CMS delays implementation of bundled payment models

CMS has further delayed the implementation date of the Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the Comprehensive Care for Joint Replacement (CJR) model by three months. This additional delay, CMS said, is necessary to allow time for additional review, to ensure that the agency has adequate time to undertake notice and comment rulemaking to modify the policy if modifications are warranted, and to ensure that in such a case participants have a clear understanding of the governing rules and are not required to take needless compliance steps due to the rule taking effect for a short duration before any potential modifications are effectuated.

CMS issued a final rule on the two models January 3, 2017. Pursuant to the Trump Administration’s “Regulatory Freeze Pending Review” memorandum, on February 17, 2017, CMS issued a final rule that delayed the effective date of the January 3, 2017 final rule, for provisions that were to become effective on February 18, 2017, to March 21, 2017. CMS’ March 21, 2017, interim final rule postponed the effective date of the January 3, 2017 final rule from March 21, 2017, until May 20, 2017. The applicability date of the new regulations at 42 C.F.R. Part 512 and specific CJR regulations are delayed from July 1, 2017, until October 1, 2017. CMS sought comments on a longer delay of the model start date, including to January 1, 2018.

Under the CJR model, which began April 1, 2016, acute-care hospitals in certain areas receive retrospective bundled payments for episodes of care for hip and knee replacements. All related care within 90 days of hospital discharge from the joint replacement procedure is included in the episode of care. The January 3, 2017, final rule made several changes to the model.

Under the CR Incentive Payment model, acute care hospitals in certain geographic areas will receive retrospective incentive payments for beneficiary utilization of cardiac rehabilitation/intensive cardiac rehabilitation services during the 90 days following hospitalization for an acute myocardial infarction or coronary artery bypass graft surgery.

The American Hospital Association criticized the pace of these mandatory demonstration projects as “too much, too soon” and said, “We will continue to urge that any new bundled payment programs be of a voluntary nature.” In addition, HHS Secretary Tom Price has asserted that CMS exceeded its authority with bundled payment initiatives like the CR and CJR models.

Let the sun shine: most Americans in the dark about payments to physicians

Physicians self-report payments from members of the pharmaceutical and medical device industries at an average rate of 40 percent; however, many of the lower rates are for providers who have fewer contacts with fewer patients. According to a study published in the Journal of General Internal Medicine, 65 percent of patients saw a provider who had received industry payments in the previous 12 months. Additionally, almost no patients know that the provider had received such payments, despite the information being publicly available.

Physician Payments Sunshine Act

Section 6002 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), known as the Physician Payments Sunshine Act, increases transparency of physician ownership and investment interests by requiring the disclosure of payments made to providers. Such payments include consulting fees, honoraria, gifts, food, entertainment, charitable contributions, and other transfers of value. This information is reported to CMS, and published online at https://www.cms.gov/openpayments/.

The purpose of this provision was to make patients aware of payments their providers received which may influence the provider’s decision-making process. However, the study notes, if patients are unaware that this information is available, they cannot make informed decisions.

Open Payments data

According to the Open Payments data, the prevalence of industry payments among physicians is around 40 percent, with variation across specialties ranging from 20 percent (pathology) to 80–90 percent (cardiology and orthopaedics). Exposure of patients to doctors who receive payments, however, is not measured by the data. As a result, individuals may incorrectly interpret the data to believe that they have a lower chance of visiting a physician who has received payments than they actually do. If patient contact with physicians who receive payments is significantly higher than the overall average, it would show that industry payments reach more patients than expected.

Study methodology

The study, the first of its kind, took a population-based approach to estimating the reach of industry payments. It used a nationally representative survey to ask patients about their knowledge of the Open Payments data and about the physicians they most often visit. The researchers then linked the physicians named with the data using National Provider Identifiers (NPIs) to determine patient-based industry exposure.

Findings

In the subgroup of respondents for whom the researchers could identify providers–matching 1971 physicians to 1987 respondents–the study found that 65 percent of patients, or almost two-thirds, visited a physician who had received industry payments, a much higher percentage than the 40 percent of physicians overall who receive such payments. The highest rates were among patients who visited orthopedic surgery physicians, with 85 percent of patients seeing an orthopedic surgery physician who received industry payments. In addition to patients visiting doctors who received payments at a higher rate than overall physician payment rates, the physicians that patients frequently visited who received payments, received amounts greater than were typical of physicians reported in Open Payments.

Patients reported some level of knowledge of industry payments to physicians, with 45 percent being aware that such payments are sometimes made. However, only 5 percent of patients knew whether the physicians they visited had received industry payments. Most believed that their providers had not received any payments, but 41 percent of them were incorrect.

Overall, the study found that although a minority of physicians accept industry payments, physicians who accept payments are caring for 65 percent of the adult patient population, while very few of the adult patient population is aware of industry payments or possible conflicts of interest.

