So it would seem. On March 26 the House of Representatives passed a Sustainable Growth Rate (SGR) repeal bill by an overwhelming vote of 392-37. Following this exciting news from the House, the Senate packed their bags and headed home for spring recess leaving docs to face a 21% pay cut for Medicare services rendered after April 1. This, of course, is nothing new as Congress has been compelled to institute 17 short-term “doc fixes” since the SGR was introduced in 1997. These temporary doc fixes are necessary because the SGR is flawed. The major barrier to a permanent fix has been money, as the Congressional Budget Office estimates the price tag for a permanent fix to be on the order of $125 billion over the next ten years. While that is certainly a large chunk of change, ironically Congress has spent approximately $150 billion on the multitude of temporary fixes mentioned above.
We discussed this topic last year when it looked like a permanent fix was in the works, only to witness the roll out of yet another temporary fix (one that was in part funded by postponing the ICD-10 transition to fall 2015). This year, however, there is a growing sense of optimism that cooler heads will prevail and the SGR will indeed finally be repealed. The bill passed last week by the House is almost identical to the one introduced a year ago. In addition to repealing the SGR, the bill creates nominal annual increases for physicians over the next four years. But it is the bill’s effect on the CMS triple threat that has my attention this first Monday in April.
As a bit of explanation for our readers who did not fill out an office pool NCAA bracket a few weeks ago, the phrase “triple threat” is used to describe a basketball player’s options when he or she catches the ball. These include throwing a pass, dribbling, or shooting. The defensive player must recognize these options in order to effectively defend the triple threat. In a similar fashion, PQRS, Meaningful Use, and the Physician Value-Based Modifier represent a threat if we ignore them. The triple threat in your court is a monetary penalty, which collectively could reach a 9% reduction in your Medicare Part B book of business in 2017. If the SGR is repealed, the triple threat will transform into a beast with similar stripes but a different name.
As I am sure you would agree, there are just not enough acronyms in the world we live in. So let me be among the first to introduce you to MIPS—the Merit-Based Incentive Payment System. Part of the SGR repeal package, MIPS effectively rolls up the three CMS incentive programs mentioned above into a single incentive program. The goal is to reduce administrative overhead while advancing a system that measures and rewards value. And as we’ve seen before, the flip side of rewarding the delivery of value is penalizing based on its absence. At a high level MIPS proposes to evaluate performance across four broad categories:
- Resource Utilization
- Meaningful Use
- Clinical Practice Improvement Activities
The first three categories will leverage much of the work that has been done to date within the “big three” CMS incentive programs mentioned above. The practice improvement category is a work in progress.
In last year’s bill, each eligible professional (EP) was to receive a composite performance score between 0 and 100 based on performance across the four categories. The EPs score would then be compared to the national mean, with payment adjustments following a linear distribution. In other words, EPs with performance scores below the national mean would be penalized while those with scores above the mean would receive a bonus. Note this is a substantial change compared with anything in place today and it appears to flying under our collective radar. Maximum penalties would be capped at 4% in 2018, 5% in 2019, 7% in 2020, and 9% in 2021. The maximum bonus would be as high as three times the annual cap for penalties, a remarkable departure from recent bonus structures. In a nod towards the growing importance of alternative payment models, EPs at risk for the quality and the cost of care would be eligible for an additional 5% bonus each year from 2018-2023.
One shining moment
Tonight the NCAA will crown the men’s college basketball national champion. Sixty-eight teams began the journey in mid-March and after game sixty-seven tonight, the champion will emerge. At the conclusion of the championship game we are typically treated to a visual montage of the memorable moments from the Madness that is March. Entitled “One Shining Moment”, in roughly three minutes we are treated to the highs and lows of three weekends of college hoops. Like tonight’s video montage, this blog post has only scratched the surface of MIPS. If in fact the SGR is repealed, we will all breathe a sigh of relief because a broken system will be mothballed. But let’s not forget repealing the SGR is not just about avoiding those last-minute temporary doc fixes. The triple threat will be riding off into the sunset and MIPS will be the new sheriff in town. As with all of these programs, the devil is in the detail, and the detail surrounding MIPS will emerge in the months ahead if the Senate does the right thing. The Senate’s opportunity is at least a week or two away, in the meantime, enjoy tonight’s game and after the champion is crowned, hang in there for a few more minutes for one more shining moment.
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.