The Medicare Physician Fee Schedule for 2022, one of the main vehicles for federal policy changes for ACOs and the Quality Payment Program, was issued in proposed form in mid-July. The rule proposes physician payment rates for 2022, taking into account the adjustments from the 2021 Consolidated Appropriations Act. The rule also proposes changes to the Quality Payment Program and ACO quality measurement, along with other MSSP program changes. Also included are several requests for information, indicating possible future directions for rulemaking.
Caravan is going through the 1,000+ page rule and developing a comment letter focused on the policies that would affect ACOs. Comments are due to CMS by September 13, 2021. CMS expects to issue a final rule in the Fall.
MEDICARE PAYMENT PROPOSALS
Health Equity: The proposed rule includes a heavy emphasis on health equity, including a request for information titled “Closing the Health Equity Gap in CMS Clinician Quality Programs.” The RFI seeks stakeholder input on modifications to quality measurement methods, such as stratifying quality measures by race and ethnicity and improving demographic data collection, as well as other ways to address health equity in MIPS. Several of the other Medicare payment rules for 2022 raise similar questions, indicating a high priority of the Biden Administration.
Telehealth: The rule proposes extending coverage of some Medicare telehealth services through the end of CY 2023. Congress would still need to act to make those services widely available after the COVID public health emergency. The rule would also improve availability of mental health care delivered by telehealth.
MEDICARE SHARED SAVINGS PROGRAM PROPOSALS
CMS is proposing to lower by 50% the requirements for the repayment mechanisms (including escrow, line of credit, and surety bond) for ACOs in two-sided risk models. Stakeholders are concerned that the current requirements are burdensome and deter ACO participation, especially for small, physician-only, or rural providers. The rule proposes lowering the required amounts for the 2022 performance year.
Primary care codes for ACO assignment
Based on feedback from ACOs, CMS is proposing to amend the definition of primary care services used for MSSP assignment methodology starting on January 1, 2022.
New codes would include Chronic Care Management (CCM), Principal Care Management, certain prolonged E/M services, and Communication Technology-Based Service (CTBS) HCPCS code G2252.
ACO QUALITY PERFORMANCE and MIPS
This rule proposes major adjustments to the quality performance measurement overhaul finalized in the 2021 Physician Fee Schedule.
Delayed/phased-in move to new quality measurement system. This proposed rule would allow ACOs to delay the mandatory transition to the new all-payer electronic Clinical Quality Measures (eCQMs) under the APM Performance Pathway (APP) from 2022 to 2024. This proposal responds to overwhelming feedback from ACO participants, Health IT vendors, and developers needing additional time to prepare for reporting all-payer eCQM/MIPS CQM measures.
CMS is proposing a phase-in to incentivize ACOs to report the new measures and get familiar with performance before they are required beginning in PY 2024. If an ACO chooses this option, its performance on all three eCQM/MIPS CQM measures would be used for purposes of MIPS scoring under the APP. An ACO can choose to report both the ten CMS Web Interface measures and the three eCQM/MIPS CQM measures. Under this approach, the ACO will receive the higher of the two quality scores for purposes of the MIPS Quality performance category and for shared savings. CMS is also seeking input on how the quality measure set can reinforce the role of specialists in ACO population health strategies.
CMS is also proposing to (1) freeze the quality performance standard at the 30th percentile MIPS Quality performance category score for 2023 and (2) revise the extreme and uncontrollable circumstances policy to align with the proposal to freeze the quality performance standard at the 30th percentile MIPS Quality performance category score for performance year 2023.
Change to MCC for ACOs measure. CMS is proposing to replace the Risk Standardized, All-Cause Unplanned Admissions for Multiple Chronic Conditions for ACOs (MCC for ACOs measure) with the Risk Standardized, All-Cause Unplanned Admissions for Multiple Chronic Conditions for MIPS (MCC for MIPS measure) for performance year 2022. This could reduce confusion for MIPS eligible clinicians who might otherwise have been scored on both measures with differing results. This also continues the effort to align quality measures between MIPS and APMs.
All-payer reporting: CMS has heard stakeholder concerns about the burden of reporting on all-payer data but maintains that this change is important to improve care quality. CMS is seeking comment on whether to create a specific sampling methodology for ACOs, alternate sampling methodologies, and phase-in and tiered implementation strategies. Options could include allowing ACOs to report on a small sample size similar to the sample size for the CMS Web Interface or broadening the beneficiary sample to include all assigned beneficiaries that meet the denominator for a given measure.
MIPS Value Pathways: CMS proposes to transition from traditional MIPS to the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) starting in 2023. This new framework will focus on specialties and population health. The seven proposed MVP clinical areas are rheumatology, stroke care and prevention, heart disease, chronic disease management, emergency medicine, lower extremity joint repair and anesthesia. More specialties will be added as the program phases in. CMS plans to sunset traditional MIPS sometime after 2027.
The proposed rule includes an extensive discussion of ACO benchmarking, including fixing the “rural glitch” and changing the risk adjustment calculation. No specific changes have been proposed, so benchmarking changes may be proposed in another regulatory vehicle or could be addressed by Congress in legislation.
ACO groups have raised concerns about the “rural glitch,” referring to the ACO benchmark calculation when an ACO has a lot of market share in a region. When an ACO is overrepresented in a region, this can create a disadvantage in benchmarking because the ACO is largely competing against itself. CMS includes an analysis of the issue and requests comments.
The rule also includes a discussion about the effect of capping the positive adjustment from HCC to the historical benchmark C at 3 percent. Stakeholders have raised concerns that this methodology penalizes ACOs because it does not account for risk score growth in the ACO’s regional service area. CMS seeks comment on approaches to improving risk adjustment methodology for SSP and ACOs with medically-complex, high-cost beneficiaries.