This Week – April 18, 2015

This Week in Washington DC:

  1. Congress Repeals SGR Formula: The Short and Long Term Impact to GI

Medicare Reimbursement Reform Becomes Law

On Tuesday, the U.S. Senate passed H.R. 2, the “Medicare Access and CHIP Reauthorization Act,” or MACRA on April 14th, with bipartisan vote of 92 to 8. This legislation repeals the sustainable growth rate (SGR) formula and reforms Medicare reimbursement moving forward. The U.S. House passed this SGR reform bill on March 26th by an overwhelming 392-37 vote. President Obama signed the bill into law on Thursday.

ACG appreciates the hundreds of members reaching out to their congressional leaders urging them to address SGR reform!

What does this mean for you near term?

Medicare began processing reimbursement claims this week for services provided in April. CMS was holding off paying claims until Congress passed the bill in order to avoid the 21% fee schedule cut scheduled to kick-in April 1st. Instead, ACG members will receive a 0% update from April 2015 to June 2015, a positive 0.5% on July 1, 2015 to December 2015, then and by another 0.5% on January 1, 2016.

What does this mean for you long term?

This legislation is a win for the House of Medicine. It also provides pathways for specialty societies to work directly with CMS instead of going through the various accreditation or consensus-based organizations under current law. There is also nothing in the law that mandates alternative payment models or maintenance of certification (MOC), nor does the bill implement any penalties for not participating in MOC.

However, much more work remains for us to improve access to GI patient care and adequately reimburse ACG members. ACG will be very busy this spring and summer on Capitol Hill addressing these issues and you will hear more about this in the coming weeks.

Highlights of H.R. 2:

  • SGR Formula is Repealed: ACG and its members have long urged Congress to repeal this broken SGR formula. A looming threat of significant Medicare reimbursement cuts every 6 months to 1 year impacts patient care and prevents GI practices from making important business and planning decisions. Congress has had to step in 17 times to avert cuts over the years. Clearly, the SGR formula was broken.
  • Predictable Updates: ACG is disappointed in the paltry annual percentage updates. However, the legislation does provide stable/positive updates for the foreseeable future instead of looming reimbursement-cliffs. In 13 out of the 17 times Congress was forced to step in and avert looming cuts, the update was .5-0%. So while ACG is disappointed to see these reimbursement freezes in this bill – and remain committed to changing this – ACG members are essentially no worse off financially under this bill than under the continuous pattern of temporary freezes or patches over the years and have the benefit of increased predictability for billing and practice management purposes.

    • 0% update to June 2015,
    • .5% update from July to December 2015,
    • .5% update for 2016- 2019,
    • 0% update from 2020-2025, and
    • .25-.75% updates from 2026 and beyond
  • The Merit Based Incentive Payment System, or “MIPS”: Beginning 2019, Medicare will merge the physician quality reporting system (PQRS), the value-based purchasing modifier, and the “meaningful use” program into a new value-based reimbursement system. This MIPS program will consist of the following components: quality, resource use, clinical improvement activities, and “meaningful use.” Each of these components will be weighted differently (30%, 30%, 15%, and 25% respectively). Each provider would be given a score for each component, for an overall score ranging from 0-100. The Secretary of HHS will determine a threshold “composite score” target, then compare this threshold benchmark to each provider’s individual composite scores in order to determine whether the provider gets a reimbursement cut, a neutral update, or a bonus. Providers scoring a “0” or who are in the bottom 25% will receive a reimbursement cut ranging from 4% in 2019 to 9% in 2022+. Providers with higher scores will receive higher payments (capped at 10% of allowable Medicare billings) assuming the money is there from cuts to other providers with low scores. This is called budget-neutrality. However, there are additional bonuses not subject to budget neutrality for those providers scoring in the top 25% in 2019-2024.
  • Reducing Reporting Burdens: ACG has worked with Congress to reduce administrative and regulatory burdens borne by GI practices. It is encouraging to see our advocacy efforts paying off as H.R. 2 aligns Medicare quality reporting. The legislation also requires HHS to further incorporate the use of clinical quality data registries (QCDRs) into the MIPS program and further streamline reporting requirements. This is good news for GIQuIC users.
  • Participating in QCDRs such as GIQuIC would help streamline GI practices’ reporting burdens in Medicare under this legislation (and proposed “meaningful use” Stage 3 requirements), as these registries would help to satisfy each of the quality, clinical improvement activities, and “meaningful use” components under the MIPS program. ACG was very active on Capitol Hill and meeting with CMS officials in urging Medicare to ease reporting burdens while at the same time improving quality of care to Medicare beneficiaries.Also, beginning 2016, H.R. 2 allows practices to participate in PQRS via QCDRs as a group, whereas only individuals are currently allowed participate in QCDRs.
  • Offsets: The SGR repeal legislation does not include items such as elimination of the in-office ancillary services exception like pathology, paying for SGR repeal by increasing the Medicare savings targets via the “misvalued code review,” or other issues important to ACG members and their practices.
  • However, this legislation may trigger “sequestration,” or across the board provider cuts up to 2% in 2015, because the bill was not completely offset with spending cuts. Once an idea is on a list of potential offsets, it is difficult to get off this list. That is why ACG will continue to monitor these issues potentially impacting ACG members.
  • A Comparison of Quality Reporting & Reimbursement Cuts: Assuming Congress would always step in and avert a looming SGR cut (a safe assumption given the history), ACG reviewed and analyzed the impact and risks of not participating in quality reporting under in this newly created MIPS program vs. under the SGR system. The chart below demonstrates that estimated overall cuts in failing to participate in the MIPS are less severe than under the current law.

If you choose not to participate: A Comparison of Cuts:

Non-Participation: MIPS Non-Participation: Current Law
2019 -4%
  • PQRS: -2%
  • Meaningful Use: -3 to -5%
  • Value-Based Purchasing Modifier**: -2% to -4% (depending on practice size)

** Estimated. Based on CMS published data for 2017 payment year

2020 -5%
  • PQRS: -2%
  • Meaningful Use: -3 to -5%
  • Value-Based Purchasing Modifier**: -2% to -4% (depending on practice size)

** Estimated. Based on CMS published data for 2017 payment year

2021 -7%
  • PQRS: -2%
  • Meaningful Use: -3 to -5%
  • Value-Based Purchasing Modifier**: -2% to -4% (depending on practice size)

** Estimated. Based on CMS published data for 2017 payment year

2022+ -9%
  • PQRS: -2%
  • Meaningful Use: -3 to -5%
  • Value-Based Purchasing Modifier**: -2% to -4% (depending on practice size)

** Estimated. Based on CMS published data for 2017 payment year

(Note: these are estimated comparisons based upon the data published in previous CMS payment rules)

Please stay tuned for further updates. Please also share and discuss your thoughts with fellow ACG members on the ACG GI Circle. To login and share your comments, go to gi.org and sign in as a member. Once you have done so, click the orange “Visit ACG GI Circle” button to be taken to the GI Circle site. If you have not yet activated your ACG GI Circle account, please email us at acgcirclefeedback@within3.com.

Contact Brad Conway, VP Public Policy, with any questions or for more information.

Brad Conway
bconway@gi.org
301-263-9000