, interest to the NI community. It is of paramount importance to gain complete facility with the methodology used to proactively offer suggestions for future episodes that will be adjudicated similarly but leaves us with clinical decision room to appropriately serve our patients. Episodic care is simultaneously the method best suited for NI practice and the most likely for our specialty group to succeed.
We would like to thank Joyce Lam and Sam Bounds for reviewing this work and providing feedback on measure specifications and policy.
. Health expenditure and financing 2013. 2014. http://stats.oecd.org/Index.aspx?DataSetCode=SHA (accessed 7 Jan 2018).
Center for Medicare and Medicaid Innovation Established Social Security. https://www.ssa.gov/OP_Home/ssact/title11/1115A.htm (accessed 7 Jan 2018).
Centers for Medicare & Medicaid Services (CMS). About the CMS Innovation Center | Center for Medicare & Medicaid Innovation. 2015 https://innovation.cms.gov/About (accessed 7 Jan 2018).
114th Congress. United States of America. Medicare Access and CHIP Reauthorization Act of 2015. 2015. https://www.congress.gov/bill/114th-congress/house-bill/2 (accessed 16 Oct 2017).
Center for Medicare & Medicaid Services. The quality payment program overview fact sheet. https://qpp.cms.gov/ (accessed 13 Nov 2017).
Centers for Medicare and Medicaid Services. Merit-based Incentive Payment System (MIPS) Overview. 2017. https://qpp.cms.gov/mips/overview (accessed 26 Nov 2017).
Centers for Medicare & Medicaid Services (CMS). 2017 quality payment program frequently asked questions, 2017:1–21.
Quality Payment Program. Alternative Payment Models (APMs) overview. 2016. https://qpp.cms.gov/apms/overview (accessed 13 Nov 2017).
Centers for Medicare & Medicaid Services. Innovation Models | Center for Medicare & Medicaid Innovation. CMS.gov 2016;0.
Centers for Medicare & Medicaid Services (CMS). Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Final rule with comment period. 2016.
Centers for Medicare and Medicaid Services. Merit-based Incentive Payment System (MIPS): Episode-Based Cost Measure Field Test Reports Fact Sheet. 2017:1–6.
Centers for Medicare & Medicaid Services (CMS). The quality payment program. https://qpp.cms.gov/ (accessed 12 Jan 2018).
Centers for Medicare and Medicaid Services. Proposed rule for quality payment program year 2. 2017 https://www.cms.gov/./Quality.Programs/./Proposed-Rule-for-the-Quality-Payment (accessed 26 Nov 2017).
Center for Medicare & Medicaid Services. QPP year 2 final executive summary. 2017. https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/QPP-Year-2-Executive-Summary.pdf.
115th Congress (2017–2018). Bipartisan Budget Act of 2018. 2018. https://www.congress.gov/bill/115th-congress/house-bill/1892/text (accessed 15 Feb 2018).
Centers for Medicare and Medicaid Services. Value based payment modifier. 2014. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html (accessed 12 Jan 2018).
Centers for Medicare and Medicaid Services. 2015 Measure Information about the Condition Specific Per Capita Costs for All Attributed Beneficiaries Measures, 2017:1–8.
Center for Medicare & Medicaid Services. Risk adjustment overview, 2015.
Centers for Medicare and Medicaid Services. Announcement of Calendar Year (CY) 2014 Medicare advantage capitation rates and medicare advantage and part D payment policies and final call letter. 2014:1–195 https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2014/ (accessed 5 Feb 2018).
Acumen LLC/CA: Company Profile – Bloomberg. https://www.bloomberg.com/profiles/companies/8203100Z:US-acumen-llc/ca (accessed 12 Jan 2018).
Acumen LLC. http://www.acumenllc.com/ (accessed 4 Dec 2017).
Contributors The initial draft was prepared by GS and JH. All authors reviewed the draft, provided meaningful edits, contributed to, and approved, the final version.
Competing interests JAH has consulted for Medtronic and Globus in the last 36 months – unrelated. JAH and ABR are supported by Research Grants from the Harvey L. Neiman Health Policy Institute NC and RD and both work for Acumen, LLC. This article does not express the opinions of Acumen, LLC.