Hello and welcome. This is episode nine of The Beat entitled, Understanding the Evolution of the Centers for Medicare and Medicaid Services, or CMS. I'm your host and co-moderator, Dr. Sandeep Saha. I'm a cardiac electrophysiologist at the Oregon Heart Center in Salem, Oregon. It is my pleasure to welcome you all to this webinar. This webinar is designed to provide an overview of CMS, including Medicare's Part A and B, along with the transition from the fee for service to the value-based payment system. This is the second session of the health policy webinar series developed by the Heart Rhythm Society's Health Policy and Regulatory Affairs Committee. I am one of the members of the Digital Education Committee, and I have the pleasure of introducing my co-moderator, Dr. David Slotweiner, from the Health Policy Committee of the Heart Rhythm Society. Dr. Slotweiner is the Chief of Cardiology at New York Presbyterian Queens Hospital located in Flushing, New York. He received his medical degree from the University of Chicago Pritzker School of Medicine, and then completed his internship in general medicine, internal medicine, cardiovascular disease, and cardiac electrophysiology fellowships at New York Presbyterian Hospital. Dr. Slotweiner is both certified in cardiovascular diseases and clinical cardiac electrophysiology, and specializes in heart diseases, including congenital heart disease, coronary artery disease, heart rhythm disorders, and heart failure. It also gives me great pleasure to welcome our speakers for this webinar. Our first speaker is Rachel Grohman, who is part of the Heart Health Strategies Incorporated team, started in this position in 2012. Prior to joining Heart Health Strategies, she served as the Senior Manager for Quality Improvement and Research at the American Association of Neurologic Surgeons and the Congress of Neurologic Surgeons. And in this role, she managed strategic planning and policy advocacy activities related to healthcare delivery and payment reforms, focusing on quality improvement, including performance measurement and patient safety initiatives, value-based purchasing, public reporting, shared savings, and bundled payment initiatives, health information technology adoption, and comparative effectiveness research. She regularly interfaced with federal officials, as well as health plan and other private industry leaders, and in that position, represented neurosurgery on various multi-stakeholder quality coalitions. Welcome Rachel. I also have the pleasure of welcoming our second speaker, Mr. Robert Jesik, who is currently the Vice President for Coverage and Payment Policy with Heart Health Strategies Incorporated. Prior to joining Heart Health Strategies, he served as the Deputy Director for Regulatory and Quality Affairs in the American College of Surgeons Division of Advocacy and Health Policy. In this position, he led ACS efforts to analyze and influence federal regulations and helped shape the value-based purchasing and quality programs being incorporated in federal reimbursement formulas. For several years, he also served as the Senior Regulatory Advisor at the American College of Orthopedic Surgeons. He received his law degree from Emory University in Atlanta, Georgia, and completed his bachelor's degree at the University of Michigan. And our other speaker, Rachel Grohman, earned her master's in public health with a focus on health policy from the George Washington University and a bachelor of arts in political science from the University of Michigan. So welcome to our speakers. And now I'm going to hand over the reins to my co-moderator, Dr. David Slotbeiner. Thank you so much, Dr. Saha, for the kind introductions. In a moment, I'll go over the learning objectives and just some background information for this webinar. I just wanted to say, on behalf of the Health Policy Committee at HRS, some of the philosophy behind this health policy webinar series. I think the members of HRS have particularly come over the past 18 months to appreciate the importance of advocacy and understanding the health policy environment with our recent experience with the ablation codes. And we on the Health Policy Committee and Reimbursement and Regulatory Affairs Committee have understood the importance of this and are very interested in developing talent from within our membership to help us on the committee. And that really is one of the key drivers behind this webinar series. So I'm really delighted today to be able to hear from Bob and Rachel from Heart Health Strategies since I started in this area at HRS, which I think was about 2010. I've learned an enormous amount from Heart Health Strategies. And I know you've been working closely with HRS for well over 15 years, probably over 20 years. And it's been a great partnership. And so I really look forward to learning from you both tonight. Let me just go over the learning objectives. At the conclusion of this webinar, participants should be able to describe how CMS has evolved and expanded since enacted as a Title 18 and Title 21 of Social Security Act of 1965, describe how Medicare uses, or CMS uses, the rulemaking process