December 5, 2016

The Quality Payment Program (QPP) mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) begins on January 1, 2017.  If you are an eligible clinician (EC) and plan to participate, your performance in this value-based incentive program in 2017 will directly influence your Medicare Part B payments in 2019.  The purpose of the QPP is to incentivize clinicians to improve the quality and cost-effectiveness of the care they deliver.  ECs can participate in one of two tracks: 1) the Merit-Based Incentive Payment System (MIPS), or 2) Advanced Alternative Payment Models (APMs).  In this first year, the vast majority of ECs, including most ABC clients, will participate in MIPS.

In this eAlert, we provide our recommendations for ABC clients for the QPP’s inaugural year, with a focus on the MIPS quality reporting category.  We will discuss the MIPS categories of practice improvement activities and advancing care information (technology) in a future eAlert.

As noted in our September 19, 2016 eAlert, 2017 is a “transition” year for ECs participating in the QPP.  The MACRA final rule gives clinicians flexibility to set their own pace for participation.  A range of options were incorporated into the rule to help clinicians make a more gradual, less burdensome transition to a value-based payment system.

We expect that most ABC clients will be prepared to participate in the “partial” option in 2017.  This option requires clinicians to submit data for 90 days.  In our view, this reporting option offers the most prudent path in 2017 because it not only allows ECs to avoid a negative payment adjustment in 2019 but also provides the opportunity to earn an incentive payment and prepare for more extensive reporting requirements.  (In an Executive Summary, the Centers for Medicare and Medicaid Services (CMS) stated that 2018 will also be “transitional in nature to provide a ramp-up of the program and of the performance thresholds” and that it anticipates “making proposals on the parameters of this second transition year through rule-making in 2017.”  Please note, however, that this may be subject to change.)

ABC is offering two interconnected services to support our clients’ MIPS participation during 2017.  First, we will continue to offer the Quality Clinical Data Registry (QCDR) for anesthesia-specific quality measures reporting begun in 2016.  QCDR reporting offers the greatest level of flexibility and the most practical and realistic alignment with anesthesiologists’ everyday practices.

ABC anticipates receiving approval for its 2017 QCDR program at the beginning of 2017 and will keep you informed.  We have been working with other QCDRs to harmonize and align anesthesia-specific quality measures that overlap with their registries so that common comparisons can be made.  We do not expect to see major changes in these measures for 2017.  We also will introduce a new service, the MACRA Made Easy Platform, designed to support clients in complying with all MACRA requirements in 2017 and subsequent years.

Your Composite Score

Your Medicare payment adjustment as a MIPS participant will be based on a composite score drawn from four areas:

1. Quality: Replaces the Physician Quality Reporting System (PQRS). 
2. Improvement Activities: A new category that includes activities in such areas as expanded practice access, care coordination and achieving health equity.
3. Advancing Care Information: Replaces the Medicare Electronic Health Record Meaningful Use Incentive Program.
4. Cost: Replaces the Value-Based Modifier.

Note, however, that during this first year of the QPP, payments will increase, decrease or remain the same in 2019 based on performance in the first three categories only—quality, improvement activities and advancing care information.  Although cost will be calculated via claims in 2017, cost will not be factored into the composite score until 2018.

CMS has said that it expects clinicians to earn a national average composite score of 60/100 during the QPP’s first year.  Note that it is possible to achieve this 60-point score by successfully completing the quality reporting requirement alone.  In our opinion, focusing solely on quality reporting through the QCDR for 90 days offers a sensible and realistic path for clients during this first year.  This option would enable you to achieve the average score of 60 points and avoid a penalty.

For clients interested in not just avoiding a penalty, but instead in working toward the bonus payment by reporting for at least 90 days in the improvement activities and advancing care information categories as well as in the quality category, the MACRA Made Easy Platform provides a guide to the steps involved.

Anesthesiology Measures

CMS released the 2017 measure specifications for MIPS on November 18.  The Anesthesiology Specialty Measure Set consists of the following:

MIPS 044: Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery

Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision.

