May 1, 2017

If, like most anesthesiologists and CRNAs, you are participating in the Merit-Based Incentive Payment System (MIPS) arm of the Quality Payment Program (QPP), you are probably aware of the various methods available for submitting data. Two of the most important of these for anesthesiologists and CRNAs are the Qualified Registries (QRs) and the Qualified Clinical Data Registries (QCDRs) developed by third-party vendors that require approval by the Centers for Medicare and Medicaid Services (CMS).

It’s important for anesthesiologists and CRNAs participating in MIPS to understand the differences between these two reporting mechanisms.  A QR and a QCDR differ in some significant ways that might not be clear at first, in part because the terminology sometimes used to describe the measures can be confusing.

Understanding the fundamental distinctions between a QR and a QCDR can help you choose the most effective reporting method for your MIPS data.  In our view, the most prudent alternative for anesthesia providers is one that will support successful MIPS participation in 2017 and in subsequent years, as the QPP’s reporting requirements and performance expectations expand.  In brief, plan ahead.  We believe a careful choice now will not only support your ability to comply with MIPS requirements this year, but will also pave the way for a smoother transition to the ramped up reporting requirements on the horizon.

As you move through this first year of MIPS, you undoubtedly will be focusing on learning and adjusting to the new reporting system and methodology.  2017 marks the start of the fundamental shift from volume-based to value-based payment mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) of which the QPP is a major part.  The intricacy and specificity of the systems designed to facilitate this transformation can be a challenge to wade through.  However, in deciding how to report your data, we believe it is in your best interest to think ahead to your MIPS participation in 2018 and beyond as well.  What reporting method will best support your ability to comply with MIPS requirements as they become more stringent and complex?

This first year of the QPP is a “transition year” offered by CMS to help you prepare for a payment system that rewards you based on the quality, safety and cost effectiveness of your anesthesia care.  Your choice of reporting mechanism this year will affect your long-term effectiveness and ability in future years to satisfy MIPS requirements as CMS accelerates the transition to value-based payment.

For example, in 2017, MIPS participants will be scored based on their reporting in three of four categories: Quality, Improvement Activities and Advancing Care Information.  However, beginning in 2018, compensation adjustments for 2020 also will be based on a fourth category: Cost.  We believe a reporting method that supports your participation now and that stays with you as the reporting requirements evolve provides the smartest solution.

QR vs. QCDR: What You Need to Know

QRs and QCDRs are CMS-approved third-party vendors that collect and submit data on behalf of participating eligible clinicians (ECs) and group practices.  ECs and groups that submit data in 2017 through the approved methods (of which QRs and QCDRs are two), will avoid a negative four percent penalty in 2019.

In our view, a QCDR is the reporting method most likely to ensure long-term success in MIPS.  Although a QR supports all of the MIPS measures, the vast majority of these measures are, in fact, not relevant to most anesthesia practices and will not give most anesthesiologists and CRNAs the six quality measures needed to meet the requirements of the MIPS Quality category.

For this reason, although a QR might appear to be an effective alternative at first glance, in reality, it provides, at best, a limited, temporary benefit to most anesthesiologists and CRNAs.  As anesthesiologists and CRNAs know, the specialty is very complicated with regard to billing, and few of the MIPS measures reflect the realities of most anesthesia practices.  (See discussion about specific measures below.)  A QR offers only three or four measures that are relevant to the practices of most anesthesiologists and CRNAs.

Further, we believe that participating in a QR this year would hinder your transition next year to a QCDR containing a wider range of relevant anesthesia-specific measures.  In essence, a QR does little to support anesthesiologists and CRNAs now or to equip them for the additional complications to come in the future of the Quality Payment Program.

A QCDR does offer this support. In contrast to a QR, a QCDR supports both MIPS and non-MIPS measures.  It is misunderstandings regarding the distinction between MIPS and non-MIPS measures and their role in meeting MIPS requirements that have caused confusion for some clinicians.  The fact that QRs support MIPS measures can create the appearance that QRs offer a more viable solution to anesthesiologists and CNRAs to achieve MIPS compliance.  But the broader offering of non-MIPS measures specific to individual QCDRs can be reported to fulfill MIPS requirements as well.  These non-MIPS measures more accurately reflect the way that most anesthesiologists and CRNAs practice.

The Quality Payment Program website outlines the following measures available to the Anesthesia Specialty Set.

Upon closer review, it becomes clear that only measures 424, 426, 427 and 430 are viable for a majority of private anesthesia practices.  If the practice doesn’t work with ICUs, then only three measures are now available.

Specifically, the exclusions are caused by the following reasons:

MIPS – 404 requires the patient to be seen preoperatively by an anesthesiologist or proxy prior to the day of surgery which may not be viable if the facilities do not have a pre-admission testing (PAT) clinic.

MIPS – 44 is only available for CABG cases.  Most anesthesia providers don’t perform CABG cases.

MIPS – 130 includes a CPT denominator exclusion which doesn’t include typical anesthesia billed codes.  This leaves the provider with a zero denominator and leaves the measure invalid.

MIPS – 76 is only for cases with central lines. Most anesthesia providers don’t insert central lines.

MIPS – 317 is directed toward primary care rather than anesthesia. It requires that the clinician document the high blood pressure condition which isn’t unusual.  However, the requirement then to create a follow up plan is unrealistic in an environment with increased patient care burdens.

For these reasons, we continue to recommend a QCDR for all of anesthesia in order to remain compliant with MACRA for 2017 and beyond.

With best wishes,

Tony Mira
President and CEO