Raghu Vir

Is MIPS really doing what it is supposed to do? Research suggests that it is not.

How well does the Merit-based Incentive Payment Program (MIPS) of Medicare measure the caliber of medical treatment that is given? According to the findings of a recent study, not very.

The 2017 introduction of MIPS, which replaced three prior quality measurement programs, aimed to enhance patient care by financially rewarding or penalizing physicians based on their performance on particular “process” and “outcome” metrics in four key areas: cost, quality, improvement activities, and fostering interoperability.

The six metrics that participating physicians choose to report on must include one outcome indicator, such as a hospital admission for a particular disease or condition. Currently, MIPS is the biggest value-based payment program in the country.

Data from Medicare statistics and claims records for 3.4 million individuals who saw about 80,000 primary care providers in 2019 were evaluated for the study by researchers. They compared doctors’ overall MIPS scores with their scores on five process measures, including breast cancer screening, tobacco screening, and diabetic eye exams, and six outcome measures, including ED visits and hospitalizations.

The findings showed there was no consistent relationship between the measures’ performance and the final MIPS ratings. For instance, doctors with low MIPS scores scored somewhat better on the other two process measures, while having much lower average MIPS scores than physicians with high MIPS scores on three of the five process measures examined.

Low-scoring doctors performed much worse on the all-cause hospitalizations per 1,000 patients metric than they did on the other four outcome measures, although they performed significantly better on the metric of ED visits per 1,000 patients. Similar to this, 21% of physicians with high MIPS scores had outcomes that were in the poorest percentile, compared to 19% of those with low MIPS scores who performed in the top quintile for composite outcomes performance.

The findings suggest that the MIPS program’s accuracy in identifying high- versus low-performing providers is really no better than chance.

For these findings, the authors provide a number of interpretations. Among them are the challenges in making meaningful comparisons when doctors are free to select the metrics they report on, the fact that many program metrics, as other research has shown, are either invalid or of dubious validity and thus may not be linked to better outcomes, and the possibility that high scores may simply be an indicator of a program’s capacity for data collection, analysis, and reporting rather than of higher quality medical care.

They claim that the latter conclusion is supported by the discovery that participants with low MIPS scores were more likely to work in independent, small practices even though their clinical outcomes were frequently comparable to those of medical professionals in large, system-affiliated practices with high MIPS scores.

This research was released in JAMA on December 6. https://jamanetwork.com/journals/jama/article-abstract/2799153

Hospital Outpatient Departments: Effective July 1, 2020 you must request prior authorization for certain hospital Outpatient Department (OPD) services

For dates of service beginning July 1, 2020, you must request prior authorization for the following hospital Outpatient Department (OPD) services:

  • Blepharoplasty
  • Botulinum toxin injections (when paired with specific procedure codes)
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation

Medical necessity documentation requirements remain the same and hospital OPDs will receive a decision within 10 days.

While only the hospital OPD service requires prior authorization, CMS wants to remind other providers that perform services in the hospital OPD setting that claims related to/associated with these services will not be paid if the service requiring prior authorization is not eligible for payment. These related services include, but are not limited to, anesthesiology services, physician services, and facility services. Only associated services performed in the hospital OPD setting are affected. Depending on the timing of claim submission for any related services, claims may be automatically denied, reviewed, or denied on a postpayment basis.

For botulinum toxin injections, consult the list of codes that require prior authorization for more details. Generally, the use of botulinum toxin injection codes paired with procedure codes other than 64612 or 64615 will not require prior authorization under this program.

Saince announces the launch of tele-medicine feature within its clinical documentation solution

Doc-U-Scribe clinical documentation solution now comes integrated with tele-medicine workflow. Physicians and administrators can create tele-consultation sessions with patients seamlessly from within the application. This process eliminates the need for providers to use separate solutions – one for clinical documentation and another for video session.

The COVID-19 public health crisis has accelerated the use of tele-medicine solutions among healthcare provides across the nation. However, many small hospitals and physician offices do not have access to a single solution that takes care of all their needs. Physicians are forced to use multiple solutions to complete their tele-medicine workflow. They are often finding this process frustrating and cumbersome.

Doc-U-Scribe clinical documentation solution which is used by hundreds of hospitals and physician offices across the country provides an integrated and seamless workflow for clinical documentation as well as tele-medicine.   This new HIPAA compliant tele-medicine solution can cut costs, increase efficiency, and improve physician satisfaction significantly.