to set payment rates and determine policies, and discuss why CMS is transitioning from fee-for-service to a value-based reimbursement system. There are another learning objective slide, or is that the only one? If not, then I'll give. Materials developed by Heart Health Strategies, Inc. are intended for informational purposes only and are not intended to serve as legal advice for internal organizational use only. Do not distribute or make available in the public domain. Okay, and before I turn it over to Bob, just a word of advice. All the participants are muted, so we ask that you please submit any questions in the Q&A box at the bottom. Dr. Saha and I will be monitoring that. Bob and Rachel are each going to speak for about 15 to 20 minutes, and then we've left the remainder of the time for questions, and so we'll be reviewing those questions and teeing them up afterward. So let me turn over now to Bob. Thank you, Bob. Thank you. Thank you, Dr. Slotweiner. Thank you, Dr. Saha. Good evening, everybody. Thanks for taking some time out of your evening or afternoon, depending on where you are, to join us, or if you are logging in and reviewing the recording of this, thanks for doing that as well. Rachel and I are going to walk you through the Centers for Medicare and Medicaid Services, sort of how it came to be, and sort of what their portfolio is. As we go through it and talk a little bit about the history and the mechanics of this, the reason that we discussed doing this webinar tonight and to really talk about the big picture of the agency is to make sure that when it comes to advocacy efforts, that you're familiar with the environment that you're operating in. A lot of times, you have to get involved. Your clinical input as physicians is incredibly important to shaping policy, but sometimes you're sort of thrust into it, and it's not what you do on a day-to-day basis. And so what we wanted to do today was really just make sure that you sort of understand the atmosphere and the environment, that all of these decisions that are being made that affect your practice on a daily basis, but that you might not always get to spend a lot of time thinking about and looking into. So we wanted to sort of lift up and explain really sort of how the puzzle pieces fit together and also how it's changed over time to help you feel like you can kind of use the same terminology and language that the agencies use when they're making decisions about you and your patients. So with that, we're going to dive into the presentation. We've broken it into two sections. One is really about the role of the agency in setting reimbursements, and we're going to break Medicare down a little bit. I know we talk a lot about, you hear a lot about A&B, but I really wanted to show you some statistics and some graphics that really put into perspective the role of physician services relative to all the other spending that happens in Medicare, particularly as I'm sure you have heard a lot about. Physician payments will continue to be under a lot of pressure because of federal budgetary rules over the next couple of years and sort of how does that fit with everything else that's happening in Medicare. And then after I talk for a few minutes on that, then I'm going to turn it over to Rachel, and Rachel's going to talk about CMS's role in incorporating quality and value into their reimbursement system and creating incentives and in some instances disincentives. So that's our plan for the evening. What I wanted to start out with, and for those of you that have been following this for a while, it will be old news, but just to make sure we're all on the same terrain here, I wanted to talk a little bit about the history of the programs. And put together a timeline here, what you're looking at is really the introduction of the different insurance programs, the Medicare benefits that have been enacted and how it all happened over time, as well as the way that the agency has sort of morphed in order to administer it over time. So if we go back all the way to 1953, some of you might recall the name of the department that was heading all things healthcare up, and it was the Department of Health Education and Welfare. That predated the introduction of Medicare and Medicaid. That was back after Social Security. Then Medicare and Medicaid are enacted in 1965. So you may often see materials from the agency come out. It's birthday, Medicare's birthday is July 30th. So we're getting ready to see the 58th birthday. There's always a lot of sort of PR around that. So you can have that to look forward to next month. But that's the year that it was enacted. That really changed the landscape of health insurance coverage. Obviously, the payments and the mechanisms that are attached to Medicare and Medicaid will spill over into other insurance products to commercial products. So it all sort of maps back to this point in time, the influence that the federal programs had on health insurance coverage and payment. In 1973, something interesting happened that I just wanted to flag. We spend a lot of time these days talking about Medicare Advantage, right? The