Sustainable Growth Rate Formula Research Articles

The Merit-based Incentive Payment System: Pearson's Chi-Square and Categorical Dependent Variable Models Analyzed for Domains-Effective Clinical Care and Efficiency/Cost Reduction.

Background: Following the 2015 repeal of the Sustainable Growth Rate formula, the US Centers for Medicare & Medicaid Services’ formula under which physicians were reimbursed, two payment systems were put in place to incentivize physicians, one of which was the Merit-based Incentive Payment System (MIPS). MIPS emphasizes high-quality care that is accessible, affordable, and supports a healthier population.Objectives: This research aims to measure characteristics of MIPS relevant to National Quality Strategy (NQS) domains, quality measure types, and clinical specialties; categorize MIPS with NQS domains and quality measure types by MIPS specialty types; and quantify the relationship between MIPS specialties, measure types, and two NQS domains, Effective Clinical Care (ECC) and Efficiency/Cost Reduction (E/CR), for years 2017 through 2020.Methodology: The Pearson’s chi-square test examined distributions of the analyzed categorical variables. The Categorical Dependent Variable Method examined the association between the dependent and independent variables.Results: The Pearson’s chi-square test showed statistically significant distributions between ECC and E/CR when analyzed with the types of quality measures. There were more process measures (93.81% vs 89.64% [P=.000]) in 2018 versus 2017. This changed minutely with significantly less process measures (93.75% vs 93.81% [P=.000]) in 2019 versus 2018. Finally, measure types changed minutely but significantly with less process measures (93.81% vs 93.75% [P=.000]) in 2020 versus 2019. The regression model showed that ECC was significantly associated with outcome measures through all analyzed years of this research.Conclusion: The above findings show scope for including additional outcome measures, given its importance in MIPS. There is potential to increase the percentage allocation for reporting more outcome measures in quality. This re-allotment infers reporting more outcome measures aligning with priority outcome measures (PROMs). Re-allocating the incentive formula to report more outcome measures aligned with PROMs shows potential to increase reporting of more outcome measures under MIPS.

No Permanent Fix: MACRA, MIPS, and the Politics of Physician Payment Reform.

Organized medicine long yearned for the demise of Medicare's Sustainable Growth Rate (SGR) formula for updating physician fees. Congress finally obliged in 2015, repealing the SGR as part of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA established value-based metrics for physician payment and financial incentives for doctors to join alternative delivery models like patient-centered medical homes. Throughout the law's initial implementation, the politics of accommodation prevailed, with federal officials crafting final rules that made MACRA more favorable for physicians. However, the era of accommodation could be short-lived. The discretion that the Centers for Medicare and Medicaid Services had during the first two years of implementation is ending. Additionally, euphoria over the SGR's repeal has given way to concerns over the new program's value-based purchasing arrangements and uncertainty over their sustainability. MACRA eliminated the SGR, but not the politics of physician payment.

Maximize Reimbursement and Minimize Risk Under the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) and the Quality Payment Program (QPP)

The Congress recently passed legislation to repeal the Sustainable Growth Rate Formula and replace it with the Medicare Access and Children Health Plan Reauthorization Act's Quality Payment Program. The Quality Payment Program is designed to move physician payment from a volume-based to a value-based methodology. There are two pathways of payment that diverge and are differentiated by managing risks or managing rewards. The Merit-based Incentive Payment System (MIPS) is a competitive payment system that is budget neutral and results in defined winners and losers with potential losses/gains in payments from 4% in 2019 to 9% in 2022. Characteristically, this is not dissimilar to the Sustainable Growth Rate Formula of days past but with quality measures applied. The second pathway is that toward Alternative Payment Models (APMs) that allow clinicians to participate in payment models that that provide rewards for higher-quality, lower-cost care with entry bonuses as high as 5%. The Virginia Cardiac Services Quality Initiative, a well-known regional quality collaborative, was awarded a federal grant as a Support and Alignment Network 2.0 in September 2016. As an awardee, the Virginia Cardiac Services Quality Initiative is offering, free of charge, educational support to clinicians to understand the Medicare Access and Children Health Plan Reauthorization Act, MIPS, and APMs. These support services will include on-site education, continual evaluation, and guided transformation of practices to move from MIPS, a very competitive and possibly very difficult system for Society of Thoracic Surgeons members, toward Advanced APMs, where they can self-direct their measurement and rewards, allowing success financially under the Medicare Access and Children Health Plan Reauthorization Act.