Saince announced that this new feature will be available to all their existing customers immediately. Saince also announced that with their plug and play model, any new hospital or physician office can be up and running with their tele-medicine program within 48 hours.

Pandemic – Peril and the promise

The world right now is hurting. And it is hurting really bad. There is a lot of physical, emotional, and economic pain all around. This pain is accentuated with fear. Fear of facing the unknown. Fear of being helpless. Health workers are helplessly watching their patients die in front of their eyes. Children are helplessly watching their parents succumb on FaceTime. The world is now firmly in a grip of fear and gloom.

But behind all this fear and sadness I see hope. I see promise.

I see hope because whenever humanity faced a calamity in the past, either natural or man-made, when it came out on the side, the world became a much better place. For everyone. Each and every event that we faced in the past, be they world wars or natural disasters, brought a lot of pain along with them but after the event they also elevated humanity as a whole.

The Gita, the holy book of Hindus, says that good and bad are two sides of the same coin. One cannot exist without the other. Sort of Yin and Yang of the Chinese philosophy.

This pandemic brought a lot of pain. It pushed a lot of people out of business. More than 40 million Americans lost their jobs. Food lines were unimaginably long.  Everyone is scared. Everyone is hurting in some way or the other. But coming out of all this suffering and pain, I’m seeing an increased feeling of compassion among people. Out of this common suffering I see camaraderie that I never saw before. Unemployment made people look deeper within themselves. The whole climate was emotionally charged.

Then George Floyd died. That triggered an outpouring of emotion. People spontaneously took to the streets, not just in big cities but also in small towns and remote corners. Not only here but all over the world. It united us as a humanity. We felt other person’s pain like we never felt it before. We felt compassionate. We saw the long-standing inequalities in the system. We started on a path to fix it. Events like George Floyd’s death happened before the pandemic too. But the reaction was sporadic. It was temporary. But this time it is different. There is something in the air this time that smells different. We are embarking on a path to make America a better nation than it already is. As a human race, we are starting to feel more united than before.

This time it is different. The scientific community is breaking down borders and collaborating in an unprecedented manner.  They are tearing apart bureaucracies. Putting aside their personal agendas. Working fearlessly and tirelessly towards a common goal for the benefit of humanity. They are realizing the power of cooperation and sharing. Governments are as usual trying to put brakes on this by making it a competitive race. I am hoping that better sense will prevail.

The earth is healing as well. We are now more open to noticing how we have been plundering the natural resources all these years. We have already reached the tipping point in climate change. We were almost at a point of no return. With this pandemic, we hit the pause button. We are seeing palpable change even in this short period when we hit the brakes on our emissions. I am hopeful that as a human race we can continue to let the planet heal.

Families are healing as well. Families are spending time together. They are talking with each other. They are having verbal conversations instead of texting to each other from across the room. They are eating together, playing together, staying together and coming together. When families stay together, communities stay together. When communities heal, nations heal.

Fighting and terrorism across the world has come down quite a bit. In this process a lot of lives has been spared. I hope they use this time to introspect and come together because the virus does not play favorites. When there is a common enemy, everyone comes together.

Hence, I see promise on the other side of this pandemic. To deliver a bundle of joy, the mother goes through a lot of pain.

I am optimistic. I am hopeful. I am human.

CMS Announces Release of 2018 National Impact Assessment of Quality Measures Report

Center for Medicare and Medicaid Services (CMS) conducts and publishes an assessment of the quality and efficiency impact of the use of endorsed measures in CMS programs every three years as required by statute.  The first report was published March 1, 2012 and the 2018 Impact Assessment Report is the third such report.   The data-driven results of this Report support the use of measures implemented in CMS reporting programs to drive improvement in the quality of care provided to patients in facilities and across settings nationwide.  This report is used by the measure developer community, patients and families, clinicians, providers, federal partners, and researchers.

The 2018 Impact Assessment Report demonstrates that performance on CMS measures contributed to better care and reduced expenditures, and identified critical areas of improvement across settings with respect to six CMS quality priorities:  patient safety, person and family engagement, care coordination, effective treatment, healthy living, and affordable care.

