At the end of July, CMS published its annual proposals for regulatory changes to the Medicare physician fee schedule (PFS). The proposals continue CMS’s push in several important areas. First, CMS is making MIPS more stringent, increasing the benefit of ACO participation and the risk of staying out of risk-based payment models. Second, CMS is continuing to refine and improve new codes supporting care management for Medicare patients, providing support for non-face-to-face services that are essential for optimal care.  

The proposals also included many other important changes that could affect ACOs and physicians in many ways, as described here. Medicare providers may see changes to MIPS, ACO quality measurement, and billable care management services.  

Here are the PFS proposals that ACOs should definitely keep an eye on.  

Change in MIPS payment adjustment threshold, move to new MIPS framework 

MIPS has been in the news recently. 2018 MIPS scores were released just a few weeks ago, with record-high participation and outstanding scores to match. The great news is that providers are excelling at MIPS. At the same time, earned part B bonuses will be modest since, as a budget neutral program, a set amount of funds must be shared among a lot of high-scoring providers.  

CMS is proposing to raise the threshold MIPS score from 30 points in 2019 to 45 points in 2020 and 60 points in 2021. Providers would have to reach this higher bar to avoid a part B reimbursement cut. The law requires CMS to adjust the threshold score, so this change is not unexpected for this new and still-evolving program. At the same time, CMS is including a providers’ cost of care in the MIPS score, making it much harder to achieve perfect scores outside of an ACO. Under the new calculations, there would likely be a smaller pool of providers with positive payment adjustments and corresponding higher payments bumps for those that come out on top.  

Along with these required threshold adjustments, CMS is also proposing to overhaul the standard MIPS program and move to a new system called MIPS Value Pathways (MVP). MVPs would be customized for specific practice specialties and medical conditions with the goal of streamlining reporting and removing barriers to APM participation. MVP would still use the 4 MIPS performance categories, and incorporate a focus on population health, while providing feedback to clinicians and better information for patients. 

If MVP goes live in 2021, as CMS envisions, it would not affect ACOs and other APMs, at least not right away. CMS’s plans to continue MIPS APM alongside the new MVP. CMS hasn’t ruled out applying MVP policies to APMs, and they call for comments on that very question.   

Alignment between MIPS and SSP quality scoring, elimination of year 1 pay for reporting 

For ACOs, one of the biggest proposed changes is to align the quality scoring between the MIPS and Shared Savings Program. Under current rules, CMS calculates separate quality scores – based on the largely the same reported data – for the MIPS and Shared Savings Program. Both calculated quality scores have financial impacts for the ACOs - MIPS scoring leads to positive or negative part B payment adjustments, while SSP quality scoring feeds into the shared savings calculation. CMS is proposing to use a single methodology under both MIPS and the SSP to reduce the burden of practices expending resources to excel on related, but distinct, metrics. Under this proposal, the MIPS quality score would partially or fully replace the SSP quality score.  

CMS is also proposing to eliminate pay for reporting in the first year of ACO operation in favor of pay for performance. Rather than earn full credit simply for reporting on quality measures during their first year, ACOs would have to achieve a threshold quality score to be eligible for shared savings. This proposal would raise the bar for sharing in savings - or avoiding shared losses - starting in year one.  

Changes to care management, new Principal Care Management code 

CMS is proposing changes to several care management services. Care management has been critical to keep ACO patients with serious health conditions on track with treatment and out of the hospital.  

CMS proposes to increase payment for Transitional Care Management (TCM) – a service to help patients transition from a hospital stay. Providers have been slow to take up this service, in part due to low reimbursement. A payment increase could lead to more participation.  

CMS is also proposing to enhance the chronic care management (CCM) coding that has been available for several years. This change would allow providers to bill incrementally to better reflect intensity of service delivery and complexity of illness. Overall these changes allow providers to get more accurate reimbursement for time spent on patient care.  

Some patients are living with a single serious chronic condition, and there has been no easy way for providers to bill for their care management services. A new proposal would add a code for Principal Care Management (PCM) for patients with a single serious and high-risk condition. This would allow providers to get compensated for the significant resources invested in these high-needs patients.  

Let CMS know what you think 

These changes could affect your future in the shared savings program. CMS is taking public comments until the end of the day September 27, 2019.  Send in your reactions here.  

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