As mentioned at the end of last month’s column, in the wake of the permanent repeal of the SGR, it will be necessary for surgeons to become familiar with an entire new lexicon of acronyms. That being said, I would like to first borrow a line from Kevin Bacon at the end of the movie Animal House and assure you that “all is well.”

The first of the new acronyms is MIPS – Merit-based Incentive Payment System.

To start, there is good news for several reasons. First, the MIPS program does not go into effect until 2019. This gives all surgeons ample opportunity to become educated and to prepare for the new program. In addition, most surgeons are already familiar with most, if not all, of the individual components of MIPS. Finally, MIPS provides payment updates based on each surgeon’s individual performance. These updates are independent of an arbitrarily set aggregate spending target as was the case previously under the SGR.

Surgeons who treat few Medicare patients or who receive a significant portion of their revenue from an eligible Alternative Payment Model program (APM) will be excluded from the MIPS program. APMs will be discussed in a later edition of this column.

MIPS will provide annual updates, again starting in 2019, based on individual performance in four categories: Quality, Resource Use, Electronic Health Record Meaningful Use and Clinical Practice Improvement Activities.

Surgeons participating in MIPS will receive an individual composite score of 0-100 based on their performance in the aforementioned four categories. Each individual composite score will then be compared to a performance threshold. The threshold consists of the mean or median of the composite performance scores for all MIPS-eligible professionals during a performance period prior to the current period. The threshold resets each year such that an individual’s score in 1 year does not impact their composite score the following year. All those with an individual composite performance score above the threshold will receive a positive payment adjustment, while those with an individual composite performance score below the threshold will receive a negative payment adjustment.

Positive adjustments can be up to 4% in 2019 and grow to 9% in 2022. Should the number of providers achieving high composite scores be low, the positive adjustments can be increased by up to a factor of three. If the number of those over the threshold far exceeds the number of those below the threshold, the incentives are scaled back to ensure budget neutrality. An additional $500 million per year is available for the top 75% of providers above the performance threshold. This ensures that in a circumstance where all physicians met the MIPS threshold, there would be funds available for positive updates.

Similarly, negative adjustments will be capped at 4% in 2019, rising to 9% in 2022. Those whose composite performance score falls in the lowest quartile below the threshold (i.e., with a performance threshold set at 60, those with scores between 0 and 15), will be subject to the maximum possible payment adjustment. Those with composite performance scores closer to the threshold will be subject to proportionally smaller negative payment adjustments.

The quality component of the MIPS will consist of quality measures currently used in existing quality performance programs. Specifically, these are the PQRS (Physician Quality Reporting System), the VBM (Value-Based Modifier program), and EHR-MU (Electronic Health Record Meaningful Use), with which most surgeons are already familiar. The Secretary of the Department of Health & Human Services will also solicit other measures from professional organizations such as ACS. Composite measures from QCDR (Qualified Clinical Data Registries) may also be used. The College is working with CMS to determine how to ensure its data registries, NSQIP and the SSR (Surgeon Specific Registry), can be utilized to meet the QCDR requirements.

The resource use component of MIPS will also include measures used in the current VBM program. The methodology by which these measures are applied will be enhanced through public input to include directly engaging providers. Surgeons will be allowed to report their specific role in treating patients. This provision seeks to allay concerns that the current methodology and attribution rules fail to accurately link the cost of services to the correct, specific professional. Additionally, research and public input will be sought on how to improve risk-adjustment methodologies such that surgeons are not penalized for providing care to sicker patients whose care is more costly.

With regard to the EHR-MU component of MIPS, the current EHR-MU requirements will continue to apply. ACS continues to advocate for changes to the EHR-MU program to make it easier for surgeons to comply with the requirements. Electronic health records are required to be interoperable by 2018 and vendors are prohibited from deliberately blocking information sharing with another vendor’s product.

In next month’s column, we will discuss the final component category of MIPS, the CPIA (Clinical Practice Improvement Activities) and the APMs as mentioned above.

Until next month …

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, D.C.

From the Washington Office