Franklin D. Gaylis, MD

	The changing U.S. health care paradigm represents an intentional shift from volume (the more you do, the more you get paid) to value (the better quality you provide, the more you get paid). A seminal event responsible for this change was the Institute of Medicine’s report, “To Err is Human,” suggesting that between 44,000 and 98,000 Americans die from medical errors each year. This report prompted major questions about the quality of U.S. health care and its cost (nearly double most developed countries).

	Together with an unsustainable rate of health care inflation, lawmakers have struggled to control health care expenditures, currently approaching $3 trillion or almost 18% of the gross domestic product. On April 16, 2015, the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law. It aims to reimburse for better value (better quality at lower cost) through the Quality Payment Program (QPP). It represents an opportunity for the medical establishment to assume responsibility and accountability for improving quality and helping to control costs.

Value-based pay in 2017: Where does urology fit?

	This article provides a practical explanation of MACRA and QPP and what they mean for practicing urologists.

		repeals the highly criticized sustainable growth rate (SGR) formula

		changes the way that Medicare rewards clinicians, favoring value over volume

		streamlines multiple quality programs under the new Merit-Based Incentive Payments System (MIPS)

		provides bonus payments for participation in eligible Alternative Payment Models (APMs).

	Clinicians have the option of choosing either MIPS or Advanced Alternative Payment Models (A-APM) track. A subset of the A-APM track is the MIPS-APM in which eligible clinicians (physicians, physician assistants, nurse practitioners) who participate in an A-APM but don’t meet certain thresholds receive credit within MIPS.

	Excluded from participating in MIPS are physicians who are newly enrolled in Medicare, physicians who fall below the low-volume threshold, and those physicians significantly participating in A-APMs.

	Participation in the QPP started Jan. 1, 2017, the start of performance data collection. For those who are not ready to collect data, data can be collected for any 90-day period that starts between Jan. 1 and Oct. 2, 2017. Performance data must be submitted to CMS by March 31, 2018. The first performance-based payment adjustments begin Jan. 1, 2019. The Centers for Medicare & Medicaid Services eased the burden of reporting obligations in the first year of MACRA (2017), creating a process known as “pick your pace”:

		Full year–submit a full year’s worth of data

	Not participating in the QPP during 2017 will result in a –4% payment adjustment. The minimum amount of data submitted in 2017 includes one Quality measure or one Improvement Activity or four to five required Advancing Care Information measures, which are explained in the section that follows.

	MIPS has four domains or performance categories:

		Quality (replaces the Physician Quality Reporting System [PQRS])

		Advancing Care Information (ACI), which replaces Meaningful Use

		Improvement Activities (IA), a new domain

		Cost (replaces the Value-based Payment Modifier).

	Each domain has a maximum score (Quality: 60%, ACI: 25%, IA: 15%, and Cost: 0% for 2017) combined into the MIPS Composite Performance Score (0-100). Clinicians will be reimbursed under Medicare Part B based on this Performance Score. For practices that report as a group (defined at the tax identification number [TIN] level), all clinicians will receive the same score.

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 The AUA Quality Registry (AQUA) is a Qualified Clinical Data Registry (QCDR) that lists 36 proposed QPP (previously known as PQRS) measures and non-QPP measures for 2017. The non-QPP measures in AQUA seem more meaningful and relevant to clinical practice and include: #8, hospital re-admissions/complications within 30 days of TRUS biopsy; and #9, use of active surveillance/watchful waiting for low-risk prostate cancer, both of which are outcomes measures. Most participants will need to report up to six quality measures, including an outcome measure, for a minimum of 90 days.

 The ACI domain promotes patient engagement and the electronic exchange of information using certified EHR technology (CEHRT) and is comprised of a base score and performance score. It replaces the Medicare EHR Incentive Program (Meaningful Use) and allows for greater flexibility in choosing measures.

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	There are two options for data submission based on the EHR edition (2014 or 2015) being used:

	Option 1: Advancing Care Information Objectives and Measures (15 measures)

	Option 2: 2017 Advancing Care Information Transition Objectives and Measures (11 measures).