MACRA and the Changing Medicare Payment Landscape.

The Medicare Access and CHIP Reauthorization Act (MACRA) is being implemented in 2017 by the Centers for Medicare and Medicaid Services (CMS) as the Quality Payment Program (QPP) and will have important and far reaching effects on how physicians are reimbursed and on how they practice. The QPP modifies the Medicare physician payment system by eliminating the Sustainable Growth Rate formula and incorporating the existing Physician Quality Reporting System, EHR Incentive Program, and the Value Modifier into a single new Merit-based Incentive Payment System (MIPS). The authors reviewed the MACRA legislation as well as the CMS resources on the QPP and other sources to summarize the regulations pertaining to the new program, particularly for the first performance period. CMS has taken great care to create a smooth transition for Medicare physicians. Clinicians can avoid any penalty for performance in 2017 by submitting a minimal amount of quality data, attesting to a single improvement activity, or successfully attaining the base score for the advancing care information portion of MIPS. The reduced reporting period also makes it possible for participants to begin collecting data as late as October 2nd and still achieve the full possible score in the program. Surgeons should be taking steps now to ensure that they are prepared to succeed in the QPP. The transition period creates a clear pathway for avoiding penalties while providing an opportunity to test one's ability to participate and improve performance.

Value-Based Payment Reform and the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015: A Primer for Plastic Surgeons.

In 2015, the U.S. Congress passed the Medicare Access and Children's Health Insurance Program Reauthorization Act, which effectively repealed the Centers for Medicare and Medicaid Services sustainable growth rate formula and established the Centers for Medicare and Medicaid Services Quality Payment Program. The Medicare Access and Children's Health Insurance Program Reauthorization Act represents an unparalleled acceleration toward value-based payment models and a departure from traditional volume-driven fee-for-service reimbursement. The Quality Payment Program includes two paths for provider participation: the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. The Merit-Based Incentive Payment System pathway replaces existing quality reporting programs and adds several new measures to create a composite performance score for each provider (or provider group) that will be used to adjust reimbursed payment. The advanced alternative payment model pathway is available to providers who participate in qualifying Advanced Alternative Payment Models and is associated with an initial 5 percent payment incentive. The first performance period for the Merit-Based Incentive Payment System opens January 1, 2017, and closes on December 31, 2017, and is associated with payment adjustments in January of 2019. The Centers for Medicare and Medicaid Services estimates that the majority of providers will begin participation in 2017 through the Merit-Based Incentive Payment System pathway, but aims to have 50 percent of payments tied to quality or value through Advanced Alternative Payment Models by 2018. In this article, the authors describe key components of the Medicare Access and Children's Health Insurance Program Reauthorization Act to providers navigating through the Quality Payment Program and discuss how plastic surgeons may optimize their performance in this new value-based payment program.

The Medicare Access And CHIP Reauthorization Act: Effects On Medicare Payment Policy And Spending.

In 2015, Congress repealed the Sustainable Growth Rate formula for Medicare physician payment, eliminating mandatory payment cuts when spending exceeded what was budgeted. In its place, Congress enacted the Medicare Access and CHIP Reauthorization Act (MACRA), which established a two-track performance-based payment system that encourages physicians to participate in alternative payment models. MACRA could have huge effects on health care delivery, but the nature of those effects is highly uncertain. Using the RAND Corporation's Health Care Payment and Delivery Simulation Model, we estimated the effects of MACRA on Medicare spending and utilization and examined how effects would differ under various scenarios. We estimate that MACRA will decrease Medicare spending on physician services by -$35 to -$106billion (-2.3percent to -7.1percent) and change spending on hospital services by $32 to -$250billion (0.7percent to -5.1percent) in 2015-30. The spending effects are critically dependent on the strength of incentives in the alternative payment models, particularly the incentives for physicians to reduce hospital spending and physician responses to MACRA payment rates.

