Congress passed the landmark bipartisan legislation MACRA (Medicare Access and CHIP Reauthorization Act) in April 2015, which permanently replaced the Sustainable Growth Rate formula and established two new tracks for physician payment.
Last week, CMS released proposals for implementing it. To save you some time, we analyzed the nearly 1,000 page rule and distilled five key takeaways radiologists need to know.
1. Your performance next year will determine 2019 payment
As with other payment initiatives, CMS would base payment adjustments for both MIPS and APM tracks on performance periods two calendar years prior to the adjustment. That means performance in 2017 will determine payments for 2019. This is especially notable for smaller radiology groups who have not yet reported under PQRS or experienced payment adjustments under VBPM.
2. Assume you’re in the MIPS track
CMS estimates that as few as 4% of participating physicians will get paid under the APM track. With the significant amount of revenue that must be received through alternative payment models, likely no radiology groups will qualify for the APM track. The rule sets a high bar for APM qualification, and the most popular alternative payment models (track 1 of MSSP, Medicare Advantage, and both bundled payment programs CJR and BPCI) all do not qualify as advanced APMs in the first performance year.
Providers will report measures across four categories, and performance will be aggregated into a MIPS composite performance score (CPS) to determine payment adjustments.
MIPS Performance Categories and Weighting
||Proposed weighting (2019 – Year 1)
Replaces PQRS and quality component of VBPM
||6 measures; at least 1 cross-cutting measure (for patient-facing clinicians) at least 1 outcomes measure
|Resource use (cost)
Replaces cost component of VBPM
||Score based on Medicare claims, meaning no reporting requirements for clinicians
|Clinical practice improvement activities (CPIAs)
Focuses on care coordination, beneficiary engagement, and patient safety
||Encouraged but not required; providers can choose from 90+ options
|Advancing care information
Replacing meaningful use of EHR technology
||Encouraged but not required; emphasis on interoperability and information exchange
The CPS will be compared to a performance threshold used to determine a payment adjustment. The payment adjustments will be scaled for budget neutrality, meaning an equivalent number of providers will receive upward adjustments as downward. The maximum negative adjustment for 2019 is 4%, which will increase to 5% in 2020, 7% in 2021, and 9% in 2022 and after.
3. MIPS will take into account unique considerations for non-patient-facing clinicians like radiologists
A major concern with the initial passage of MACRA was that MIPS performance metrics may not take into account the unique needs of non-patient-facing clinicians, such as radiologists. In response to feedback from commenters, CMS created a new definition for non-patient-facing clinicians, addressing several issues with the definition used under the current quality reporting programs.
- Non-patient-facing MIPS eligible clinician: An individual or group that bills 25 or fewer patient-facing encounters during a performance period (one calendar year). CMS established the 25 patient encounter threshold based on an analysis of specific HCPCS codes.
- Patient-facing encounter: An instance in which the MIPS eligible clinician or group billed for services such as general office visits, outpatients visits, and surgical codes under the Physician Fee Schedule (PFS). The proposed list of face-to-face encounter codes will be published on a CMS website.
CMS estimates that 25% of MIPS eligible clinicians will qualify as non-patient-facing.
4. Radiology performance metrics consistent with recent regulatory areas of emphasis
The MACRA proposed rule contains 22 performance criteria for radiology, which includes interventional radiology and radiation oncology measures. Of the four performance categories, quality metrics represent the largest bucket of radiology metrics. The areas of focus should not be surprising to individuals familiar with recent Joint Commission and Medicare decisions. As such, radiology leaders will have three major areas of focus:
- Radiation dose management: The MACRA proposal includes several performance metrics concerning the documentation of radiation dose exposure, participation in a radiation dose index registry, and other efforts to minimize the amount of radiation patients receive.
- Recommendation follow-up: With recent attention on the low rate of follow-up on radiologist recommendations, it is unsurprising that CMS has included this as an area of focus. The majority of these requirements are related to imaging screening exams and incidental findings follow-up.
- External image sharing: CMS’s proposal encourages providers make DICOM images available to external health care facilities, and encourages searching for DICOM images from those same facilities prior to ordering an imaging exam for a patient. These measures are currently focused on CT scans and will also serve to reduce patient exposure to radiation.
5. Appropriate Use Criteria (AUC) not a 'get out of MIPS free card'
CMS notes that Appropriate Use Criteria (AUC) can be incorporated into the CPIA performance category by including activities related to appropriate assessments and reducing unnecessary services. CMS incorporated AUC into some of these activities, however, they encourage MIPS eligible clinicians who are already required to use AUC (for example, in the imaging CDS mandate) to report a CPIA other than one related to appropriate use.
It is important to note that this is still just a proposal, and many significant aspects could change between now and the final rule. CMS is soliciting feedback on APM qualification, reporting mechanisms, and proposed list of performance metrics. As always, we will be keeping a close eye on this legislation and providing any insights through this blog and our new Twitter account @Advisory_IPP.