Tag: proposed rule

CMS Proposed Rule Change for ACO Payments

By Curtis Campbell, Class of 2019; Andrew F. Solinger, Attorney at Waller

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would overhaul the Medicare Shared Savings Program, which was established by the Affordable Care Act (ACA). Currently, the vast majority of Medicare’s Accountable Care Organizations (ACOs) operate under the Medicare Shared Savings Program. The redesigned program is called “Pathways to Success” and was developed based on a comprehensive analysis of the performance of ACOs to date.

What is an “ACO”?

ACOs are groups of health care providers that agree to take responsibility for the total cost and quality of care for their patients. Under the Medicare Shared Savings Program, the ACOs get to keep a portion of the savings they achieve. CMS provides ACOs with Shared Savings Waivers to allow the savings to be applied in virtually any manner to further innovation.  Presently, there are 561 Shared Savings Program ACOs that serve over 10.5 million Medicare fee-for-service beneficiaries.

Results of the Medicare Shared Savings Program

Since the Medicare Shared Savings Program was established by the ACA, and launched in 2012, it has been faced with a mix bag of success:

  • Shared Savings Programs have shown increases in net spending for CMS and taxpayers because 82 percent of all ACOs in the program are not taking on risk for increases in cost.
  • ACOs that are not at risk for cost increases end up increasing Medicare spending in the aggregate.
  • ACOs participating in the two-sided, risk-sharing model in which eligible ACOs share in a larger portion of any savings, but are also required to take on losses if spending exceeds certain benchmarks, have proven successful in accounting for significant savings to the Medicare Program.

Pathways to Success

The proposed rule, Pathways to Success, would redesign the participation options available under the program to transition more to two-sided models. The projected proposal is estimated to lead to savings to Medicare of $2.2 billion over ten years.

Pathways to Success is designed to advance five goals:

  • (1) Accountability and (2) Competition: Currently, ACOs have up to six years without taking on risk for increases in cost. These ACOs receive a shared savings payment from CMS when they keep their costs down, but do not have to pay back taxpayers when costs are high. Under the proposed rule, ACOs can only remain in the program without taking risk for two years, instead of six.
  • (3) Beneficiary Engagement: CMS proposes to require that beneficiaries receive a notification at their first primary care visit of a performance year informing them that they are in an ACO and what it means for their care. To bolster beneficiary engagement, CMS proposes to allow certain ACOs to provide incentive payments to patients for taking steps to achieve good health.
  •  (4) Quality: CMS proposes allowing physicians in risk-sharing ACOs to receive payment for telehealth services provided to patients regardless of the patient’s location. This would expand the use of telehealth even in situations in which the beneficiary’s home is the originating site. In addition, the proposed rule promotes interoperability and patient control of their medical data by proposing a new requirement around ACOs adopting the 2015 edition of the Certified Electronic Health Records (EHR) technology.
  • (5) Integrity: CMS’s proposed rule would change the benchmark calculations to better account for regional adjustments by accurately reflecting the spending levels and growth rates in each ACO’s local market. The proposed ruled will also strengthen the monitoring of financial performance and permitting termination of ACOs with multiple years of poor financial performance.

In sum, Pathways to Success is aimed at mitigating losses, increasing program integrity, and promoting regulatory flexibility for ACOs. As CMS Administrator Seema Verma stated, “ACOs can be an important component of a system that increases the quality of care while decreasing costs.” With the proposed rule change, the program will hopefully achieve its original intent of decreasing net spending for CMS and taxpayers.