private, privately administered plans that are administering Medicare benefits. I just wanted to highlight here, this isn't Medicare Advantage per se in name. But you can go all the way back to 1973 when HMOs are starting to be involved to administer Medicare benefits. So the private insurance market administering care for these federal programs is a little bit older than sometimes we think. Again, it wasn't in the Medicare Advantage form that we know now. But it does go back a while. Then in 1977, we get the Healthcare Financing Administration. So this is under the Department of Health and Health Education and Welfare at the time. And really, it is the department that then is tasked with administering these programs. This is the agency that really is getting involved in the sort of mechanics and the nuts and bolts of reimbursement for Medicare. In 1980, just so we keep all of our terminology straight, that's the year that HEW turned into the Department of Health and Human Services. So HHS that we all know now, that's when it comes into being and takes the place of its predecessor department, HEW. So that was 1980. Then over time, and we're not going to talk a lot in detail about all of these things, but I did want to highlight that the nature of the Medicare benefit and health insurance coverage, federal health insurance coverage, starts to change and expand over time. So in 1983, we see the introduction of the Medicare Hospice Benefit. We know how that's changed over time. 1997, the Children's Health Insurance Program is introduced. Really reducing the number of uninsured children in the United States. A lot of children had remained uninsured, and this really created a new mechanism for covering those individuals. So that's in 1997. 2001, we have another name change. We might be getting into terrain that some of you are familiar with. I am. I was over at the agency at that point. But HCFA, the Health Care Financing Administration, changes to the Centers for Medicare and Medicaid Services. So that's when we start referring to the agency, the sub-agency that's administering all of this as CMS. 2003, prescription drug coverage is introduced. So previous to this, Medicare only covered inpatient drugs. So if you were hospitalized, if you were otherwise institutionalized, then it was, but there was no outpatient drug coverage. And so this was a big, big change that I think we've gotten used to now, but it's hard to believe how not long ago that didn't even exist. And then, of course, most recently, the Affordable Care Act passed in 2010. Not Medicare-related, but a federal marketplace for exchange plans to, again, try and bring the uninsured down. And I mention it, whether it's the exchange programs, whether it's the Medicare Part D drug coverage programs, whether it's CHIP, whether it's the hospice benefit, it's CMS that's administering all of those programs. So inside of the Department of Health and Human Services, you have the Centers for Medicare and Medicaid Services involved in all of those different benefits that are available because of federal legislation and federal regulation. So now, on this timeline, it's a little bit shorter here, but what I wanted to emphasize is that as those benefits were introduced and as the agencies were implementing them, they have to figure out, obviously, how to reimburse for the services that are received in them. Way back when, when it all started, it was essentially a charge-based system, reasonable charges for your services. But as that sort of turned into a really big budgetary item for the federal government, and so along the way, methods to try to control that were introduced. So one of the first examples of that at the far left is the introduction of the Inpatient Prospective Payment System, the IPPS for hospitals. This is sort of the lump sum, right? Hospitalization. We are familiar with DRGs now. There's one payment, no matter how long you're there, with certain exceptions. But the idea is that they start sort of price-setting, for lack of a better word. This is how much we believe it should cost to treat this type of patient with this type of condition. 1983 is when Medicare starts to play with those sorts of systems. That was limited to hospital inpatient payments. And then in 1989 is when the fee schedule is administered under the Resource-Based Relative Value Scale, the RVRVS. This is the RVU system that we all know, maybe don't love, but we all know. And that was introduced in 1989. One of the things that I would keep in mind about that and why that's an important moment of time is that was sort of the original valuation of all of the services, at least all of the services that existed at the time. There are some services that haven't been revalued since then. You'll hear references back to when the system was created and their original valuation. So this just sort of gives you a visual of that moment in time and how everything since then for the Medicare Physician Fee Schedule has basically been updating what was implemented there in 1989. So that is an important part on our timeline. Then if we go back to the top of the arrow, you see the Balanced