Medicare Access and CHIP Reauthorization Act: What do Geriatrics Healthcare Professionals Need to Know About the Quality Payment Program?

Commencing in 2017, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will change how Medicare pays health professionals. By enacting MACRA, Congress brought an end to the (un)sustainable growth rate formula while also setting forth a vision for how to transform the U.S. healthcare system so that clinicians deliver higher-quality care with smarter spending by the Centers for Medicare and Medicaid Services (CMS). In October 2016, CMS released the first of what stakeholders anticipate will be a number of (annual) rules related to implementation of MACRA. CMS received extensive input from stakeholders including the American Geriatrics Society. Under the Quality Payment Program, CMS streamlined multiple Medicare value-based payment programs into a new Merit-based Incentive Payment System (MIPS). CMS also outlined how it will provide incentives for participation in Advanced Alternative Payment Models (called APMs). Although Medicare payments to geriatrics health professionals will not be based on the new MIPS formula until 2019, those payments will be based upon performance during a 90-day period in 2017. This article defines geriatrics health professionals as clinicians who care for a predominantly older adult population and who are eligible to bill under the Medicare Physician Fee Schedule. Given the current paucity of eligible APMs, this article will focus on MIPS while providing a brief overview of APMs.

Health Policy and Clinical Practice in the New Era of Quality

April 27th, 2016 executive notice by the US Department of Health and Human Services issued key provisions to the Medicare Access and Summary CHIP Reauthorization Act of 2015, (MACRA). MACRA replaced the 1997 Sustainable Growth Rate formula for determining Medicare reimbursement. MACRA provides a new approach in Medicare reimbursement based on value and quality care. MACRA legislation is guided by the Quality Payment Program, directing two paths for Medicare reimbursement: The Merit-based Incentive Payment System (MIPS), or the Advanced Alternative Payment Model (APM). Nurse Practitioners, require knowledge and information to prepare for MIPS and APM to begin January 1, 2017.

MACRA Final Rule Offers Options for Value-Based Reporting

MACRA Final Rule Offers Options for Value-Based Reporting

Understanding Value-based Reimbursement Models and Trends in Orthopaedic Health Policy: An Introduction to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

In 2015, the US Congress passed legislation entitled the Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act (MACRA), which led to the formation of two reimbursement paradigms: the merit-based incentive payment system (MIPS) and alternative payment models (APMs). The MACRA effectively repealed the Centers for Medicare and Medicaid Services (CMS) sustainable growth rate (SGR) formula while combining several CMS quality-reporting programs. As such, MACRA represents an unparalleled acceleration toward reimbursement models that recognize value rather than volume. The first pathway, MIPS, consolidates several Medicare quality-reporting programs into one composite score that will be derived by four performance categories, including quality (30%), resource utilization (30%), meaningful use (25%), and clinical practice improvement activities (15%). The APM pathway includes the following programs: Medicare accountable care organizations as part of the Medicare Shared Savings Program, Bundled Payments for Care Improvement, and Comprehensive Primary Care initiative. Existing APMs have yet to be determined as eligible. We provide a contextual framework of the healthcare legislation that has led to the formation of current health policy and offer recommendations regarding SGR how orthopaedic surgeons may best steer through such reimbursement models.