Highlights include these main findings:

  • Patient impacts estimated from improved national measure rates indicated approximately:
    • 670,000 additional patients with controlled blood pressure (2006–2015).
    • 510,000 fewer patients with poor diabetes control (2006–2015).
    • 12,000 fewer deaths following hospitalization for a heart attack (2008–2015).
    • 70,000 fewer unplanned readmissions (2011–2015).
    • 840,000 fewer pressure ulcers among nursing home residents (2011–2015).
    • 9 million more patients reporting a highly favorable experience with their hospital (2008–2015).
  • Costs avoided were estimated for a subset of Key Indicators, data permitting. The highest were associated with increased medication adherence ($4.2 billion–$26.9 billion), reduced pressure ulcers ($2.8 billion–$20.0 billion), and fewer patients with poor control of diabetes ($6.5 billion–$10.4 billion).
  • National performance trends are improving for 60% of the measures analyzed, including a majority of outcome measures, and are stable for about 31%.
  • Overwhelmingly, hospitals (92%) and nursing homes (91%) surveyed reported they consider CMS measures clinically important. Likewise, 90% of hospitals and 83% of nursing homes agreed that performance on CMS quality measures reflects improvements in care. Respondents also described barriers to reporting, including burden; barriers to improving performance; and unintended consequences of CMS measures.

CMS introduces new payment model for both inpatient and outpatient care

The Centers for Medicare & Medicaid Services (CMS) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced). Under traditional fee-for-service payment, Medicare pays providers for each individual service they perform. Under this bundled payment model, participants can earn additional payment if all expenditures for a beneficiary’s episode of care are under a spending target that factors in quality.

Bundled payments create incentives for providers and practitioners to work together to coordinate care and engage in continuous improvement to keep spending under a target amount. BPCI Advanced participants may receive payments for performance on 32 different clinical episodes which are listed below.

Of note, BPCI Advanced will qualify as an Advanced Alternative Payment Model (Advanced APM) under the Quality Payment Program (QPP). Under Advanced APMs, providers take on financial risk to earn the Advanced APM incentive payment.

BPCI Advanced will operate under a total-cost-of-care concept, in which the total Medicare fee for services (FFS) spending on all items and services furnished to a BPCI Advanced Beneficiary during the  Clinical Episode, including outlier payments, will be part of the Clinical Episode expenditures for purposes of the Target Price and reconciliation calculations, unless specifically excluded.

Clinical Episodes

BPCI Advanced will initially include 29 inpatient Clinical Episodes and 3 outpatient Clinical Episodes. Participants selected to participate in BPCI Advanced beginning on October 1, 2018, must commit to be held accountable for one or more Clinical Episodes and may not add or drop such Clinical Episodes until January 1, 2020.

Inpatient Clinical Episodes – 29

  • Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis *
    *(New episode added to BPCI Advanced)
  • Acute myocardial infarction
  • Back & neck except spinal fusion
  • Cardiac arrhythmia
  • Cardiac defibrillator
  • Cardiac valve
  • Cellulitis
  • Cervical spinal fusion
  • COPD, bronchitis, asthma
  • Combined anterior posterior spinal fusion
  • Congestive heart failure
  • Coronary artery bypass graft
  • Double joint replacement of the lower extremity
  • Fractures of the femur and hip or pelvis
  • Gastrointestinal hemorrhage
  • Gastrointestinal obstruction
  • Hip & femur procedures except major joint
  • Lower extremity/humerus procedure except hip, foot, femur
  • Major bowel procedure
  • Major joint replacement of the lower extremity
  • Major joint replacement of the upper extremity
  • Pacemaker
  • Percutaneous coronary intervention
  • Renal failure
  • Sepsis
  • Simple pneumonia and respiratory infections
  • Spinal fusion (non-cervical)
  • Stroke
  • Urinary tract infection

Outpatient Clinical Episodes – 3

  • Percutaneous Coronary Intervention (PCI)
  • Cardiac Defibrillator
  • Back & Neck except Spinal Fusion

Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018

On November 1, CMS issued the CY 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule with comment period, which includes updates to the 2018 rates and quality provisions and other policy changes. CMS adopted a number of policies that will support care delivery; reduce burdens for health care providers, especially in rural areas; lower beneficiary out of pocket drug costs for certain drugs; enhance the patient-doctor relationship; and promote flexibility in healthcare.

