News and noteworthy information for October 2018

• CMS conducts field tests of outcomes for musculoskeletal conditions and procedures, including Lumbar Spinal Fusion
• ISASS meets with The Centers for Medicare and Medicaid Services (CMS) to review physician reimbursement for minimally invasive spine surgical procedures
• Leapfrog Group Expands Performance Ratings to Outpatient and Ambulatory Surgery Centers
• Department of Health and Human Services 2019 Budget Signed Into Law

CMS conducts field tests of outcome cost measures for musculoskeletal conditions and procedures

The Centers for Medicare & Medicaid Services (CMS) and its contractor, Acumen LLC, have been conducting field testing for 13 cost measures before consideration of their potential use in the cost-performance category of the Merit-based Incentive Payment System (MIPS) of the Quality Payment Program in 2020 or beyond. These measures were developed with input from members of ISASS and other medical specialty societies.

Field testing is an opportunity for clinicians and other stakeholders to provide feedback on the measures. Feedback shared on the draft measure specifications will be used to consider potential refinements.

Clinicians and clinician groups that meet the minimum number of cases (episodes or beneficiaries) outlined below will receive a future Field Test Report via the CMS Enterprise Portal with information about their cost performance:

• 10 episodes for at least one of the 11 episode-based cost measures
• 35 episodes for the Medicare Spending Per Beneficiary (MSPB) clinician measure
• 20 beneficiaries for the Total Per Capita Cost (TPCC) measure

Field Test Reports and supplemental documentation will be available for the following measures currently under development:

• Acute Kidney Injury Requiring New Inpatient Dialysis
• Femoral or Inguinal Hernia Repair
• Elective Primary Hip Arthroplasty
• Hemodialysis Access Creation
• Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
• Lower Gastrointestinal Hemorrhage
• Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
• Lumpectomy, Partial Mastectomy, Simple Mastectomy
• Non-Emergent Coronary Artery Bypass Graft (CABG)
• Psychoses/Related Conditions
• Renal or Ureteral Stone Surgical Treatment

ISASS members who are part of the field testing and have not yet provided input can provide feedback on the draft measure specifications, Field Test Report format, and supplemental documentation through this online survey through October 31.

• All survey questions requesting feedback will be optional
• You may attach a comment letter (as a PDF or Word document) in addition to, or as an alternative to, responding to the survey questions
• The link to the survey, which does not require a login, will be included in the field test reports and supplemental documentation so that you will be able to navigate to it easily from the documents you review.

In addition to the Field Test Reports, stakeholders may review a number of supplemental documents, which are available for download on the CMS MACRA Feedback page. Supplemental documentation includes:

• Draft Measure Methodology for each measure
• Draft Measure Code Lists with specifications for each measure
• Episode-based Cost Measure development process document
• Mock Field Test Report for each measure
• Fact Sheet with an overview of field testing
• Frequently Asked Questions document
• User access guide with guidance on how to access your report through your CMS
• Enterprise Identity Management account

SUMMARY OF THE LUMBAR SPINE FUSION FOR DEGENERATIVE DISEASE, 1-3 LEVELS EPISODE-BASED COST MEASURE

The episode-based cost measures under development for potential use in the Quality Payment Program evaluate a clinician’s cost for the episode group by averaging their risk adjusted costs across all episodes attributed to the clinician during the measurement period. The cost of each episode is the sum of the Medicare Parts A and B costs for clinically related items and services as determined by input received from a measure-specific workgroup, consisting of clinicians with relevant expertise. These services can include those performed by the attributed clinician as well as other healthcare providers during the episode window.

The cohort for this cost measure consists of Medicare beneficiaries, excluding beneficiaries for whom the following conditions apply:

• The beneficiary has a primary payer other than Medicare for any time overlapping the episode window or 120-day lookback period prior to the trigger day.
• The beneficiary was not enrolled in Medicare Parts A and B for the entirety of the lookback period plus episode window or was enrolled in Part C for any part of the lookback plus episode window.
• No main clinician is attributed to the episode.
• The beneficiary’s date of birth is missing.
• The beneficiary’s death date occurred before the episode ended.
• The episode trigger claim was not performed in an ambulatory/office-based care, IP hospital, OP hospital, or ASC setting based on its place of service.
• The IP facility is not one that is paid under the Inpatient Prospective Payment System (IPPS) when an IP stay concurrent with the trigger is found.

Measure Name: Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels Episode-Based Cost Measure

• Description: The Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo surgery for lumbar spine fusion during the measurement period.
• Input Received to Date: The Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels measure has been developed with input from the Musculoskeletal Disease Management – Spine Clinical Subcommittee and Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels measure-specific workgroup, which were convened in April and will continue to meet until December. The Subcommittee comprises 22 individuals affiliated with a total of 19 specialty societies, while the workgroup comprises 13 individuals affiliated with a total of 13 specialty societies. Clinical Subcommittees set the overall direction of measure development, choosing the measures to develop and providing input on the composition of workgroups. The workgroups provided detailed input on each component of the cost measure that the Clinical Subcommittee selected for development.
• Components: The components for the Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels measure are as follows:
  • Defining the episode group: A Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels episode is triggered by the CPT/HCPCS codes 22558, 22612, 22630 and 22633, excluding services associated with revision surgery. An episode will not be triggered when the trigger code occurs with certain diagnosis exclusions as determined by the measure-specific workgroup, or if it occurs during an IP stay without a relevant Medicare Severity Diagnosis Related Groups.
  • Attributing the episode group: For this procedural episode group, an attributed clinician is any clinician who bills a trigger code for the episode group on the day of the procedure.
  • Assigning services to episode costs: Only services that have been determined to be clinically related to the episode (based on input from the workgroup) are included in episode costs. Services are assigned beginning 30 days before the trigger through a post-trigger period up to 90 days after.
  • Risk adjusting: The Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels cost measure accounts for case-mix severity using a risk adjustment model based off of the CMS Hierarchical Condition Category Version 22 (CMS-HCC V22) 2016 Risk Adjustment Model and supplemented with additional episode group-specific risk adjusters informed by the workgroup’s input. Along with this, certain high-risk populations are excluded from the cost measure calculation to make the patient population more homogenous.