Ready, Set, Go: Helping Physicians Move to Value as MACRA Begins

Passed with the broad bipartisan support of Congress in 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) will bring about comprehensive changes to how Medicare pays for physician services. MACRA aims to accelerate the transformation from fee-for-service payment to alternative payment models that require physicians to assume risk for the cost and quality of care. Civen the nation's unsustainable healthcare costs, MACRA is expected to survive regardless of the outcome of the November presidential and congressional elections.MACRA is critically important legislation for all providers, not just physicians. This column addresses implications and challenges for hospitals and health systems and complements an earlier column by Bosko and Hawkins (2016) that examined implications for physicians and physician groups.A CATALYST FOR MOVING PHYSICIANS TO VALUEReplacing the long-contentious Sustainable Growth Rate formula, MACRA rewards physicians for providing value-based care through a two-track framework: The advanced alternative payment model (ARM) track incentivizes providers who are taking risk on the basis of the quality and cost of care for particular episodes or defined patient populations and requires use of certified electronic health record (EUR) technology. The Merit-Based Incentive Payment System (MIPS) track is based on the fee-for-service model but is directly and rigorously tied to performance in four areas: quality, resource use, advancing care information (use of EHRs), and clinical practice improvement.For most physicians participating in the Medicare program, inclusion in one of the two tracks is mandatory; those who do not select the advanced APMs track will be default participants in MIPS. Implications for both tracks begin imminently; performance reporting by physicians starts lanuary 1, 2017, for payment 2 years later, in 2019. Based on feedback received and to allow physicians time to obtain help and experience before the program affects them, the Centers for Medicare & Medicaid Services (CMS) may consider postponing implementation of portions of MACRA or shortening the reporting periods; but even with these possible changes, the time for physician and hospital and health system leadership teams to prepare is now.The MIPS track is revenue neutral, so there will be winners and losers. MIPS payment adjustment of up to 9%, plus or minus, is making small practices feel vulnerable, as indeed CMS projects to be the case: Buried in a table on page 215 of the 426-page proposed rule as published in the Federal Register (CMS, 2016), CMS's estimation is that 87% of eligible clinicians currently in solo practices and nearly 70% in practices with two to nine clinicians will experience a negative adjustment in payment beginning in 2019. In contrast, 81% of clinicians in practices with than 100 clinicians are expected to experience a positive adjustment in payment (Table 1 ).The stakes are high for those who participate in the APM track, which offers physicians and physician groups a 5% incentive payment through 2024. To qualify as an advanced APM, physicians and physician groups must meet financial standards for bearing risk for monetary losses, as well as eligibility thresholds based on Medicare volume or payment standards. The requirements as outlined by CMS are complex (CMS, n.d.), but the aim is clear: to ensure that qualifying APMs assume more than a nominal amount of risk-i.e., significant downside risk-for monetary losses under value-based payment contracts.CMS anticipates that these six models will qualify as advanced APMs in 2017 (Quality Payment Program, n.d.): Comprehensive ESRD Care (CEC)-two-sided risk; Comprehensive Primary Care Plus (CPC+); Next Generation ACO Model; Shared Savings Program-Track 2; Shared Savings Program-Track 3; and Oncology Care Model-two-sided risk. Additional models, such as a new voluntary bundled payment program, a new Medicare ACO+ track, and an amended Comprehensive Care for Joint Replacement (CJR) model, are being evaluated for possible inclusion in 2018 or later years. …

MACRA Marks New Start for Medicare Payment of Physicians

MACRA Marks New Start for Medicare Payment of Physicians

Neurology Advocacy 2.0: After Sustainable Growth Rate Repeal.

Neurology Advocacy 2.0: After Sustainable Growth Rate Repeal.

Goodbye, Sustainable Growth Rate-Hello, Merit-Based Incentive Payment System.

On 16 April 2015, President Obama signed the Medicare Access and Children's Health Insurance Program Reauthorization Act, or MACRA. In addition to repealing the sustainable growth rate formula, thi...