Budget Act. Here we have the introduction of additional prospective payment systems. So now inpatient rehab facilities have a PPS, skilled nursing facilities, home health. This all happens in 1997. So you're starting to see an expansion of these mechanisms, these payment mechanisms or reimbursement methodologies that are designed to contain costs, to hopefully measure resource use accurately. I think we have questions about whether that's true, but at the same time to contain costs. Then 1997 comes along. The Sustainable Growth Rate Formula. It's something that some of you are probably familiar with from past advocacy efforts. It was sort of the cloud that was hanging over our head every year. The Balanced Budget Act, that same legislation that brought those prospective payment systems also implemented the Sustainable Growth Rate Formula. I won't go into too much detail about it, but basically what it did is it set spending and utilization targets for the Medicare Physician Fee Schedule. And updates for subsequent years were predicated on those targets. And so if overall fee schedule spending or utilization was under that target, then there might be a payment increase. If you went over the targets, not you as an individual, but the entire Medicare Physician Fee Schedule, then that would sort of be clawed back or a reduction of the conversion factor the following year to try and level set to where sort of the target spending was for the Medicare Physician Fee Schedule. So that gets implemented. For a couple of years, everything's going along fine. And then certain parts of Medicare Physician Fee Schedule spending and utilization just sort of skyrocket and we blow past those targets. There is a point in time at which there was a payment reduction that was levied on the Medicare Physician Fee Schedule. But then after that, there were payment cuts that were perceived to be, and a lot through the advocacy of you all and other medical societies, that the cuts were unsustainable, that the physicians could not maintain their practices with Medicare reimbursements being cut at the levels that they were slated to be cut. Congress would come in every year and they would try to patch that. Sometimes they would pay for it. So if you were gonna be subject to a 2% across the board cut, Congress would pay for that and sort of wipe the slate clean. But as this kept happening, it started to turn into another big budgetary item. And so what they would do, what Congress would do, is instead of sort of paying for avoiding that cut, they would tack that cut onto the end of a 10-year budget window or outside of that bill. And so basically what was happening was these cuts were starting to compound. And it was getting to the point where there were, at the end of the sort of safety zone that Congress had created for us, there would be 10, 20% cuts that were hanging over our head and it just became untenable. And so in 2015, after a lot of advocacy and a lot of pushing and a lot of weariness on the part of members of Congress of having to come back and fix this every year, the Medicare Access and CHIP Reauthorization Act, MACRA, came along. And what that did first and foremost was it wiped out the sustainable growth rate formula. So now there is no sort of generalized spending target that the Medicare physician fee schedule has to live within. And in addition to that, which we will hear more about from Rachel, it introduced a payment consequence to quality reporting and performance on measures. And so this is for the fee schedule, a big turning point in the way that quality and cost are going to affect physician payments. And we'll talk more about that. So that's really the history of sort of how we got to where we are today. Before we dig into sort of that where we are, I also just wanted to put the physician fee schedule into the context of the rest of the Medicare program and Medicare benefits. So we hear a lot about part A, part B, part C, part D. Just a quick overview of what we mean when we say that. And a couple of important takeaways, I think. First of, and inside of each of these, there are different financing mechanisms. So you hear a lot about the trust fund and general revenues funding some of this, premiums fund these different parts of Medicare in different ways. We're not gonna get into that today, but just know that that's part of the consequence of being part A or part B or part D. But part A, you can see really, and to keep it straight in my head, I really think of it sort of as the institutional payments for the most part, where your facility-based payments, the payments to the facility. So hospital inpatient, inpatient rehab, skilled nursing facility, hospice benefit, and home health when home health is after a hospital stay. Part B is a lot of times I think used as a synonym for physician fee schedule spending, but it's really important to note that there is a lot more that's inside of Medicare part B. So there's a lot of part B spending where part B is getting bigger that is not due to the Medicare physician fee schedule. And so you wanna make sure that nobody, that policymakers and stakeholders