 

ISASS meets with CMS to discuss potential misvaluation of minimally invasive spine surgical procedures, submits comments in the Medicare Physician Fee Schedule

On October 22, 2018, ISASS held a face-to-face meeting with officials at the Centers for Medicare and Medicaid Services (CMS) headquarters in Baltimore.

ISASS was represented by Morgan Lorio, MD, chair of the ISASS Coding and Reimbursement Taskforce, and CMS was represented by Carol Blackford, the Director, Ing-Jye Cheng Deputy Director for the Office of the Department of Hospital and Ambulatory Policy Group (HAPG), and other officers in the Outpatient Care, Practitioner Services and Ambulatory Services Divisions, including Gift Tee, Acting Director Division of Practitioner Services, Marge Watchorn, Deputy Director Division of Practitioner Services, and Ryan Howe, Director Division of Ambulatory Services.

ISASS presented information regarding the misvaluation of minimally invasive spine surgical services in the Medicare Physician Fee Schedule and the increased costs and decreased patient benefits that result from these errors in valuation. The meeting was an important opportunity for ISASS to continue to advocate for proper payment for efficacious and less invasive spine surgery options on behalf of patients suffering from spine and disc conditions and seeking a full array of treatment options that best suit their needs as patients.

CMS officials indicated a significant interest in collaborating with ISASS to improve care for Medicare beneficiaries and invited Dr. Lorio and others to continue to regularly interact and continue their dialogue with them in future rulemaking comment letters and face-to-face meetings.

 

Leapfrog Group Expands Performance Ratings to Outpatient and Ambulatory Surgery Centers

Leapfrog Group will start publishing safety and quality performance of hospital outpatient surgery departments and ambulatory care centers in 2020, the group said on October 16, 2018.

Like its hospital safety grades, the outpatient data will be available to the public. Leapfrog will ask the centers to voluntarily submit performance data. The group has asked centers for input on which questions it should ask on the surveys.

Outpatient procedures have become more popular in recent years, but it’s hard to gauge performance quality. More than 23 million surgeries are performed annually at ambulatory care centers, but the CMS only requires they publicly report four quality measures. The White House recently approved an HHS plan to launch a patient safety database for ambulatory surgery centers.

Leapfrog’s Hospital Survey will include a new section for data from hospital outpatient surgery departments.

Ambulatory care centers will likely have to submit infection rates, medical and nursing staff information, procedure volume, outcomes data and patient experience results.

Leapfrog will limit the first year of published surveys to 250 ambulatory care centers and assess the results for potential adjustments. Leapfrog expects that centers will be eager to participate in Leapfrog’s grading system because the centers now don’t have a way to show patients and employers how they perform in an unbiased way.

 

Department of Health and Human Services 2019 Budget Signed Into Law

President Trump on September 29. 2018 signed into law the 2019 Department of Health and Human Services (DHHS) budget. The budget provides $90.5 billion in discretionary funding for HHS, an increase of $2.3 billion from the prior year.

National Institutes of Health (NIH): The NIH will receive $39.1 billion, an increase of $2 billion from the prior year, including:

• $2.3 billion for Alzheimer’s disease research, up $425 million from the prior year, which would exceed the $2 billion funding goal for the National Plan to Address Alzheimer’s disease for the first time.
• $550 million to combat antibiotic resistant bacteria, increase of $37 million.
• $429.4 million for the BRAIN Initiative to map the human brain, an increase of $29 million.
• $140 million for research on the universal flu vaccine, a $40 million increase.

Fighting Opioid Abuse: This section provides $3.7 billion for the Centers for Disease Control (CDC) and other agencies to fight opioid abuse, an increase of $145 million from the prior year including:

• $1.9 billion for the SAMHSA’s State Opioid Response Grant, which includes a 15 percent set-aside for states with the highest opioid use disorder mortality rate and $50 million set-aside for Indian tribes and tribal organizations.
• $500 million for research related to opioid addiction, development of opioid alternatives, pain management, and addiction treatment.
• $476 million for CDC opioid overdose prevention and surveillance programs, and a public awareness campaign.

Affordable Care Act funding: No new funding was provided for the Affordable Care Act (ACA, commonly known as Obamacare) but does include the following oversight provisions:

• The risk corridor program, which compensates health insurance plans that lose money, would have to be operated in a budget neutral manner so no appropriations could be used as payments to insurers.
• The Centers for Medicare and Medicaid Services (CMS) would be required to notify relevant congressional committees two business days before any ACA-related data or grant opportunities are released to the public.
• ACA-related spending would have to be classified by category since its inception, and information about employees, contractors, and activities involved in administering Obamacare would have to be published.