	In order to achieve the base score, which is all or nothing, the following must be reported:

	The Performance Score 2017 ACI transition measures include:

	MIPS-eligible clinicians can earn bonus percentage points by doing the following:

	Reporting “yes” to one or more additional public health and clinical data registries including a QCDR. In addition, reporting “yes” to the completion of at least one of the specified Improvement Activities using CEHRT will result in a bonus. The ACI performance category is summarized in the 

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	A QCDR is a quality data reporting registry that collects and submits MIPS quality measures’ data on behalf of eligible clinicians. QCDRs automate and streamline the quality measures reporting process, reducing cost and time spent for participating practices.

 These are attestation measures that do not require data submission, are very generic and not as defined as the Quality measures, and need to be fleshed out into protocols that make sense to the individual practice. Most participants will need to attest that they completed up to four Improvement Activities for a minimum of 90 days. Examples include:

		population management, which includes participation in a QCDR

		patient safety and practice assessment.

 While Cost will have a 0% weighting under MIPS in the 2017 performance period, the MIPS cost measurement and attribution guidelines have maintained many of the same definitions as the Quality and Resource Use Reporting System (QRUR). In performance period 2018, cost will be 10% of the MIPS score impacting 2020 payments, and by 2019, cost will be 30% of the MIPS score impacting payments in 2021. Under QRURs, costs were specialty and risk adjusted. Going forward under MIPS, they will only be risk adjusted.

	The approach to cost assessment and attribution remains a work in progress. CMS is currently engaging technical expert panels and clinical committees to help define and refine the process. CMS intends to include 

 (Part A and B medical expenses per beneficiary per calendar year) and 

 (MSPB), which represent the cost of services performed by hospitals and other health care providers during an MSPB episode, including a period immediately prior to, during, and following the patient’s hospital stay. While MSPB was part of the Hospital Value-Based Purchasing program, CMS believes that clinicians who provide a significant number of services during a hospital visit have some responsibility for overall cost.

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	It is important to understand the different methodologies based on primary care services (eg, CPT codes 99201-99215) that CMS uses to determine cost attribution. While urology is a surgical specialty, urologists are considered to provide primary care services if they bill any of these codes and will have costs attributed to them if the patient has not seen a PCP in a performance period. Physicians should examine their cost-reporting feedback from CMS (QRURs) to gauge their performance and determine how they might do better and to audit patients attributed to them.

	A cost measure is comprised of several components:

 of patient care including the items and services used to treat a condition. The episode is a specific instance of an episode group for a given clinician and patient.

		The episode group (the actual condition or the procedures performed). A surgical procedure episode group, for example, might include: preoperative services, the surgical procedure, anesthesia, services to manage complications, and readmissions. CMS has listed TURP for BPH as an episode-based measure for 2017.

		Assignment of cost to the episode group. This includes assignment of items and services (direct: provided by the attributed [principal or managing] clinician and indirect: provided or ordered by other clinicians managing the patient) known as attribution, which depends on the role of the respective clinicians.

		Attributing episode groups to the clinicians. CMS suggests that “attribution should be transparent to clinicians and only hold them responsible for outcomes they can reasonably be expected to influence.”

		Risk-adjusting episode groups will adjust for factors beyond the clinician’s control that can impact cost, including age, comorbidities, illness stage, and severity. The goal is to avoid penalizing clinicians who treat complex patients. CMS currently is addressing the methodology of risk adjustment using technical expert panels and clinical committees.

		Alignment of cost with indicators of quality necessary to compensate for information not obtained by episode costs alone. Quality evaluation might include outcomes, processes of care, and patient experience/satisfaction.

	CMS will also develop patient relationship categories and codes that define and distinguish the relationship and responsibility of a physician with a patient.

Articles

This article provides a practical explanation of MACRA and the Quality Payment Program and what they mean for practicing urologists.

Author | Franklin D. Gaylis, MD

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MACRA: A practical perspective for urologists