PQRS Meets MACRA: Help is On the Way!!

Allan L. Klein, MD, FASE, FRCP (C), FACC, FAHA, and FESC
The ASE is a great organization that has been around for 41 years and is committed to excellence in cardiovascular ultrasound through its focus on education, advocacy, research, and innovation . Over those years, there have been many accomplishments in the evolution of echo including 3-D, strain imaging, and contrast echo. At the same time, there has been an evolution of our healthcare system that is shifting from a volume-based to a value-based system that will impact our society. The overall goal of this healthcare reform is to improve patient outcomes, decrease costs, and improve the health of populations. To adapt to these challenges, ASE has organized a strong advocacy committee that “advocates” for its members in these changing times. This president’s page is a primer about the basics of advocacy, and the new realities that we are facing as an organization.

My medical degree did not prepare me for the alphabet soup of acronyms out there. As a start, there are many unfamiliar terms that we have to get up to speed on. This includes CPT (not CCTV), RUC (not Rock), PFS (not PMS), HOPPS (Not IHOP), MACRA (not Macarena), MIPS (not Hips), APMs (not ATMs), and many more…

Our advocacy committee includes very strong leadership at the top including Drs. Michael Main and Peter Rahko as well as our ASE staffer “par excellence” Irene Butler and our experienced committee members. The committee’s focus is on regulatory and legislative issues which is supported by our consultants, Denise Garris, Diane Millman, and Peggy Tighe. Each of these experts are responsible for their domains. Now let’s discuss the key issues.

What is CPT © ? CPT © stands for C urrent P rocedural T erminology which are codes from the American Medical Association (AMA) that provide a standard language that describes medical, surgical, and diagnostic services. There is a CPT © editorial panel made up of 17 members that assess new codes. The newer codes affecting echo include interventional echo, strain, and myocardial perfusion. New CPT © codes pass through this board, and if approved then goes to the RUC.

What is the RUC, and how does it work ? RUC stands for the R elative value scale U pdate C ommittee which is part of the AMA. It is an independent body of 31 volunteer physicians that decide the relative value of Medicare allowed charges for C enters for M edicare and Medicaid S ervices (CMS) Physician Fee Schedule. The Resource-Based Relative Value Scale (RBRVS) decides how payments are made to physicians based on the resource costs to provide them. These costs are dependent on physician work and practice expenses as well as professional liability. Drs. Main and Geoffrey Rose are current “rock star” ASE RUC advisors. Working closely with our ACC colleagues, they make detailed and very high level presentations to the RUC supporting adequate payment for transthoracic echo, stress echo, and TEE codes. This information then goes to CMS who make the final call. Sounds like the “Supreme Court.” To date, there have had many wins for our excellent team in keeping our codes and the “echo room” being adequately reimbursed. What can our members do to help? First make sure you join the AMA since ASE needs to have a substantial number of ASE members to also hold AMA membership in order to maintain our current status. Also if new surveys are proposed, please take a few minutes to thoughtfully complete them adequately since your input is critical to ensuring appropriate valuation for services. If only a few surveys are received, it may compromise the results. Please do not forfeit you opportunity to contribute to this process. Don’t forget to “RUC the vote!!”

What is PFS? PFS stands for the P hysician F ee S chedule and refers to Medicare Part B payment for physician services based on relative value units, conversion factors, and geographic practice cost indices. Based on the RUC recommendations to CMS, our transthoracic echo and stress echo codes have been evaluated and will have a new fee schedule (the normal trend is to lose value over time) and start in 2018. Current trends that could affect these payments will include bundling of services as well as implementation of MACRA (see below) as well as “appropriate use” of AUC criteria.

What is HOPPS? HOPPS stands for the H ospital O utpatient P rospective P ayment S ystem and is the hospital outpatient prospective payment system that classifies all hospital outpatient services into Ambulatory Payment Classifications (APC’s), similar to Diagnosis Related Group’s (DRG) for inpatient services. Recently, CMS proposed restructuring all imaging Ambulatory Payment Classifications (APCs) which would have led to a potential catastrophic decrease (-37%) in the payment for contrast echo. ASE and ACC met with CMS and proposed an innovative alternative APC grouping methodology intended to preserve adequate reimbursement for contrast-enhanced echocardiography, while not increasing the cost to Medicare. Due to our strong advocacy efforts, those of our industry partners, ACC and several other organizations, CMS did implement our proposal. We are incredibly proud that this victory will ensure adequate reimbursement for contrast-enhanced echocardiography and, most importantly, that patients will continue have access to the necessary care they need.

What is MACRA, and when will it be implemented? MACRA stands for M edicare A ccess and C HIP Reauthorization A ct from 2015 and this will dramatically change the way physicians are being paid from a previous volume -based to a quality-based health care model based on value. There will be two tracks for payment: A M erit-Based I ncentive P ayment S ystem (MIPS) which adjusts payments based on pay for performance or the other track called Advanced A lternate P ayment M odels (APMs) as in ACO’s, patient centered medical homes or a comprehensive ESRD model. Most physicians (about 90% of specialists) will be evaluated under the MIPS system and will be paid accordingly for their performance. The four categories of performance in 2017 will be quality (weighted 60% and this replaces PQRS and is based on six measures of quality), resource use (weighted 0% and replaces Value-Based Modifier Program), advancing care information (weighted 25% and this replaces the Medicare EHR Incentive Program and include four elements), and Clinical Practice Improvement Activities, (weighted 15% and includes four activities). However, this weighting system will be modified with time. Dr. Rose recently gave an excellent ASE webinar on MACRA and its implications (archived on ASEUniversity.org and on our MACRA webpage), and this topic was discussed further in detail at our ASE November 2016 retreat. Reporting information collected in 2017 will impact reimbursement in 2019. The 2017 reporting period CMS has multiple options for participation. It will be important to understand the reporting requirements and scoring methodology of MACRA and how it will affect echocardiographers and echo labs. More information on this can be found on ASE’s MACRA webpage. There will be “winners and losers” in MACRA and hopefully, you will be a winner!

What are CMS Bundled Payments? They are initiatives linking the payment of all providers involved in delivering an episode of care intended to lead to higher quality and more coordinated care at a lower cost to Medicare. CMS is working on a number of demonstration projects, such as acute myocardial infarction and coronary artery bypass surgery. This project will start on July 1 st , 2017, and its goal will be to provide better coordinated and high quality of care at lowered costs. The final changes in this bundled care model remain to be seen. ASE is committed to demonstrating the value of echocardiography and best position echocardiography in this new, and evolving, payment structure.

ASE is very fortunate to have an outstanding advocacy committee with strong leadership, ASE staff, and consultants that will have our back navigating this winding road of health care reform from PQRS to MACRA. It is a good thing that ASE advocates for its members. Now back to studying the alphabet soup of acronyms ….TUVWXYZ

Allan L Klein, MD, FASE, FRCP (C), FACC, FAHA, and FESC, is the Director of the Center for the Diagnosis and Treatment of Pericardial Disease and Staff Cardiologist at the Cleveland Clinic and Professor of Medicine at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University.

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Apr 15, 2018 | Posted by in CARDIOLOGY | Comments Off on PQRS Meets MACRA: Help is On the Way!!

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