A first analysis by Healthcare Informatics of the “SGR repeal” legislation introduced into the U.S. House of Representatives on Thursday, March 19 to repeal Medicare’s Sustainable Growth Rate Formula for physician payment, and instead institute a 0.5-percent payment update for the next five years for physicians, under Medicare, offers the prospect of a sweeping change in how physicians will be paid under the Medicare program.
The legislation would replace physicians’ mandatory participation in the Value-Based Payment Program under Medicare (for all physicians participating in Medicare) with a new Merit-based Incentive Payment System, or “MIPS.” Under the new “MIPS,” to be applied to payments beginning Jan. 1, 2019, the Secretary of Health and Human Services would “assess appropriate adjustments to quality measures, resource use measures, and other measures used under the MIPS; and… assess and implement appropriate adjustments to payment adjustments, composite performance scores, scores for performance categories, or scores for measures or activities under the MIPS.”
The legislation targets four key areas: quality, resource use, clinical practice improvement (including care coordination and improvement activities), and the meaningful use of certified EHR (electronic health record) technology.
There are layers of details in the legislation. “Clinical practice improvement, the bill states, would include requirements for “care coordination… such as timely communication of test results, timely exchange of clinical information to patients and other providers, and use of remote monitoring or telehealth,” as well as “beneficiary engagement, such as the establishment of care plans for individuals with complex care needs, beneficiary self-management assessment and training, and using shared decision-making mechanisms,” and “patient safety and practice assessment, such as through use of clinical or surgical checklists and practice assessments related to maintaining certification.”
The legislation also directs that “[T]the Secretary shall give consideration to the circumstances of small practices (consisting of 15 or fewer professionals and practices located in rural areas and in health professional shortage areas…”
Under the MIPS, the HHS Secretary would “establish an annual final list of quality measures from which MIPS-eligible professionals may choose for purposes of assessment.”
The legislation states that “Eligible professional organizations and other relevant stakeholders shall be requested to identify and submit quality measures to be considered for selection under this subparagraph in the annual list of quality measures published under clause (i) to identify and submit updates to the measures on such list.” And it adds that failure on the part of a MIPS-eligible professional “to report on an applicable measure or activity that is required to be reported by the professional… she be treated as achieving the lowest potential score applicable to such measure or activity.”
The legislation would also direct the HHS Secretary to “encourage” MIPS-eligible professionals “to report on applicable measures… through the use of certified EHR technology and qualified clinical data registries; and… with respect to a performance period, with respect to a year, for which a MIPS-eligible professional reports such measures through the use of such EHR technology, treat such professional as satisfying the clinical quality measures reporting requirement….”
Importantly, the legislation would direct the HHS Secretary to order that a “composite score” performance system be developed, in which every MIPS-eligible professional would be evaluated annually and given a “composite performance score,” which would result in a “MIPS adjustment factor” to that provider’s Medicare reimbursement for the year. What’s more, a provision in the legislation would include the evaluation of entire physician groups based on quality, which would represent a payment innovation under Medicare.
Among the numerous factors to be evaluated and assigned points under the system would be expanded practice access, “such as same day appointments for urgent needs and after hours access to clinician advice”; “population management, such as monitoring health conditions of individuals to provide timely health care interventions or participation in a qualified clinical data registry”; “care coordination,” which would include “timely communication of test results, timely exchange of clinical information to patients and other providers, and use of remote monitoring or telehalth”; and “beneficiary engagement, such as the establishment of care plans for individuals with complex care needs, beneficiary self-management assessment and training, and using shared decision-making mechanisms”; “patient safety and practice assessment, such as through use of clinical or surgical checklists and practice assessments related to maintaining certification”; “participation in an alternative payment model.”
With regard to the meaningful use program, the legislation directs the HHS Secretary to, “as feasible, emphasize the application of outcome measures”; and also to “use global measures, such as global outcome measures, and population-based measures” to determine quality performance levels.
The legislation envisions the composite performance score as starting out in the first and second years with 30 percent of the total score being based on quality, 30 percent on resource use, 15 percent on clinical practice improvement activities, and 25 percent on meaningful use of certified EHR technology.
Healthcare Informatics will continue to update readers on new developments in this emerging story.