Physician Payment: CMS Seeks Suggestions for SGR, PQRS, Meaningful Use and VBM Replacement

by Baker Ober Health Law

CMS would like your help in developing the replacement to the Sustainable Growth Rate adjustment (SGR). But you need to act quickly because CMS' cutoff date for your suggestions is October 31, 2015.

CMS is developing the replacement to the SGR in accordance with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) [PDF]. MACRA repealed the widely unpopular SGR, which had reached a double digit reduction in the conversion factor used to determine physician reimbursement, with a temporary ½ percent increase to the conversion factor until the end of 2018. MACRA requires CMS to replace the SGR, the Physician Quality Reporting System (PQRS), the Electronic Medical Record Incentive Program (Meaningful Use), and the Value Based Modifier (VBM) incentive programs by 2019, with a new Merit-Based Incentive Payment System, called MIPS. MACRA also created an incentive for eligible professionals to participate in alternate payment models (APMs) by providing a ½ percent factor increase for those professionals participating in an APM and exempting those providers from MIPS.

CMS requested suggestions on how to transition these programs in a request for information [PDF] published in the Federal Register on October 1. CMS sought specific comments in the following areas:

  1. Whether certain mid-level providers like physical therapists, clinical social workers, certified nurse midwives, registered dieticians, and others should be eligible for MIPS (and be included in MIPS as Eligible Professionals), or whether only physicians (as defined by Medicare), physician assistants, nurse practitioners, and certified registered nurse anesthetists should be Eligible Professionals;
  2. How to allow Eligible Professionals to participate in MIPS, including those who billed claims to Medicare under multiple tax identification numbers, and how to allow virtual groups of like-minded eligible professionals to submit their MIPS data collectively;
  3. How to address CMS' concerns over data quality, the use of different reporting mechanisms to report quality indicators, and whether MIPS should require Eligible Professionals to report data using Certified EHR Technology standards or merely record and capture the quality data;
  4. What resource measures should be used for MIPS, in comparison to those used in the VBM incentive program;
  5. What clinical practice improvement measures should be used that would most likely result in improved outcomes for Eligible Professionals, including special rules for small and rural providers;
  6. How to implement the meaningful use of Certified EHR Technology methodology;
  7. Recommendations for other measures, including those used in other CMS payment systems;
  8. Input on process issues, including how to assess an Eligible Professional's performance history, how to implement the scoring system, and what flexibility CMS should have in weighing performance categories; and
  9. Requirements for APMs and the relationships between APMs, MIPS, Eligible Professionals, and providers exempt from MIPS because they participate in a QPM.

Ober|Kaler's Comments

Stakeholders should act quickly and submit their comments by October 31, 2015. The transition to MIPS is an opportunity to promote positive aspects of PQRS, meaningful use, and VBM and to remove aspects of each of those programs which offer little benefit or are perhaps more arduous than they are worth. APMs and the physicians who participate in APMs should also consider responding to CMS' request for information. Lastly, midlevel providers like clinical social workers, certified nurse midwives, physical therapists, and registered dieticians should consider whether MIPS would be a welcome intrusion, or an unwanted one, in their care delivery.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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