“We heard you and will continue listening.”
Those were the words that Andrew Slavitt, then-acting administrator of the Centers for Medicare and Medicaid Services, used in a blog post on Oct. 14, 2016.1 (Slavitt no longer maintains that title since the new federal administration took office on Jan. 20, 2017.)
Mr. Andy Slavitt
Indeed, when it came to issuing its final rules for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS appears to have considered the input it received, including that from SHM and other physician societies.2
And, it seems they are still listening. Since issuing the final rule, CMS has continued to seek input from stakeholders. The SHM and other groups are working to clarify and pursue improvements to the bipartisan law. Reporting under MACRA begins this year and several changes that appeared in the final rule already may make living with the law less challenging for hospitalists.
Dr. Ron Greeno
“We think this will all end up fine, but we’re still working on it,” said Ron Greeno, MD, MHM, founding member of SHM and chair of SHM’s Public Policy Committee (PPC). “They’re very receptive to the feedback we give them.” Dr. Greeno met with CMS in January 2017 to continue advocating on behalf of the hospitalist community.
For instance, 13 specialty measures were required under the final rule in order for hospitalists to begin reporting under the Quality category of the Merit-based Incentive Payment System (MIPS), one of two pathways to reimbursement available to all physicians under MACRA’s Quality Payment Program. However, of these, Dr. Greeno said that just seven are relevant to the hospitalist practice. The CMS now requires six reported measures in the Quality category, reduced from the initial nine.3
The measures include:
- Heart failure: ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction
- Heart failure: Beta-blocker for LVSD
- Stroke: DC on antithrombotic therapy
- Advance Care Plan
- Prevention of catheter-related bloodstream infection: CVC (central venous catheter) Insertion Protocol
- Documentation of current medications
- Appropriate treatment of methicillin-susceptible Staphylococcus aureus bacteremia
“Of the seven available, not all will be reportable because hospitalist practices have a lot of variation, both in their practices and in their patient mix,” Dr. Greeno said. “Most hospitalists will only be able to successfully report on four measures, but we are seeking clarification on what they call a validation test and how that will function.”
In the final rule, CMS said that it will perform that “validation test” to evaluate physicians who cannot report the minimum number of measures to ensure they are not penalized for it.
In addition to Quality, the other reporting categories under the umbrella of MIPS include Advancing Care Information, Cost, and Improvement Activities. For 2017, CMS gave physicians the option to “pick your pace.”4 As long as doctors report just one quality measure, one improvement activity, or the required advancing care information measures (most hospitalists will be exempt from this category), they will avoid a penalty.1,5 Cost will not be included for 2017, the first performance year for MIPS. This year’s reporting will be used to determine payments in 2019, though all physicians will see a 0.5 percent fee increase between now and 2019.
Additionally, just for this year, physicians can choose to report for either a full or partial year (90 days). They will not be subject to the penalty and may be eligible for a positive payment adjustment. However, those who submit nothing are subject to a negative 4% adjustment penalty.
Dr. Suparna Dutta
This gives hospitalists the opportunity to decide “how much to dip your toe in this year,” said Suparna Dutta, MD, a hospitalist at Rush Medical College in Chicago and a PPC member. “You can go all in and submit data in all categories, with the potential for a large positive payment adjustment no matter how you perform, or you can submit just one piece of data and avoid any negative adjustment. It gives you the chance to get feedback on your performance from CMS and play around with how to best integrate MACRA measurement and reporting into your practice.”
Additionally, CMS took steps to make MACRA easier on small and rural physician practices. The final rule exempts physicians who bill $30,000 or less in Medicare Part B or 100 or fewer Medicare patients, up from the previous $10,000 threshold.1
Dr. Robert Berenson
Mr. Slavitt “was very concerned about small practices and raised the threshold from $10,000 to $30,000 in Medicare revenue a year,” said Robert Berenson, MD, FACP, institute fellow of the Health Policy Center at the Urban Institute and former member of the Medicare Payment Advisory Committee.
However, this is unlikely to apply to the majority of – if any – hospitalists, Dr. Dutta said. “By virtue of being a hospitalist, you are seeing all comers to your institution. We don’t really have the choice to see fewer Medicare patients, to be honest, and, [for] most hospitalists – whether employed by a hospital or contracting – one of the main reasons we are in place is to help the hospital and take the patients nobody else will take.”
The CMS has also allotted $20 million each year for five years to support training and education for practices of 15 providers or fewer, for rural providers, and for those working in geographic health professional shortage areas.1,6 According to CMS, as of December 2016, experienced organizations (regional health collaboratives, quality improvement organizations, and others) began receiving funds to help these practices choose appropriate quality measures, train in improvement techniques, select the right health information technology, and more.
Under MACRA, small practices (10 clinicians or fewer) may also join “virtual groups” in order to combine their MIPS reporting into a composite score. However, this is not yet well defined, and the option is not available in 2017. The CMS said that it will continue to seek feedback on the structure and implementation of virtual groups in future years.1
Hospitalists may find themselves presented with another option for performance measurement, Dr. Greeno said. The SHM has asked CMS to consider allowing hospitalists to align with their hospital facility instead of being measured separately.
“Hospitalists are in the unique position of working at only one acute care hospital, for the most part, and we actually floated this idea around years ago, to give hospitalists the option for all their quality metrics – not as a standalone physician group – to be judged on hospital performance metrics,” he said, adding, “It would be easier if we could do this for everybody, but not all hospitalist groups that work for hospitals may want to do that.”
Dr. Dutta said that this would be “a great and efficient option,” especially since hospitalists oversee the bulk of quality improvement activities in their hospitals.
“Hospital-level data would be a reflection of what we’re involved in, as the bulk of hospitalists not only provide clinical care but also participate in a multitude of hospital activities,” she said, like: “helping to develop and promote practices around high-value care, to serving on groups like safe transitions in care. It’s hospitalists who are usually the hospital leaders around quality improvement.”
This includes coming up with ways to work with pharmacists at patient admission and on medication reconciliation upon discharge, as well as providing input on clinical protocols, such as what should be done when someone falls or when potassium is high, Dr. Dutta said.
“Performance should be tied to the performance of the hospital. It moves in the right direction to force more collaboration and a joint fate,” Dr. Berenson added.