AHA asks MedPAC to slow its roll on MACRA proposals

The American Hospital Association (AHA) believes that changes to the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) (P.L. 114-10) should wait until more data is available from providers. In a letter to the Medicare Payment Advisory Commission (MedPAC), the AHA expressed concerns about several proposals, including assigning clinicians to groups, aggregating results at the local market level, and replacing most clinician-reported measures. The AHA also addressed rising drug costs, encouraging MedPAC to focus on the issue.

MedPAC meeting

The letter serves as AHA’s response to MedPAC’s January meeting, during which the commission discussed items to include in a report to Congress in June. MACRA created two payment systems, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM), which are in the early stages of implementation by clinicians and hospitals. The January meeting involved discussion of several policy changes, including a MIPS redesign, which the AHA believes should be delayed until data and experience from these clinicians is available for consideration. The AHA noted that the first performance period for both programs began January 1, 2017, and that CMS views this as a “transition year” for MIPS.

Policy proposals

MedPAC proposed assigning clinicians to groups or regions and assigning an aggregate MIPS quality and cost performance score based on the performance of others in the community. The AHA believes that clinicians should be permitted to voluntarily collaborate, and that applying an aggregate score would be arbitrary. Additionally, the AHA proposes providing an option for hospital-based physicians to use the hospital’s CMS quality and resource use measure performance for MIPS. However, the association opposes the proposal to replace clinician-reported outcomes measures with CMS measures based on Medicare claims data. The AHA pointed out that claims data does not reflect a patient’s particular history, course of care, and risk factors, which would result in basing clinician performance on unreliable data.

The APM has an incentive payment designed to encourage participation in the model, rather than reward or penalize performance. MedPAC proposed only allowing participating clinicians to receive this incentive upon successfully achieving the APM’s goals. The AHA views such a change as a double reward or double penalty for participants, rather than compensation for the learning curve and resource investment required upon entering new payment models. The AHA also expressed concerns about the proposals intended to “balance” incentives offered for MIPS and APMs, believing that these proposals make MIPS less attractive than APMs, even though AHA members believe that MIPS is already a less attractive option.

Drug pricing

The AHA believes that changes to Medicare Parts B and D could alleviate some of the drug cost burdens borne by the federal government and beneficiaries. The AHA expressed several concerns about Part B drug payment policy solutions, fearing that these changes could penalize hospitals for price increases and shift the burden for high list prices onto physicians. However, the AHA supports MedPAC’s Part D proposals while offering proposals of its own: disallowing co-pay assistance cards, developing value-based payment arrangements, requiring rebates, varying patient cost-sharing, and issuing annual reports.

$100M allocated to help small practices use the Quality Payment Program

Congress, through the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10), has recognized the importance of small and rural medical practices and provided funding for their assistance in navigating the new Medicare Quality Payment Program (QPP). To this end, CMS has announced the award of approximately $20 million to 11 organizations for the first year of a five-year program to provide on-the-ground training and education about the QPP. The program is for individual clinicians or small group practices of 15 or fewer clinicians. CMS also intends to invest up to an additional $80 million over the remaining four years of the program.

The Quality Payment Program

MACRA ended the sustainable growth rate formula, which threatened clinicians participating in Medicare with potential payment cliffs for 13 years. The QPP improves Medicare by helping practices focus on care quality. The QPP has two tracks to choose from: (1) the Advanced Alternative Payment Models (APMs); or (2) the Merit-based Incentive Payment System (MIPS). If a practice decides to participate in an Advanced APM, through Medicare Part B, it may earn an incentive payment for participating in an innovative payment model. If it decides to participate in MIPS, it will earn a performance-based payment adjustment.

A practice is part of the QPP in 2017 if it is in an Advanced APM or if it bills Medicare more than $30,000 a year and provides care for more than 100 Medicare patients a year. If a practice is below either threshold, it is not in the program. For MIPS, the practice must also be a physician, physician assistant, nurse practitioner, clinical nurse specialist, or a certified registered nurse anesthetist.

Training and education effort

The training and education contracts have been awarded to the following organizations: Altarum; Georgia Medical Care Foundation (GMCF); HealthCentric; Health Services Advisory Group (HSAG); IPRO; Network for Regional Healthcare Improvement (NRHI); Qsource; Qualis; Quality Insights (West Virginia Medical Institute); Telligen; and TMF Health Quality Institute.

These 11 organizations will provide hands-on training to help thousands of small practices, especially those that practice in historically under-resourced areas including rural areas, health professional shortage areas, and medically underserved areas. The training and education resources will be available immediately, nationwide, and will be provided at no cost to eligible clinicians and practices. The organizations will provide customized technical assistance to clinicians and practices. For example, clinicians will receive help choosing and reporting on quality measures, as well as guidance with all aspects of the QPP, including supporting change management and strategic planning and assessing and optimizing health information technology.

Other free training and education

CMS reports that thousands have received free training and education through webinars and in-person training from CMS staff since the QPP Final Rule was released last October (see MACRA final regulations reflect input from ‘months-long listening tour’, October 14, 2016).

In addition, every clinician in the QPP can receive in-person training through the established Quality Innovation Networks, the Transforming Clinical Practice Initiatives, and the Alternative Payment Model Learning Systems.