Alternative Payment Models in Vascular Surgery

Introduction

Alternative payment models were introduced with the Quality Payment Program, which was established with the Medicare Access and Children’s Health Insurance Plan (CHIP) Reauthorization Act of 2015 (MACRA). Prior to MACRA, payments for Medicare services were set by the Sustainable Growth Rate (SGR). Under the SGR law, spending increases were capped in accordance with growth in the Medicare population with a modest allowance for inflation. In practice, this did not allow for an increase in service utilization by healthcare providers, and the reimbursement for each unit of service had to be adjusted downward to hold costs relatively constant. In order to prevent large decreases in the Physician Fee Schedule, Congress had to pass a new law annually to authorize the current fee schedule and prevent large cuts in payments to providers. MACRA was passed with strong bipartisan support, passing the House of Representatives with a 392–37 vote and the Senate with a 92–8 vote, and is not part of the Affordable Care Act.

The objectives of MACRA are defined by the Centers for Medicare and Medicaid Services (CMS) as follows:

• To improve beneficiary population health

• To improve the care received by Medicare beneficiaries

• To lower costs to the Medicare program through improvement of care and health

• To advance the use of healthcare information between allied providers and patients

• To educate, engage, and empower patients as members of their care team

• To maximize Quality Payment Program (QPP) participation with a flexible and transparent design, and easy-to-use program tools

• To maximize QPP participation through education, outreach, and support tailored to the needs of practices, especially those that are small, rural, and in underserved areas

• To expand alternative payment model (APM) participation

• To provide accurate, timely, and actionable performance data to clinicians, patients, and other stakeholders

• To continuously improve QPP, based on participant feedback and collaboration.

The QPP started on January 1, 2017 and is designed to reward high-value, high quality Medicare clinicians with payment increases, while penalizing those providers who do not meet performance standards. There are two participation tracks with the QPP – the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPM). Clinicians who bill Medicare Part B more than $30,000 per year and/or provide care for more than 100 Medicare patients per year must participate in either MIPS (increased to $90,000 and 200 patients in 2018) or AAPM to avoid a negative adjustment to their reimbursements. When QPP became active in 2017, there were no advanced payment models (APMs) with a vascular focus that qualified as a Medicare AAPM, thus the majority of vascular surgeons have had to participate in MIPS. ^,

Merit-Based Incentive Payment System

MIPS has four components: Quality, Promoting Interoperability (PI; previously called Advancing Care Information), Improvement Activities (IA), and Cost. Each of the four components is scored to create a final composite score that determines reimbursement rate. While data collection began in the performance year 2017, QPP rates did not go into effect until 2019. In the first year, quality comprised 60% of the score, PI comprised 25%, and IA comprised 15% (Cost was not included initially to allow for additional data collection and to enable planning for future years). ^, It is important to note that specific measures of each component may change on an annual basis reflecting policy changes.

The Quality performance category replaced the former Physician Quality Reporting System (PQRS), and it pertains to the quality of care delivered based on performance measures created by CMS. Clinicians pick six measures (out of 300) which best fit their practice ( https://qpp.cms.gov/mips/overview ). One example of a vascular surgery quality measure is the “percentage of patients 18 years and older undergoing infra-inguinal lower extremity bypass who are prescribed a statin medication at discharge.” ^, This has created unexpected challenges for vascular surgeons in academic practices or large multi-specialty groups, as the six allowable measures are selected for the entire group. For example, they may select measures on total knee replacements, depression, etc., that do not pertain to the care of vascular surgery patients. Efforts by the Society for Vascular Surgery (SVS) to allow for reporting by the vascular surgery practices within the larger group have thus far been unsuccessful.

The Promoting Interoperability (PI) performance category was previously known as the Advancing Care Information performance category. This focuses on patient engagement and the electronic exchange of health information using certified electronic health record technology (CEHRT). PI replaced the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Clinicians and is satisfied by proactively sharing information with other healthcare providers or the patient. Examples include sharing test results, encounter summaries, and therapeutic plans with patients or other healthcare facilities.

Improvement Activities is a new performance category, which collects information regarding actions taken to improve a clinician’s care processes, enhance patient engagement, and increase access to care. This category creates an inventory which allows the provider to choose the activities appropriate to their practice, and includes over 90 activities in nine subcategories. Examples include expanded practice access, population management, care coordination, beneficiary engagement, patient safety, and practice assessment. ^,

The Cost performance category replaced the Value-based Payment Modifier, and is calculated by CMS as the cost of care provided. MIPS uses these cost measures to gauge the total cost of care during the year and during individual patient encounters. This metric was incorporated into clinicians’ MIPS score beginning in 2018 and weighted at 10% of the total MIPS score. The first two cost measures were: (1) Medicare Spending Per Beneficiary (MSPB) and (2) Total Per Capita Cost (TPCC). The MSPB cost measure was designed to evaluate efficiency of care during a hospital stay, and includes a global period starting 3 days prior to hospitalization and ending 30 days after discharge. The TPCC cost measure evaluates overall efficiency of a provider’s care, and is calculated using all Medicare beneficiaries under a provider’s care. Episode-based cost measures are currently in development, with additional categories being added each year. Vascular surgery episode-based cost measures were first introduced in the performance year 2020 and include Hemodialysis Access Creation and Revascularization for Lower Extremity Chronic Critical Limb Ischemia. These episode-based cost measures are a critical component of the QPP MIPS APM model, as the MIPS cost performance category was weighted at 30% of the final MIPS score beginning in the performance year 2019.