What I Learned as Resident-Fellow Member Trustee

Back to table of contents Previous article Residents’ ForumFull AccessWhat I Learned as Resident-Fellow Member TrusteeLara Cox, M.D.Lara CoxSearch for more papers by this author, M.D.Published Online:12 May 2015https://doi.org/10.1176/appi.pn.2015.5b27AbstractThe end of this year’s annual meeting marks the end of my tenure on the Board of Trustees. I can’t believe that it’s almost over—my first meeting does not seem so very long ago, and I’m no less excited about the position now than I was then. It has been an incredible experience, and I have discovered so much about the organization, about leadership, and about myself. Looking back, here are some things I’ve learned. Setting a frame and sticking to it is as important for a meeting as a therapy session. This goes beyond having an agenda. It means having a sense of time and giving everyone an equal chance to speak but moving along when necessary, even if the discussion isn’t over. A meeting serves the purpose of the organization, not its leader—and should be run accordingly. People want to hear what we have to say, and they take us seriously. Being junior does not mean you’re treated as a kid who is just along for the ride. You bring a unique perspective that is essential for the future of our APA, and people will listen. What that means is that you should speak up. It also means that you should do so in a way that is worthy of the respect and attention you’re given. Listen carefully, so that when you speak, you are adding something new and valuable to the conversation. Do your homework before meetings and bullet-point out your thoughts (in advance, or in the moment) so that you can be concise and to the point. And skip the self-effacement. Don’t discount your opinion when you are asking others to give it weight.Surround yourself with passionate people. Even when you are passionate about different things, sharing that kind of excitement and drive creates a climate where ideas grow and flourish and can help to push something from idea to implementation faster than you could have imagined. The people that I have met over the past two years are some of the most passionate, intellectually curious, devoted, generous people I know, and it is truly a privilege to have them as colleagues and friends.When we pull together as an organization, we are powerful. Issues of mental health and mental illness are still surrounded by so much stigma, and the public discourse can be discouraging. But in just the past few months, we have had an impact in pushing forward legislation on veterans mental health and the repeal of the sustainable growth rate formula, and we have joined with other organizations in a national campaign to change the conversation about mental health. Physicians, legislators, and the public are looking for a direction on mental health, and we are in a unique position to provide it.It has been an honor and a pleasure to serve as the resident-fellow member trustee, and the impact it has had on me cannot be overstated. I want to thank all of you for giving me this opportunity. And one last thing that I have learned is that I will stay involved. As I grow and change through my career, that involvement may change, but I am confident that I will continue to be an active member of the community that is our APA. ■Lara Cox, M.D.,is APA’s resident-fellow member trustee. ISSUES NewArchived

Analysis of the Carrot and Stick Policy of Repeal of the Sustainable Growth Rate Formula: The Good, The Bad, and The Ugly

The Balanced Budget Act which became law in 1997 was designed to help stem the increasing in costs of healthcare. The Sustainable Growth Rate (SGR) formula was incorporated into that law as a method of helping balance the budget through a complex formula tying reimbursement to the growth in the economy. Soon after its inception, the flawed nature of the formula, linking the balancing of the federal budget to physician professional fees was realized. Congress has provided multiple short-term fixes known as SGR patches over the years so as to avoid generally progressively larger negative corrections to professional reimbursement. The near annual SGR correction requirement has been compared to Groundhog Day in the legislative arena. Over the years, physician and other providers faced numerous looming, large cuts. Most recently, on April 1, 2015 physicians faced a 21.2% cut in provider payments. To the surprise of many, in April 2015 a bipartisan bicameral effort permanently repealed the Medicare SGR formula for controlling provider payment. The repeal of SGR means the temporary measures to override the growth rate formula will no longer dominate Medicare policy discussions and now the focus turns to continue payment reforms. The MACRA provides physicians and other health care professionals with stable fee update for 5 years and it follows with a new incentive program, termed the Merit-based Incentive Payment System (MIPS) replacing and consolidating preexisting incentive payment programs: meaningful use of electronic health records (EHR), physician quality reporting system, and the value-based payment modified. Thus, payments to clinicians will be subjected to adjustments based on participation in MIPS or other approved alternative payment mechanisms. This legislation also creates numerous other regulations. The MACRA has been criticized for providing insufficient statutory updates, enacting a flawed quality and performance improvement program associated with MIPS and inappropriate use of utilization and payment data. Thus, the MACRA offers physicians a predictable schedule for Medicare rates – a carrot, and controls the physician behaviors with payment reforms analogous to a stick. Thus, it could be said that this legislation embodies some good, bad, and ugly aspects. Key words: Balanced Budget Act, sustainable growth rate, alternative payment models, Medicare Access and CHIP Reauthorization Act of 2015, Merit-based Incentive Payment System, payment reform, payment modernization, health information technology

