On April 15th, the Medicare Sustainable Growth Rate [SGR] was repealed by Congress. Afterward, there was much celebration by the AMA and other medical societies. But, it may be a little premature to celebrate based upon the language of the Bill that was used to repeal the SGR.
The SGR was a method used by the Centers for Medicare and Medicaid Services (CMS) to control spending by Medicare on physician services. It was enacted in 1997. It was designed to ensure that the yearly increase in the expense per Medicare beneficiary did not exceed the growth in the GDP. Unfortunately, the SGR was unworkable and every year since Congress had to suspend its implementation with legislation called the “Doc Fix.”
The language in the Bill repealing the SGR mandated a new Medicare means of reimbursing physicians. It is called the Merit-based Incentive Payment System [MIPS]. It expands Obamacare’s “pay for performance” strategies in which reimbursement is based on provider performance against a variety of metrics. It consolidates the Physician Quality Reporting System, the Value Based Modifier and Electronic Health Records System [EHR] Meaningful Use into it. The penalties associated with these consolidated systems will remain in effect. Physicians will be evaluated and given a score based upon on quality, risk-adjusted resource use, EHR meaningful use and clinical practice improvement.
Clinical practice improvement areas that will be evaluated by CMS must include:
1. “expanded practice access such as same day appointment …”
2. “population management, such as monitoring health conditions of individuals to provide timely health care interventions …”
3. “care coordination, such as timely communications of test results, timely exchange of clinical information … and use of remote monitoring or telehealth …”
4. “beneficiary engagement, such as the establishment of care plans for individuals with complex care needs … and using shared decision making mechanisms …”
5. “patient safety and practice assessment, such as through use of clinical or surgical checklists and practice assessments relating to certification …” and
6. “participation in alternative payment models …” such as shared savings programs and other models under Federal law.
The secretary of HHS can expand on these.
MIPS incentives will range from a maximum 4% bonus or penalty in 2019 to a 9% bonus or penalty in 2022. The penalty levels seem significant to me.
To meet the demands of MIPS, physicians will have to expand their IT use well beyond the current usage level of their electronic health records systems. This will require increased expenditures and increased disruptions to their practices.
The repeal legislation is pushing telehealth and remote monitoring as a way to increase physicians scoring under MIPS. I find this problematic. I have a difficult time seeing how physicians will continue to increase, or even maintain, quality of care without touching the patient. The liability issue of treating a patient without touching the patient is also self-evident.
The repeal legislation, 158 pages, covers a wide range. 158 pages of verbiage was not needed to repeal the SGR. One or two pages would have sufficed. How or if it can be effectively and fairly implemented is a question that remains. So, now is not the time to celebrate. Now is the time to remain anxious.