June and the QPP

Here we are in the last week of June, and what a busy month it has been. We kicked off the month with a face-to-face meeting in DC with CMMI, where ESCO participants joined Next Gen ACO participants in a 2-day session. If that wasn’t enough, this past Tuesday in an email innocently entitled “CMS Proposes Quality Payment Program Updates to Increase Flexibility and Reduce Burden,” CMS released a 1,000-plus page document with proposed changes for the 2018 Quality Payment Program (QPP). With so much material to work with, where’s a blogger to begin?

ESCO News

Let’s start at the beginning of the month. On June 1 and 2, a large number of folks joined CMMI in our nation’s capital for the 2017 Cross-Model ACO Face-to-Face Meeting. In attendance were representatives from essentially all of 37 ESCOs in operation today, and a large number of the 44 existing Next Gen ACOs. On Day 1, Dr Patrick Conway, a man who holds so many titles it would take more than 1 blog post to capture them all, provided the keynote address and shared a number of valuable insights with the audience. (As an aside, this guy is a rock star and we should all hope he hangs around in his current position for at least another decade.) Related to the ESCOs, Patrick shared the following:

• ESRD patients represent less than 1% of the Medicare population but they consume 7.2% of the Medicare FFS spend
• The CEC Model (37 ESCOs) serves ~46,000 dialysis dependent ESRD beneficiaries today. That’s about 10% of the Medicare ESRD population receiving dialysis today
• There’s at least 1 ESCO in 28 states and in Washington D.C.
• 1,291 physicians and 792 dialysis facilities are participating in an ESCO today

QP status

While the numbers above are impressive, what caught the attention of the audience were the comments Patrick made relative to the Qualifying Participant (QP) designation. As you may recall, one of the substantial financial carrots attracting nephrologists to the ESCO model is the fact that the ESCO is an Advanced APM. As an Advanced APM, if an ESCO clears specified QP hurdles in 2017, every doc participating in the ESCO avoids MIPS in 2017, and in 2019, those docs collect a bonus payment equivalent to 5% of their 2018 Part B book of business. You read that correctly, 5% of their Medicare allowable for every Medicare beneficiary they see that year.

We expect to get our first view of the 2017 QP results in late July or early August, but CMMI ran the numbers for 2016 to give everyone a sneak peek of what’s likely to come. To the delight of hundreds of folks in the room, Patrick let us know that had the Quality Payment Program been in play last year, based on 2016 claims data, essentially all of the docs participating in the ESCO or Next Gen ACO models of care would have received the QP designation. The applause in the room was deafening. Importantly, that was a bit a dry run of sorts. But those of us who understand the importance of the QP status could not have been happier.

QPP in 2018

Next on the menu today is the excitement that lives in the proposed changes for the QPP next year. Spoiler alert: I am going to barely scrape the surface of this 1,000-page beast today. My colleague Diana Strubler will burn the midnight oil to give this thing the attention it deserves in a future post. Today, I’ll share a few morsels related to MIPS.

1. The low-volume threshold exclusion has been raised. This year if you encounter fewer than 100 Medicare beneficiaries per year OR bill Medicare less than $30,000, you are excluded from MIPS. What’s proposed next year is to raise those figures to 200 beneficiaries or $90,000. Those of you with Advanced Practioners who just missed the exclusion in 2017 may find this change attractive, but frankly this is unlikely to be of value to the typical nephrologist.
2. Cost is being kept out of the equation next year, so the category mix in 2018 will be identical to what you face in 2017. As it stands today 60% of your MIPS score comes from Quality and 0% from the elusive Cost category. That was supposed to change next year with Quality accounting for 50% and Cost entering the game at 10% prior to landing at the final spilt in 2019 (30% Quality and 30% Cost), but the change is not coming yet. Although we’ve mentioned this before, it bears repeating. Be very careful when you select your quality measures! The lion’s share of your MIPS score lives here in 2017, and it looks like that trend will continue next year.
3. The proposed rule makes a run at a nephrology measure set. Remember how nephrology was ignored within the Quality category in the original QPP final rule? This proposed rule would add a nephrology measure set. The proposed nephrology measure set includes 17 MIPS quality measures. They range from ESRD-specific measures (what percentage of your HD patients start with a catheter?) to CKD measures (what percentage of your CKD stage 3, 4 and 5 patients have a BP <= 140/90, or a plan of care if not?) to measures that are in many respects general internal medicine measures (what percentage of your patients had a flu vaccine?). While it’s nice to see that we’ve been heard, the devil as usual is in the detail. When you pick a measure, make sure you know the benchmark and that you consider how well you can execute against that benchmark.
4. A number of Advancing Care Information (ACI) changes show up in the proposed rule, including removal of the requirement to use 2015-edition CEHRT in 2018. CMS is proposing to continue to allow docs to use 2014-edition CEHRT in 2018, postponing the mandated change to 2015 CEHRT until 2019. Those using 2015 CEHRT in 2018 will receive a small bonus in their ACI score, which will not be awarded to those using 2014 CEHRT. This is likely to provide some of you with a bit of breathing room, and I suspect there are a few EHR vendors out there who are sleeping a little better this week.
5. Speaking of ACI, there’s some welcome news about a “complexity bonus”. CMS has the ability to reward providers caring for “sicker” patients. One of the commonly used measures of how “sick” your patients are is the Hierarchical Condition Category (HCC) risk score. In the words of the proposed rule, the HCC risk score is “a valid proxy for medical complexity”. Importantly, the HCC scores estimate how Medicare beneficiaries’ FFS spending will compare to the overall average for the entire Medicare population, i.e. they are using the Medicare spend as a proxy for medical complexity. Within the HCC framework, the average risk score is set at 1.08 this year; beneficiaries with scores greater than that are expected to have above-average spending, and vice versa.

There’s a pretty cool table in the proposed rule (Table 36), which displays the average HCC score for every specialty recognized by Medicare. What’s the specialty caring for the most complex patients? You guessed it. The average HCC risk score for patients cared for by nephrologists is 3.05—the only score north of 3 in that table. Folks, there are almost 70 physician categories on that list! Next time you are having a debate with your oncology or critical care colleagues about who takes care of “sicker patients”, Table 36 has your back. Suffice it to say, CMS intends to use this complexity score to add a few points to your score—all in an effort to avoid penalizing docs who care for sicker patients. Let’s hope their logic extends to the Cost category when it raises its ugly head during the 2019 performance year.

Stay tuned

As usual, there’s a truck load of material in the proposed rule and I know we will see a number of summaries appear over the next few weeks. This 26-page fact sheet is a little easier to consume than the 1,058-page PDF and it’s definitely worth a read. Keep your eyes on the Acumen blog as I am certain we are not done with this proposed rule. The comment period for this rule closes on August 21. Let CMS know what you think, or send us a comment and join the QPP conversation.

Terry Ketchersid, MD, MBA, practiced nephrology for 15 years before spending the past seven years at Acumen focused on the Health IT needs of nephrologists. He currently holds the position of Chief Medical Officer for the Integrated Care Group at Fresenius Medical Care North America where he leverages his passion for Health IT to problem solve the coordination of care for the complex patient population served by the enterprise.

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