SGR Repealed in Historic Bipartisan Agreement

Back to table of contents Previous article Next article Government NewsFull AccessSGR Repealed in Historic Bipartisan AgreementMark MoranMark MoranSearch for more papers by this authorPublished Online:23 Apr 2015https://doi.org/10.1176/appi.pn.2015.5a28AbstractThe law eliminates the sustainable growth rate component of the Medicare payment formula and creates a merit-based incentive payment system that consolidates several quality-incentive programs.The sustainable growth rate (SGR) component of the Medicare payment formula was repealed when the U.S. Senate approved the bipartisan Medicare Access and CHIP Reauthorization Act (MACRA) on April 14, and President Obama signed the legislation into law a day later. The House had approved the bill two weeks earlier, just as Congress was heading out of town for its spring recess.President Obama signs the Medicare Access and CHIP Reauthorization Act of 2015 last month in the Rose Garden of the White House in Washington, D.C. The law eliminates the sustainable growth rate (SGR) formula created in a 1997 law that aimed to slow the program’s growth by limiting reimbursements to physicians. APA had long advocated for the repeal of the SGR formula. See story at right. Also last month, the president called for a ban on “reparative” or “conversion” therapies.AP Photo/Carolyn KasterMACRA permanently repeals the SGR and averts a 21 percent across-the-board cut in physician pay that was scheduled to go into effect on April 15. For more than a decade, repeal of the SGR has been an advocacy priority for APA, the AMA, and other medical groups. Each year, the SGR—which mandates cuts in physician reimbursement to offset increases in overall Medicare volume—has required increasingly steep payment cuts that have been averted by last-minute congressional action; the cumulative cost of the yearly “patches” enacted by Congress is estimated at $170 billion. APA, along with the AMA and many other physician groups, hailed passage of the new law as a welcome—and too-long deferred—relief from the yearly drama of scheduled payment cuts and last-minute patches by Congress.“Senate passage of the SGR reform bill is a major step toward a reliable and rational payment system for Medicare beneficiaries and their physicians. It is long overdue,” said APA President Paul Summergrad, M.D. “APA, our members, and the entire medical community advocated strongly for this legislation, which will eliminate uncertainty from the Medicare system to make sure patients and families can get the care they need and deserve from their physicians.”APA CEO and Medical Director Saul Levin, M.D., M.P.A., said passage of the new law is a victory for APA’s advocacy efforts. “Repealing the SGR has been a decades-long process that has involved the advocacy of thousands of APA members and other medical experts—a grassroots effort that will truly benefit both patients and physicians,” he said. “I commend the president and Congress for their leadership and efforts in this process.”Importantly, the legislation will provide stable updates of 0.5 percent in physician payment for the next five years, from this year until 2019. In 2019, it establishes a streamlined incentive payment program, known as the Merit-Based Incentive Payment System (MIPS), which will focus the fee-for-service system on providing value and quality. The MIPS would consolidate the three existing incentive programs—the Physician Quality Reporting System, the Value-Based Modifier Program, and Meaningful Use of Electronic Health Records—in a cohesive program that avoids redundancies.It also provides financial incentives for professionals to participate in alternative payment models (APMs) that meet defined criteria. The payment rate in 2019 will be maintained through 2025—that is, there will be no update—but physicians will be able to receive additional payment adjustments through the MIPS. In 2026 and subsequent years, professionals participating in APMs that meet certain criteria will receive annual updates of 0.75 percent, while all other professionals will receive annual updates of 0.25 percent. The payment-reform legislation also extends and funds the Children’s Health Insurance Program (CHIP) through September 30, 2017, and the Community Health Center program. The bill is estimated by the Congressional Budget Office to cost $141 billion, which will be only partially offset by several provisions in the package, including an income-related premium adjustment for some seniors. Starting in 2018, this policy will increase the percentage that beneficiaries pay toward their Part B and Part D premiums in two income brackets: for individuals with an annual income between $133,500 and $160,000 ($267,000 and $320,000 for couples), the percentage of premium paid above the standard premium will increase from 50 percent to 65 percent. For those with incomes between $160,000 and $214,000 ($320,000 and $428,000 for couples), the percentage will increase from 65 percent to 75 percent. ■A summary of the SGR legislation can be accessed here. ISSUES NewArchived

Solving the Sustainable Growth Rate formula conundrum continues steps toward cost savings and care improvements.

