A review of the SGR fix supported by a bipartisan group from the House and Senate and supported by the AMA identifies numerous features that incentivize providers to measure, report and disclose results on care outcomes and costs. I think this approach is long overdue. All providers are simply not the same. There are wide disparities on the outcomes of care and in order to move those outcomes to a narrower disparity that is collectively better we must first acknowledge those differences, reward those high performers, and provide encouragement and a roadmap for improvement for those that are underperforming.
Here is a summary of the SGR 2014 fix with some items of particular interest in bold.
§ The current rule is repealed,
which takes the April 2014 23.7% cut off the table.
§ Part B base professional payment rates will increase 0.5% per year
in years 2014-2018 and
then held flat through 2023.
§ All PQRS, VBM and MU (Physician Quality Reporting System,
Value-Based Modifier and EHR Meaningful Use) incentives (carrots and sticks) will be sunset at the end of 2017 and
net dollars added back into the base Part B payments to professionals.
§ From 2018 forward, a
consolidated Merit-Based Incentive
Payment System (MIPS) will govern incentive payments, based on assessment
of professionals’ performance in four categories (the first three will draw on
existing measures; the fourth will require development of new measures):
§ Quality
§ Resource use
§ EHR Meaningful Use
§ Clinical practice improvement
activities
§ MIPS quality measures will be
updated annually, and professionals will be able to select what measures to use
in rating them.
§ Each provider will be scored
on a scale of 0-100 each year, and the composite score will be compared to a
performance threshold to determine whether, and how much of, an incentive
payment will be made, or a negative adjustment will be made.
§ An additional incentive
payment for superstars will be available, capped at an aggregate amount of $500
million for each of the years 2018-2023.
§ GAO is to issue MIPS evaluation reports in 2018 and 2021.
§ Technical assistance will be available to small practices (<15)
to help improve MIPS performance or transition to alternative payment models
(APMs), with
priority given to low-performing and rural practices, and some technical
assistance funding specifically reserved for practices in health professional
shortage or medically underserved areas.
§ From 2024 on, professionals participating in certain APMs will
receive annual updates of 1% while everybody else gets 0.5% updates. (Providers
who recieve “significant” payments through APMs will not be eligible for MIPS
payments.)
§ Professionals who make a “significant” portion of their revenue
through APMs with downside financial risk and a quality component get a 5%
annual bonus in 2018-2023. Patient-centered medical home APMs are exempt from
the downside risk requirement.
§ APM and quality measure
development and review processes are spelled out.
§ Care management for
chronically ill beneficiaries is to be promoted by creating one or more payment
codes for such services. [This FFS notion seems to cut
against the general movement towards APMs - Ed.]
§ GAO is required to study the AMA RUC process and file a report
within a year. HHS is permitted (not required) to collect information from
providers about potentially misvalued services and adjust the MPFS accordingly
(some aspirational targets are included: identify misvalued services worth at
least 0.5% of the MPFS spend each year, 2015-2018), and is asked to consider
smoothing RVUs within groups of services as well. Beginning in 2015, any
downward RVU adjustment of 20% or more will be phased in over two years.
§ Clinical appropriateness for
advanced diagnostic imaging is to be determined by criteria developed in
consultation with stakeholders that are based on stakeholder consensus, are
evidence-based, are based on publicly-available studies, and are not developed
by HHS acting alone.
§ Clinical decision support (CDS) mechanisms for advanced diagnostic
imaging are to be identified by April 1, 2016; beginning 2017, payment may not
be made unless the claim includes evidence of consulting a qualified CDS
mechanism;
beginning 2020, outliers (docs with low adherence with the CDS requirement; up
to 5% of all docs) will be subject to a prior authorization requirement. GAO
has 18 months to recommend other areas that should be treated similarly (e.g.,
radiation therapy, clinical lab services).
§ Utilization and payment data
will be reported on the Physician Compare website (July 2015 for physicians,
2016 for other professionals).
§ The bill promotes broader availability
of claims data to providers and provider associations.
§ Evidence of
participation/nonparticipation in MIPS cannot be used in med-mal litigation.
§ MedPAC is tasked to submit
reports on the 2014-2018 experience (impact on beneficiary access to services
and quality of care) and recommendations for future tweaks and (in 2017 and
2021) on the relationship between Part B payments and Part A, C and D payments
(since those are driven by the professionals paid under Part B).
§ EHR interoperability required by 2017.
§ HHS to issue report on how to develop a permanent physician-hospital
gain sharing program.
§ GAO to report on barriers to
expanded use of telemedicine and remote patient monitoring.
§ HHS to publish information
used to establish multiple procedure payment reduction policy for imaging.
