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MACRA Rule Proposed by Medicare; Brief Overview of Orthopaedic Impact

April 29, 2016

Yesterday, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule to implement MACRA (Medicare Access & Chip Reauthorization Act), which Congress passed last spring to replace the SGR method for Medicare physician payments.

The following graphic from the American Academy of Orthopaedic Surgeons (AAOS) shows the two paths to incentives in the new Medicare physician payment program:

  • MIPS (Medicare Incentive Payment System), which will be based on quality payments.
  • APM (Alternative Payment Model), which will base incentives on whether a certain percentage of a physician’s patient population is derived from alternative payment models (and certain quality thresholds).


Click here for AAOS’s page that archives all of the organization’s work on MACRA. Click here for a broad overview of MIPS produced by the American College of Surgeons. Click here for a broad overview that focuses on APM and is produced by the American Academy of Family Physicians.

Yesterday’s proposed rule was 962 pages (click here to reference it). AAOS will provide extensive feedback to regulators over the next two months and provide analysis to orthopaedic surgeons.

In the meantime, the following is a very quick look at some of the orthopaedic issues in the draft regulation.

2017 Is the First Performance Year
As Jason McCormick indicated in his article in TOA’s last newsletter, 2017 will be the first performance year. Click here to review the article.

AAOS and other organizations are working on lengthy guidance for their members regarding how the quality reporting will work, what additional tools you may need to report, and other important details. This summary is a very brief overview.

Shift away from PQRS, Meaningful Use & Value-based
The MIPS route in MACRA consolidates PQRS, meaningful use, and value-based modifier and replaces them with new quality measures. Some of the proposed orthopaedic measures can be found below.

Click here to read a summary of the new quality categories under MIPS. Clinical Practice Improvement Activities (CPIA) is the new concept that has been introduced.

  • Quality (50 percent of total score in year 1): For this category, clinicians would choose to report six measures from among a range of options that accommodate differences among specialties and practices.
  • Advancing Care Information (25 percent of total score in year 1): For this category, clinicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting.
  • Clinical Practice Improvement Activities (15 percent of total score in year 1): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities that match their practices’ goals from a list of more than 90 options.
  • Cost (10 percent of total score in year 1): For this category, the score would be based on Medicare claims, meaning no reporting requirements for clinicians. This category would use 40 episode-specific measures to account for differences among specialties.

Meaningful Use = Advancing Care Information
The EHR Meaningful Use program will be changed and now be referred to as the Advancing Care Information program. Click here for an overview from CMS.

The key aspects of the new plan would include:

  • Physicians will be allowed to select the measures that reflect how they use EHR technology and what suits their practices.
  • CMS will no longer require all-or-nothing EHR measurement or quality reporting. EPs would receive a base score of 50 percent for reporting on their use of EHR technology, and can earn another 50 percent based on their performance; they also can receive a bonus for reporting to more than one registry.
  • The number of measures will be reduced from 18 to a new all-time low of 11.
  • Reporting of clinical decision support and computerized physician order entry will no longer be required.
  • EPs only have to report to a single public health immunization registry.
  • Some physicians will be exempt from reporting when EHR technology is less applicable.

Patient-reported Outcome Measures (PROMs)
Beginning in 2014, TOA spoke extensively in these newsletters and at TOA conferences on how PROMs will play a major role in how we determine quality and value in medicine.

The MACRA proposal includes an extensive number of PROM measures for MIPS reporting beginning in 2017. Turn to page 789 in the proposal for a look at some of the orthopaedic-specific measures for Proposed Individual Quality Measures Available for MIPS Reporting in 2017 (Table A).

Proposed Clinical Condition and Treatment Episode-based Measures (Table 4)
The musculoskeletal measures can be found on page 151. Some of the measures include:

  • Hip Replacement or Repair.
  • Knee Arthroplasty.
  • Spinal Fusion.
  • Hip/Femur Fracture or Dislocation Treatment (Inpatient).
  • Rheumatoid Arthritis.

The table provides commentary on whether the measure was included in the 2014 sQRUR (most are new). In addition, the commentary indicates when the episode is triggered (ICD or CPT codes).

Winners & Losers: Impact on Orthopaedics
Some have said that the new incentive payment program is a zero sum game. The bonuses paid to the “winners” will be offset by the “losers.”

In the proposal, CMS attempts to perform an analysis of the impact on each specialty. Beginning on page 674, CMS projects the potential percentage of orthopaedic surgeons who will face a negative payment adjustment (46.4%) and those who will witness a positive payment adjustment (53.3%). The table includes an analysis for all other medical specialties and podiatrists (78% with a negative payment adjustment) and chiropractors (98.4% with a negative payment adjustment).

BPCI & CJR Bundled Payments: Won’t Count as APMs
Some orthopaedic practices planned to pursue a blend of MIPS and APMs for their Medicare incentive payments. However, in what was very disappointing to the American Hospital Association, the draft proposal would not recognize the Bundled Payment Care Improvement (BPCI) initiative or Comprehensive Care for Joint Replacement (CJR) initiative as advanced APMs. The hospitals and surgeons are likely to fight this proposal.

“They’re essentially dooming physicians to participating in MIPS,” Harold Miller, president and CEO of the Center for Healthcare Payment and Quality Reform, said in Modern Healthcare. “They’ve been doing all this work and none of it qualifies. I think there’s going to be a lot of pushback from a lot of people.”

Page 501 lists a table of recognized advanced APMs. The handful of current Medicare alternative payment models that would count as advanced APMs are mostly limited to primary care models, such as accountable care organizations (ACOs).

ASCs & EHRs: Meaningful Use
The use of electronic health records (EHRs) in ambulatory surgery centers (ASCs) was excluded from the 2009 meaningful use legislation. Since that time, the ASC industry has tried to be included.

The proposed draft does provide discussion regarding EHR cases in which a surgeon does the majority of his or her work in an ASC and may not have access to their advancing care information performance category. The discussion can be found on page 241.