Congress is again attempting to repeal the Sustainable Growth Rate (SGR) formula. The formula is a failed mechanism intended to constrain Medicare Part B physician spending by adjusting annual physician fee updates. Congress has averted formula-driven physician fee cuts each year beginning in 2003 by overriding the SGR, usually accompanied with last-minute disputes about how these overrides should be paid for. Last year Congress achieved bipartisan and bicameral agreement on legislation to replace the SGR—the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, which we refer to as the "2014 SGR fix"—but was unable to find a way to pay for the legislation under current budget rules. Current congressional deliberations appear focused on how to pay for the fix, with wide consensus that the 2014 legislation should remain the basic model for reform. We describe key features of the 2014 SGR fix, place it in the context of both past and ongoing Medicare health policy, assess its strengths and weaknesses as a mechanism to foster improved care and lower costs in Medicare, and suggest further actions to ensure success in meeting these goals.

Half of Medicare Payments Tied to Value, Quality by 2018

Half of Medicare Payments Tied to Value, Quality by 2018

Medicare Gives Details on Care Coordination Pay

Starting Jan. 1, 2015, Medicare will pay physicians about $42 for certain care management (CCM) services outside of the face-to-face office visit, according to a new government proposal. The proposed rule (s3.amazonaws.com/public-inspection.federalregister.gov/2014-15948.pdf) for the 2015 Medicare Physician Fee Schedule, released in July, offers details on how officials at the Centers for Medicare & Medicaid Services (CMS) plan to roll out the new CCM services payments that begin next year. The proposal also expands telehealth services offered by Medicare and makes changes to the Open Payments program. CMS proposes to pay $41.92 for a new G-code for chronic care management services provided to patients with two or more chronic conditions that are expected to last at least a year. The code could be billed only once a month for each patient. To bill for the code, physicians would have to offer some type of 24/7 access, continuity of care, care management for chronic conditions including medication reconciliation, creation of a patient-centered care plan, management of care transitions including visits to the hospital and emergency department, and coordination with community-based services. According to Dr. Charles Crecelius, CMD, chair of AMDA's Public Policy Committee and a past AMDA president, CMS has taken the value code proposed by the Relative Value Update Committee, a multispecialty CMS advisory panel, and tweaked it by substantially decreasing the staff scope of practice and other burdensome requirements and also by decreasing the level of proposed reimbursement. “AMDA has participated in the development of the CCM code since its inception,” he said. “Whether the reimbursement will truly provide adequate reimbursement given the level of documentation required remains to be seen. This code only applies to the outpatient codes, which many of our members use.” In the 2015 Physician Fee Schedule, CMS is also proposing to require that physicians use certified electronic health record technology. The American Academy of Family Physicians (AAFP), a group whose members will benefit from the coding change, applauded CMS for introducing the care management code. But they said the benefit of the code would be overshadowed if Congress allows the scheduled cut to the Medicare sustainable growth rate (SGR) formula to go into effect on April 1. The fee schedule proposal reiterates that physicians will face a 20.9% across-the-board fee cut next year if Congress does not repeal or postpone the SGR. “The AAFP welcomes the new code, but we also look to a day when policies designed to strengthen primary medical care are not undermined by drastic cuts to the underlying foundation on which all payment is based,” Dr. Reid Blackwelder, AAFP president, said in a statement (www.aafp.org/media-center/releases-statements/all/2014/statement-medicare-physician-fee-schedule.html). The proposed fee schedule also seeks to add annual wellness visits, psychoanalysis, psychotherapy, and prolonged evaluation and management services to the list of telehealth services that can be furnished to Medicare beneficiaries under the telehealth benefit. Medicare also proposes to eliminate the coinsurance payment on the anesthesia portion of a screening colonoscopy when it is provided separately by an anesthesiologist.