CMS is increasing the OPPS payment rates by 1.35 percent for 2018. The change is based on the hospital market basket increase of 2.7 percent minus both a 0.6 percentage point adjustment for multi-factor productivity and a 0.75 percentage point adjustment required by law. After considering all other policy changes under the final rule, including estimated spending for pass-through payments, CMS estimates an overall impact of 1.4 percent payment increase for providers paid under the OPPS in CY 2018.

CMS updates ASC payments annually by the percentage increase in the Consumer Price Index for all urban consumers (CPI-U). The Medicare statute specifies a Multi-Factor Productivity (MFP) adjustment to the ASC annual update. For CY 2018, the CPI-U update is 1.7 percent. The MFP adjustment is 0.5 percent, resulting in a CY 2018 MFP-adjusted CPI-U update factor of 1.2 percent. Including enrollment, case-mix, and utilization changes, total ASC payments are projected to increase approximately 3 percent in 2018.

Physician Fee Schedule Final Policy for Calendar Year 2018

On November 2, CMS issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018.

The overall update to payments under the PFS based on the finalized CY 2018 rates will be +0.41 percent. This update reflects the +0.50 percent update established under the Medicare Access and CHIP Reauthorization Act of 2015, reduced by 0.09 percent, due to the misvalued code target recapture amount, required under the Achieving a Better Life Experience Act of 2014. After applying these adjustments, and the budget neutrality adjustment to account for changes in Relative Value Units, all required by law, the final 2018 PFS conversion factor is $35.99, an increase to the 2017 PFS conversion factor of $35.89. 

Highlights of Quality Payment Program for Year 2 (Calendar Year 2018) Under MACRA

Here are the highlights of the Final Rule for QPP for Year 2 under MACRA as announced by CMS yesterday:

• Weighting the MIPS Cost performance category to 10% of your total MIPS final score, and the Quality performance category to 50%.
• Raising the MIPS performance threshold to 15 points in Year 2 (from 3 points in the transition year).
• Allowing the use of 2014 Edition and/or 2015 Certified Electronic Health Record Technology (CEHRT) in Year 2 for the Advancing Care Information performance category, and giving a bonus for using only 2015 CEHRT.
• Awarding up to 5 bonus points on your MIPS final score for treatment of complex patients.
• Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the MIPS final score for clinicians impacted by Hurricanes Irma, Harvey and Maria and other natural disasters.
• Adding 5 bonus points to the MIPS final scores of small practices.
• Adding Virtual Groups as a participation option for MIPS.
• Issuing an interim final rule with comment for extreme and uncontrollable circumstances where clinicians can be automatically exempt from these categories in the transition year without submitting a hardship exception application (note that Cost has a 0% weight in the transition year) if they were have been affected by Hurricanes Harvey, Irma, and Maria, which occurred during the 2017 MIPS performance period.
• Decreasing the number of doctors and clinicians required to participate as a way to provide further flexibility by excluding individual MIPS eligible clinicians or groups with ≤$90,000 in Part B allowed charges or ≤200 Medicare Part B beneficiaries.
• Providing more detail on how eligible clinicians participating in selected APMs (known as MIPS APMs) will be assessed under the APM scoring standard.
• Creating additional flexibilities and pathways to allow clinicians to be successful under the All Payer Combination Option. This option will be available beginning in performance year 2019.

New Medicare Cards from CMS

 medicare cardsMedicare is taking steps to remove Social Security numbers from Medicare cards. Through this initiative the Centers for Medicare & Medicaid Services (CMS) is trying to prevent fraud, fight identity theft and protect essential program funding and the private healthcare and financial information of Medicare beneficiaries.

CMS will issue new Medicare cards with a new unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI) to replace the existing Social Security-based Health Insurance Claim Number (HICN) both on the cards and in various CMS systems that are in use now. CMS will start mailing new cards to people with Medicare benefits in April 2018. All Medicare cards will be replaced by April 2019.

CMS is developing capabilities where doctors and other healthcare providers will be able to look up the new MBI through a secure tool at the point of service. To make this change easier for physicians and their business operations, there is a 21-month transition period where all healthcare providers will be able to use either the MBI or the HICN for billing purposes.

Therefore, even though your systems will need to be able to accept the new MBI format by April 2018, you can continue to bill and file healthcare claims using a patient’s HICN during the transition period.  However, you need to work with your billing vendor to make sure that your system will be updated to reflect these changes as soon as possible.

Beginning in April 2018, Medicare patients will come to your office with new cards in hand.