Public Policy

SHM suggests tweaks to CMS QPP proposal

Docs may tie personal risk to hospital value-based purchasing performance


The Society of Hospital Medicine approves of the direction the Centers for Medicare & Medicaid Services is heading when it comes to measuring pay-for-performance for hospitalists in its Quality Payment Program (QPP) but is suggesting some tweaks to make it a better system.

The proposed CMS 2018 update to the QPP, the value-based payment scheme developed by the Medicare Access and CHIP Reauthorization Act (MACRA), included an option that would allow all physicians who primarily practice in a hospital setting to report as a unified group under the hospital umbrella – as an alternative to reporting as an individual in the Merit-Based Incentive Payment System (MIPS) track.

SHM President Ron Greeno, MD
Dr. Ron Greeno
“Instead of reporting MIPS metrics, they will be able to opt out and tie their risk to the hospital value-based purchasing performance at their hospital,” SHM president Ron Greeno, MD, MHM, said. “That is a completely new way to measure physician performance. We like it as a concept because it creates more alignment between the hospital-based doctors and the hospital. It is why CMS likes it also.”

He said there is lot to like in that option, although there are things that need to be changed as well.

One key area SHM would like to see changed is how time spent in a hospital is measured. In the CMS proposal, codes related to site of service capture only those in the emergency room and those admitted for in-patient services. Doctors who are seeing patients on an observation basis before they are admitted are not captured and could not be included in the facility payment.

“Observation services are virtually indistinguishable from inpatient care and frequently occur on the same wards of the hospital,” SHM said in Aug. 21, 2017, comments to CMS on the proposed QPP update, noting that observational care is built around the two-midnight rule.

“We disagree with this interpretation,” the SHM letter continues. “While it is true observation is generally time limited for a given patient, practice structures and provider scheduling have a profound [impact] on the proportion of observation care an individual clinician provides.” The letter noted that hospitalists who are on observation service could have a high proportion of observation (outpatient) billing, which could in turn exclude them from qualifying for a facility-based reporting option “despite the fact they are truly hospital-based inpatient providers.”

Dr. Greeno noted that some hospitals have hospitalists that exclusively provide observational care.

The proposal designates physicians who meet a 75% threshold of providing care in an emergency room or in-patient setting as eligible to opt into facility-based reporting.

SHM suggests that if observation services cannot be included in the 75% threshold, those services should be included and “couple the calculation with a cross-check to ensure most other billing is also hospital-based. As a further check, CMS could look at specialty codes – is the provider also enrolled in Medicare as a hospitalist?” SHM also recommends lowering the threshold “to 70% or, ideally, 60%. Due to the wide variation in hospitalist practice, we are uncomfortable with the use of thresholds in general, but lowering this threshold would at least provide a kind of safety net for hospitalists who are caring for high numbers of patients on observation.”

Another key area that needs to be addressed is the quality metrics that are used for scoring, which Dr. Greeno acknowledged is “surprisingly hard to do.”

For the 2018 reporting year, CMS is proposing that the required number of measures for the MIPS program be six, that same is it currently is for 2017. While SHM agrees with this level, “we remind CMS that even six measures may be a challenge for some providers, including hospitalists, to meet. Concerted efforts should be made to ensure that those providers who have fewer than six measures available for reporting are not disadvantaged in any way.”

Dr. Greg Seymann, clinical professor and vice chief for academic affairs, UCSD Division of Hospital Medicine
Dr. Greg Seymann
Gregory Seymann, MD, hospitalist and professor at the University of California, San Diego, noted that, for example, “one of the measures is about the way you put in a central venous catheter. For groups that don’t do that, then you are not likely to be able to report on that measure. You are not going to be able to reap the full benefits of the quality bonus, even if you are practicing high-quality care in all other aspects of your practice.”

Two of the six hospitalist-specific quality metrics relate to heart attacks, Dr. Seymann noted.

“Most hospitalists do take care of these patients, but they can only be reported via registry or via an electronic health record, and I don’t know that all hospitalist groups have access to reporting those ways,” Dr. Seymann said. “Most folks are reporting when they submit their billing claims. That takes two measures away from them. That may significantly decrease your score, even if you are trying your best.”

While Dr. Seymann applauded CMS for the slow rollout of the MIPS program in general, “we haven’t seen great progress as far as the growth of available relevant measures for hospitalists, and I am not confident that 2 years down the line we are going to have 12 measures to choose from.”

He did suggest that hospitalists would like a greater variety of measures and want to be measured on the quality of care they provide.

“We truly believe that the majority of hospitalist groups are really heavily invested in improving the quality of care that is provided at their hospitals – that is a big part of the culture of hospital medicine in general,” Dr. Seymann said. “We want to make our ability to succeed and participate in this program as effective as we can. We want to try to minimize barriers to hospitalists hitting this one out of the park.”

SHM also noted that certain measures rarely meet the volume threshold, which could ultimately put hospitalists at a disadvantage when it comes to receiving bonus payments.

“This is not an acceptable outcome, and we strongly urge CMS to develop a solution for providers with low-volume measures, such as removing low-volume measures from the Quality category score,” SHM wrote.

Ultimately, Dr. Greeno believes the facility reporting opt-in will survive when the rule is finalized.

“We fully expect there to be a facility-based option for hospital-based doctors, including hospitalists,” he said. “So rather than reporting on physician metrics, especially metrics through MIPS, they can get rewarded or penalized based on the hospital value-based purchasing metrics for their hospital.”

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