are not sort of putting that Medicare part B in Medicare growth. It doesn't have anything to do with sort of the physician fee schedule onto your shoulders when we run into reimbursement issues. So there are hospital payments in that, right? The hospital outpatient payments come out of part B. Ambulatory surgery center payments are paid out of part B. Home health, when it's not post-hospital stay is part B. DME is part B. The whole lab fee schedule is part B and also physician administered drugs. You think of the sort of in-office drugs, rheumatology, oncology, those types of drugs are also part B and separate from the Medicare physician fee schedule. So a lot of things going on inside of part B. Just to be sort of thorough here, part C if you ever hear it referred to, that's the sort of statutory reference to Medicare Advantage. Before Medicare Advantage, it was called Medicare Plus Choice. And this is sort of the private format of Medicare. And if you have Medicare Advantage, it sort of combines the A and B benefit along with an outpatient drug benefit. And then part D is the standalone outpatient prescription drug coverage we talked about. So an individual might have parts A, B, and D or part C, but you're not gonna have C and the rest of them. But if you ever hear of part C, it's Medicare Advantage. That's what folks are talking about. One other thing before we leave this slide that I wanted to mention, inside each of those little arrows that describes the part of the benefit that's covered, there's a different payment system for each of those. And inside of that payment system, whether it's a prospective payment system like the inpatient prospective payment system, whether it's fee schedule based, like for physician services, they each sort of live in their own little silo. And so savings to one does not accrue to another. So if you're avoiding hospitalizations and the inpatient spending is going down because of that, there is no benefit for that. There's no way to account for that inside of the physician fee schedule. They're each sort of operating independently from each other for the most part. And that goes for Medicare Part B, all of those different Medicare Part B services too. So physician services are operating on a different reimbursement mechanism with different targets and rules than hospital outpatient, for example. So focusing in a little bit more on the Part B piece of this, you'll see that what I put at the top of the slide here, Medicare Part B spending is more than just the Medicare physician fee schedule. So when you look at the way that they break down spending, they're sort of the institutional Part B services that are covered. So hospital outpatient lab, and then you have the practitioner-based services they're referred to as. So the physician fee schedule to MIPOS, as we talked about. So you can see that the institutional payments are a large part of Part B and that the physician fee schedule is just a piece of the orange slice of the pie here. And it's not quite 50-50, but the fee schedule doesn't make up as much of Part B as a lot of folks think that it does. This is taken right from the trustee's report. In the trustee's report, since they are focused on the solvency of Medicare, they also look at, make estimates about the future. These pie slices are gonna flip in 2028. So in 2028, the practitioner side, let alone physician fee schedule, that won't even be the biggest part of Part B anymore. The institutional hospital side of that is gonna take over. Also, if you look here at the growth of each of these different components of Part B. So the B is the fee schedule increase for each of these year-over-year changes. The orange is hospital Part B and the gray is Part B drugs. You kind of ignored 2019 to 2021, because obviously we've got some volatility there from COVID. You can see how little physician fee schedule spending overall is growing compared to these other parts of Part B. But you wouldn't know it from all of the pressure that keeps getting placed on annual updates for the physician fee schedule. Here, if you look at it from the 10-year window that the trustees took a look at, fee schedule from 2013 to 2022, total spending only increased by a little bit over 2%, right? Part B drugs doubled. Hospital outpatient grew by over 60%. All of those payment systems have increases that are built into them annually, which is contributing to that spending, no doubt, but Part B spending is not being driven by the physician fee schedule. But again, you wouldn't know it from all of the heat that the physician fee schedule takes in terms of how it's paid for. So why is fee schedule spending really under control? First, we have the pre-macro world, right? So the SGR that I mentioned before was really driving down payments. You can see, going back to 2000, kind of where payments would be if they had kept up with inflation, but the SGR kept pushing those down. And I was talking about those 10, 20% cuts that were hanging over our head. That's what payment increases would have looked like if they had been allowed to go into effect. In the world we're living now, even though the