2017 MIPS Performance Feedback Reports may erroneously report 2019 Medicare payment adjustments

By Tayler Chambless, Class of 2020; Elizabeth N. Pitman, Counsel at Waller

2017 was the first year for participation in the Merit-based Incentive Payment System (MIPS), a Quality Payment Program (QPP) implemented by CMS, to award or penalize participating clinicians with regard to future Medicare reimbursements based upon reporting under four categories:

  1. Quality
  2. Improvement Activities
  3. Promoting Interoperability (2017 Advancing Care Information; previously Meaningful Use)
  4. Cost

In July, CMS released 2017 Performance Feedback Reports detailing clinicians’ MIPS final scores, performance category details, and 2019 MIPS Medicare payment adjustments. According to CMS, approximately 621,700 providers received negative adjustments.  At the same time as release of reports, CMS conducted a “targeted review” and discovered major calculation errors in the following areas:

  • Advancing Care Information and Extreme and Uncontrollable Circumstances Hardship Exceptions
  • Awarding Improvement Activity credit for successful participation in Improvement Activities Burden Reduction Study
  • All-Cause Readmission measure

On September 25th, CMS announced that clinicians have 20 days to request a targeted review of their  MIPS report.  Lack of transparency by CMS has buoyed critic positions that MIPS is too complicated.  CMS, however, states that it has “reviewed the concerns, identified a few errors in the scoring logic, and implemented solutions. The targeted review process worked exactly as intended, as the incoming requests quickly alerted us to these issues and allowed us to take immediate action.”

Clinicians are encouraged to review Performance Feedback Reports and request a Targeted Review by Oct. 15, 2018, at 8 p.m. EDT.

What is a targeted review, and how do I submit a request?

Clinicians must request a Targeted Review through the formal online process established by CMS. The Performance Feedback Report may be found at the QPP Portal.

No targeted review is available for:

  1. Methodology used to determine the amount of the MIPS payment adjustment factor and the amount of the additional MIPS payment adjustment factor and the determination of such amounts;
  2. Establishment of performance standards and performance period;
  3. Identification of measures and activities specified for a MIPS performance category and information made public or posted on the Physician Compare CMS website; and
  4. Methodology used to calculate performance scores and calculation of such scores (weighting measures and activities)

CMS will generally require additional supporting documents that the clinician must provide within 30 days. All targeted review decisions are final and without further review.

Clinicians should be prepared to submit supporting documents:

  • Supporting extracts from the electronic health record (EHR)
  • Performance data provided to third-parties
  • Performance data submitted to CMS
  • QPP Service Center ticket numbers
  • Signed contracts or agreements between clinician/group and third-party intermediaries
  • Alternative Payment Model participation agreements
  • Partial qualified participant (QP) election forms
  • Other requested documents.

CMS is in the process of reviewing over 15,000 comments on a proposed rule that was issued in July to outline changes for year three of the MIPS Quality Payment Program and update the Medicare physician fee schedule. The final rule will be issued later this fall.

 

CMS Proposes Change to Joint, Episodic, and Cardiac Rehabilitation Payment Models

By Emmie Futrell, Class of 2018; Patsy Powers, Partner at Waller; Daniel Patten, Associate at Waller

On August 17, 2017, CMS published a proposed rule that could bring about significant changes to some of its Innovation Center’s major payment models. Specifically, the Proposed Rule would:

  • reduce the number of mandatory geographic area participants of the Comprehensive Care for Joint Replacement (CJR) model;
  • cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model; and
  • increase the pool of practitioners that qualify under the Advanced Alternative Payment Model.

These changes may be surprising to some as these models are still in their infancy. The CJR model started last year, and the EPMs and CRs were not scheduled to begin until January 1, 2018.

Perhaps the most striking element of the Proposed Rule is the removal of 33 geographic areas (of the currently 64 geographic areas) where participation in the CJR model has been mandatory. Instead, CMS proposes that such hospitals participate in the CJR model on a voluntary basis, especially hospitals with low volume or those located in rural areas. These hospitals are provided with a one-time option whereby continued participation in the CJR model will be left to their discretion. CMS believes that moving the CJR model away from a mandatory requirement will increase the likelihood that providers will participate in future voluntary initiatives. Hospitals that choose to continue participation in the CJR model will receive a target price for these procedures from CMS each year, and the proposed rule includes refinements and clarifications to this payment process.

CMS is accepting public comments on these revisions, which can be electronically submitted here, until October 16, 2017.