By Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC
As we count down the days until ACCC’s Capitol Hill Day on March 31, ACCCBuzz will feature a primer series on the key issues ACCC members will be talking about. In this first of four installments, we’ll look at SGR repeal and replacement.
Due to the flawed sustainable growth rate (SGR) formula that determines Medicare reimbursement, each year physicians face reimbursement uncertainty. Each year, Congress has been forced to step in with a “doc fix” to prevent enormous pay cuts for providers.
We’ve been following the progress on SGR reform in ACCCBuzz.
As you know, there’s been much discussion on how best to fix the SGR. Should there be a time-limited pay freeze vs. annual updates? Which quality metrics should be used? Should the new policy develop over five years or ten? At last Congress is showing some consensus around the policy discussion, while still grappling with the question of how to pay for a fix. Companion legislation in the House (HR 4015) and Senate (S 2000) is now moving forward and includes the following reforms:
Predictable Payment Updates—Under these bills, a positive 0.5% for fee-for-service update would be implemented for 2014–2018. The 2018 Medicare reimbursement rate would then remain in place through 2023. Starting in 2024, provider reimbursement could increase by 1% for those participating in alternative payment models, while remaining at 0.5% for those not participating.
Reimbursement Tied to Quality—The proposed legislation would consolidate the three Medicare incentive/penalty programs –Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM), and Meaningful Use of electronic health records (EHR MU)—into one streamlined program, the Merit-Based Incentive Payment System (MIPS). The MIPS will evaluate providers based on quality, resource utilization, EHR meaningful use, and clinical improvement activities. Although specific measures would be established through CMS rulemaking, positive or negative payment adjustments would be made to providers using a composite score compared to a performance threshold. Negative adjustments will be capped at 4% in 2018, 5% in 2019, 7% in 2020, and 9% in 2021.
Providers who receive a significant portion of their revenues through alternative payment models (APMs) involving risk of financial loss and with a quality measurement component would receive a 5% bonus each year 2018–2023. Importantly, the legislation encourages CMS to test APMs relevant to specialty professionals, like oncology.
Additionally, at least one new payment code will be created for care management services provided to patients with chronic conditions.
Each year CMS would propose a plan for establishing the quality measures to be used in the MIPS and APM programs. Annual funding of $15 million would be allocated for the development of such measures, and stakeholders would be able to submit comments to CMS’s proposed plans.
Physician-Specific Data Would be Made Public—Starting in 2015, CMS would publish utilization and payment data for providers on the Physician Compare website, including information on the most commonly provided services and the submitted charges for those services. Providers would have the opportunity to review and correct inaccurate data.
Potentially Misvalued Codes—As ACCC has noted previously, identification of potentially misvalued codes remains in the SGR repeal legislation. The current goal is 0.5% of fee schedule expenditures to be slated for identification of misvalued services each year in 2015–2018.
Although the current legislation reflects much consolidation on SGR reform, much work remains in identifying $126 billion in offsets to pay for this fix. The current “doc fix” runs out at the end of March. On Capitol Hill Day ACCC members will be walking the halls of Congress, urging members from the House and Senate to work together to pass this reform and permanently replace the SGR with responsible policy that emphasizes value over volume.
Join us for ACCC’s Capitol Hill Day and help educate your representatives about the importance of SGR reform.
Stay tuned to the rest of this blog series for a deep dive into the issues ACCC members will be talking about on Capitol Hill: Exempt cancer drugs from the 2% Medicare sequester, create equity in out-of-pocket expenses for oral and IV-infused therapies, and eliminate of the prompt pay discount. See you on the Hill!