MIPS 076: Prevention of Central Venous Catheter (CVC) Related Bloodstream Infections

Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.

MIPS 130: Documentation of Current Medications in the Medical Record

Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter.  This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

MIPS 317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated in MIPS 404: Anesthesiology Smoking Abstinence: The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.

MIPS 424: Perioperative Temperature Management

Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.

MIPS 426: Post-Anesthetic Transfer of Care: Procedure Room to Post Anesthetic Care Unit (PACU)

Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized.

According to the PQRS specification, the key handoff elements that must be included in the transfer of care include:

1. Identification of patient 
2. Identification of responsible practitioner (PACU nurse or advanced practitioner)
3. Discussion of pertinent medical history
4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed) 
5. Intraoperative anesthetic management and issues/concerns. 
6. Expectations/Plans for the early post-procedure period. 
7. Opportunity for questions and acknowledgement of understanding of report from the receiving PACU team MIPS

427: Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)

Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member.

According to the PQRS specification, the key handoff elements that must be included in the transfer of care protocol or checklist include:

1. Identification of patient, key family member(s) or patient surrogate
2. Identification of responsible practitioner (primary service)
3. Discussion of pertinent/attainable medical history 
4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed)
5. Intraoperative anesthetic management and issue/concerns to include things such as airway, hemodynamic, narcotic, sedation level and paralytic management and intravenous fluids/blood products and urine output during the procedure
6. Expectations/Plans for the early post-procedure period to include things such as the anticipated course (anticipatory guidance), complications, need for laboratory or ECG and medication administration
7. Opportunity for questions and acknowledgement of understanding of report from the receiving ICU team

MIPS 430: Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy

Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively.

Reporting Requirements

MIPS 424 has been defined as an outcome measure.  All measures with the exception of MIPS 044 and MIPS 317 are defined as high-priority measures.  ECs and group practices are required to report at least six quality measures, including one outcome measure, or (if an outcome measure is not available) one high-priority measure.  (A tool for sorting quality measures by keyword, data submission method, specialty and other criteria is available at CMS’s new Quality Payment Program website.)

ECs and group practices may report MIPS and/or non-MIPS measures to meet the quality reporting requirement; however, CMS encourages participants to report more than six measures to potentially earn bonus points.  ECs can earn bonus points by reporting additional outcome and high-priority measures.  For ECs and groups for whom fewer than six measures apply, all applicable measures must be reported.

Lessons Learned in 2016

Based on our experience with clients who participated in ABC’s 2016 QCDR, MIPS 044 and MIPS 076 are not necessarily available to all providers, as few anesthesiologists perform anesthesia for CABG surgery or insert central lines regularly.

MIPS 130 has caused some concern with most anesthesia providers as the procedures (identified by CPT code) to which it applies largely exclude cases performed by anesthesia providers.  Very few providers in the 2016 ABC QCDR are able to include this measure as part of the yearly reporting due to this issue.

Prevention of PONV (MIPS 430) caused some uncertainty among QCDR participants in 2016 regarding the definition of at-risk patients.  According to the PQRS, risk factors for PONV are:

• Female gender 
• History of PONV
• History of motion sickness
• Non-smoker
• Intended administration of opioids for post-operative analgesia.  This includes use of opioids given intraoperatively and whose effects extend into the post anesthesia care unit (PACU) or post-operative period, or opioids given in the PACU, or opioids given after discharge from the PACU.

Anesthesiologists who report MIPS 426 and MIPS 427 should note that the specifications require the clinician only to use a checklist and to document the use of that checklist; however, the clinician is not required to document the answers to each item on the checklist.

The changes looming on the horizon as CMS shifts from a fee-for-service to a pay-for-performance methodology can seem daunting.  ABC is with you every step of the way.  If you have any questions, please contact your client service executive.

With best wishes,

Tony Mira
President and CEO