From Volume to Value: Medicare’s New Payment Model Quality reporting takes a front seat in a new system likely to affect audiologists and SLPs in 2019. Here’s what you need to know. Bottom Line
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Bottom Line  |   May 01, 2016
From Volume to Value: Medicare’s New Payment Model
Author Notes
  • Tim Nanof, MSW, is director of ASHA health care policy and advocacy. tnanof@asha.org
    Tim Nanof, MSW, is director of ASHA health care policy and advocacy. tnanof@asha.org×
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Practice Management / Regulatory, Legislative & Advocacy / ASHA News & Member Stories / Bottom Line
Bottom Line   |   May 01, 2016
From Volume to Value: Medicare’s New Payment Model
The ASHA Leader, May 2016, Vol. 21, 26-28. doi:10.1044/leader.BML.21052016.26
The ASHA Leader, May 2016, Vol. 21, 26-28. doi:10.1044/leader.BML.21052016.26
A new method for reimbursing Medicare outpatient services will likely include audiologists and speech-language pathologists in 2019.
The new Merit-Based Incentive Payment System (MIPS) will replace a reimbursement system in place since 1997. The outgoing system, based on a formula called the Sustainable Growth Rate (SGR), is a fee-for-service model intended to control Medicare spending by triggering automatic rate cuts when budgetary limits are exceeded.
The SGR system has proved ineffective at controlling the growth of Medicare spending, as Congress has voted year after year to overturn cuts the SGR would trigger. As a fee-for-service system, the SGR has been ineffective in controlling the volume of services provided.
The 2015 Medicare Access and CHIP Reauthorization Act of 2015 transitions payments from fee-for-service to MIPS, a hybrid that includes payment incentives for quality, outcomes and efficiency. MIPS is considered a hybrid system—because it continues to reimburse providers based on volume (as in fee-for-service), but payments will be modified by aspects of quality and efficiency that promote more effective care.
How does MIPS modify provider payments?
Current Medicare incentive and penalty programs—including the Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM) and Electronic Health Record Meaningful Use (MU)—end Jan. 1, 2017. MIPS consolidates the measures of those programs into four performance categories: quality reporting, meaningful use of electronic health records, cost efficiency, and clinical practice improvement.
Quality reporting is expected to be a combination of existing PQRS measures and newly developed measures based on the National Quality Strategy—a compass for a nationwide focus on quality improvement efforts established in the Affordable Care Act—including the following domains:
  • Patient safety.

  • Patient and family engagement.

  • Care coordination.

  • Clinical processes/effectiveness.

  • Population and public health.

  • Efficient use of health care resources.

Qualified clinical data registries will help develop measures, facilitate data reporting by eligible providers, and collect data that can be used by CMS, ASHA and ASHA members.
Clinical improvement is a completely new category. The Centers for Medicare and Medicaid Services (CMS) will likely provide additional details and guidance through new regulations, but has indicated that such activities could include expanded practice access and hours, patient engagement, care coordination and patient safety assessments/screenings.
ASHA is monitoring clinical improvement developments and advocating with CMS to reduce provider response burden to the extent possible and to align other requirements—such as functional limitation reporting—with this category so that SLPs can get credit for those activities.

MIPS is designed to be a budget-neutral program—that is, it provides financial winners and losers based on performance against one’s peers.

When does MIPS go into effect?
Physicians, physician assistants, nurse practitioners, clinical nurse specialists and nurse anesthetists are required to report in MIPS in 2017; the data will affect their payments in 2019. (As with the current PQRS program, MIPS data collected in any given year affects payments two years later.)
Audiologists and SLPs—along with physical therapists, occupational therapists, psychologists and other skilled providers—are likely to begin MIPS reporting in 2019, with payment adjustments in 2021 based on their 2019 MIPS “score.”
How is a MIPS score calculated?
Each Medicare provider will receive an aggregate score of 0–100 that combines the results of the four performance categories. The categories carry different weights: quality reporting and cost efficiency each count as 30 percent of the overall score, with meaningful use weighted at 25 percent and clinical improvement activities weighted at 15 percent.
Not all providers are eligible for the current programs that MIPS will replace—audiologists and SLPs, for example, are not eligible for the existing MU and VBM programs—and therefore will not be eligible for some of the new MIPS categories. In those cases, CMS will rebalance MIPS calculations according to the categories in which the providers are eligible to participate.
However, CMS is working with ASHA and other stakeholders to allow currently ineligible providers to participate in all of the MIPS categories. This issue contributed to the decision to delay MIPS participation for many non-physician providers, including ASHA members.
How will MIPS scores be used?
CMS will use the MIPS score—based on the provider’s performance in the four designated categories—to modify the provider’s payments and to encourage quality improvement. The ultimate goal is to increase quality care for beneficiaries and increase payments to the highest-quality providers.
CMS will publically report MIPS scores, just as it now reports quality information on the Physician Compare website. Consumers, other health care providers and insurance plans will be able to find the MIPS score of all eligible providers.
What are the payment incentives and penalties?
MIPS payment incentives and penalties far exceed those of current quality measurement programs. The adjustments grow over time, but payment adjustments in 2021 (when audiologists and SLPs will most likely participate, based on 2019 reporting) could increase by as much as 21 percent and decrease by as much as 7 percent from base fee schedule payments.
MIPS is designed to be a budget-neutral program—that is, it provides financial winners and losers based on performance against one’s peers. Providers performing at the 50th percentile will receive the base fee-schedule rate. High performers will see payment increases and low performers will receive penalties.
Providers who already participate in Medicare-recognized alternative payment models, such as accountable care organizations and demonstration projects, automatically receive the maximum MIPS payment as a way to encourage providers and health care systems to adopt alternative payment methods.
What is ASHA doing to prepare for MIPS?
ASHA’s Health Care Economics and Advocacy Team is working closely with ASHA’s National Center for Evidence-Based Practice in Communication Disorders to advocate for members’ interests and to ensure that members can meet MIPS requirements. To that end, ASHA is developing qualified clinical data registries for audiology and for speech-language pathology. Members would use these registries to report MIPS quality measures directly to CMS).
CMS recognition of ASHA registries for audiology and speech-language pathology also allows ASHA to develop meaningful quality measures that better capture the value of members’ services within the health care system. The measure development flexibility allowed within a qualified clinical data registry can help drive best practices in audiology and speech-language pathology and give clinicians meaningful feedback on the quality of their care and patient outcomes.
ASHA will build its new registries from its experience with and member participation in the National Outcomes Measurement System (NOMS), which has been operating for more than 15 years. The speech-language pathology registry will incorporate some of the functional communication measures that NOMS has collected and additional measures based, in part, on the six National Quality Strategy domains. A similar audiology platform is being developed, with input from audiology members to incorporate measures most meaningful to audiology practice. Both registries will also consider including current PQRS measures.
ASHA also plans to develop educational materials and training for members. CMS will likely issue additional guidance and regulations that will help inform the development of those educational materials and resources well before the 2019 reporting year.
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May 2016
Volume 21, Issue 5