After years of difficulty ensuring continuous, predictable payments for physicians, Congress finally enacted its version of a solution in 2015. However, in the last couple of years, uncertainty again threatens the goal of a more stable payment system. ASN is working to ensure that stability continues as some changes to that system loom on the horizon.
The Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act of 2015 (MACRA) ended the troubled Sustainable Growth Rate (SGR) formula, which often left Congress addressing a “doc fix” annually to prevent significant cuts in payment rates for participating Medicare clinicians over the SGR's 17-year lifespan. MACRA required the Centers for Medicare & Medicaid Services (CMS) to implement an incentive program, the Quality Payment Program (QPP). There are two pathways through which clinicians can choose to participate in the QPP:
Merit-based Incentive Payment System (MIPS): If you are a MIPS-eligible clinician, you will be subject to a performance-based payment adjustment through MIPS.
Advanced Alternative Payment Models (APMs): If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for sufficiently participating in an innovative payment model.
The program began in earnest in 2017, and the MIPS pathway ran smoothly in its first 3 years. Until, of course, 2020 when the COVID-19 pandemic arrived. The avalanche that was COVID-19 included more than just the tragedy of lost lives and compromised health, it also overtook the delivery, quality measurement, and payment structures of care built into Medicare's system and those of other payers as well. As a result, the MIPS program offered hardship waivers and other delays in the program during 2020 and 2021.
As in most cases involving payment models in Medicare, there is a 2-year delay between a performance year and a payment year. Therefore, the exceptions applied to MIPS in 2020 and 2021 softened the blow of cost issues from those in payment years 2022 and 2023. For 2024, MIPS participants need to re-evaluate their standing in the program in anticipation of a very different payment landscape for this year based on 2022 data.
With a majority of nephrologists in the United States participating in the MIPS pathway of the QPP, ASN is concerned that many MIPS-eligible clinicians have not checked their data in the QPP portal (https://qpp.cms.gov/) and will be unprepared for the change. Although many clinicians have reported that they previously performed well in MIPS, some are going to receive Medicare penalties, which may be as high as the maximum of 9%, starting January 1, 2024.
There are multiple reasons that physicians did not do as well during the 2022 performance year:
During the beginning of the pandemic, CMS automatically applied a hardship exemption for MIPS. In 2022, the hardship exemption was no longer automatic, and physicians had to apply.
CMS increased the MIPS performance threshold.
For the first time since 2019, CMS is counting the MIPS cost category. The cost category has numerous problems, and it is worth 30% of the MIPS score for the 2022 performance year.
Although the MIPS cost category accounted for 30% of eligible professionals’ MIPS final scores and significantly contributed to physicians’ 2024 MIPS payment adjustments, physicians had no way to anticipate, monitor, and improve their cost category performance because CMS did not share any data about its attributed measures, attributed patients, and observed costs until August 2023—more than 8 months after the conclusion of the performance period.
Prior to August 2023, there had been no information about this category since 2020 based on 2019 performance when only a few episode-based cost measures and the now-retired versions of the Total Per Capita Cost and Medicare Spending Per Beneficiary were in use.
Last fall, the American Medical Association, of which ASN is a member, strongly urged CMS to extend the targeted review or appeal deadline of October 9, 2023, and also to allow physicians to apply for a COVID-19 Extreme and Uncontrollable Circumstances (EUC) hardship exception. CMS declined to extend the deadline or allow EUC applications to be submitted during this time; however, ASN continues to urge CMS to re-weight the 2022 cost performance category to zero to minimize the penalties that some physicians will experience this year.
ASN will continue to monitor this situation. Please feel free to share your concerns or experiences with ASN at policy@asn-online.org.