SGR is gone, there are still statutory mechanisms that are keeping fee schedule spending tamped down. And there are really two big components to this. One is that statute requires budget neutrality for changes or additions in the value of services under the fee schedule. So anytime that CMS makes a change in value, that whether it's for medical practice, coding changes, new RVU components, whatever it is, if those changes result in a change in spending of more than $20 million, then they come back and they take it away to pay for it. So in 2019, everybody is probably familiar with the revaluation of the office and outpatient codes. That was a, they increased, and there was a giant influx of RVUs into the fee schedule that had it just been implemented as is, would have generated higher spending. So that triggered a reduction to the Medicare conversion factor to essentially claw that money back so that we didn't change spending overall. The other thing is that there is no inflationary update that's built into the fee schedule payment calculations. So there's nothing that accounts for increased practice costs. There's nothing that is basically saying the cost of care, the cost of employees is going up every year, and therefore spending is not keeping up with the pace of inflation. What does that mean? We have seen conversion factors that for the last couple of years have decreased. If you look over at the left, you'll see 2021, 2022, 2023. Those are the updates that Congress provided. So Congress was trying to fill the hole this year, for example, by throwing a 2.5% increase into the fee schedule, but the budget neutrality mechanism is still sort of off and running. And so even with that patch, they weren't able to outpace the budget neutrality component to this. So you still got a 2% reduction in your conversion factor. The AMA has a nice slide on the last point that I wanna make here before we talk about sort of where there is real movement in physician payments right now. But what I wanted to show you here was, again, this is just happening to you in Medicare. That's why I showed you all of those different parts of Medicare, the different components of part A and part B. They're all operating on different payment systems and annual update mechanisms. So you can see the payments for everyone is going up almost commensurately with inflation, except for the Medicare physician fee schedule. It's just the physician fee schedule that this is happening to, which is also, I think, when we think about advocacy, an important thing to be highlighting because you are being treated differently than the rest of the providers inside of Medicare. The last thing I just wanna round out here is to bring it back to CMS. So I talked a lot about the statutory components of this that are driving the big wins in Medicare physician fee schedule reimbursements, and it makes it sort of sound like CMS doesn't have anything to do with this. That's not true. As I mentioned, inside of Health and Human Services, and CMS has a really important portfolio here. So they will establish coverage policy for Medicare in line with statute. They establish service codes and billing modifiers. Those of you that are familiar with the AMA RUC and other AMA activities, certainly CPT, know that the AMA is involved, but when all is said and done, Medicare gets to approve or deny those as recommendations. So it really is landing in Medicare's lap and CMS's lap. Claim submission documentation guidelines. They set the rules for Medicare on relative values and other payment rates. And then the other part of their portfolio, which I'm gonna use as an opportunity to transition over to Rachel's presentation, is that they are now, because of MACRA and other programs in existence, they establish the paper for reporting and performance standards that are affecting payments. So this is a big change from thinking back to our timeline back in 1965 of how CMS started out or how Medicare started out. And Rachel's gonna talk about that sort of quality and value piece of CMS and Medicare payments now. Thanks, Bob. And also thank you to Dr. Saha and Dr. Slot-Warner. So as Bob said, CMS is increasingly tying payments to quality. There are multiple levers that CMS uses for that. They have multiple approaches they've taken to improving the healthcare of Medicare and Medicaid beneficiaries. And this ranges from quality measurement to value-based payment programs and models, public reporting. They even have initiatives to enforce health and safety standards and even to provide quality improvement technical assistance. But in terms of quality measurement per se, CMS administers about over 25 programs that focus on quality reporting or value-based sort of purchasing. And in those programs, they employ almost 700 different measures that generally fall into the themes listed on the slide here. They tend to sort of fall into, these measures and these programs fall into two buckets. One is more pay for reporting where the clinician or the facility is held accountable simply for reporting on metrics. And the other bucket is pay for performance or the value-based programs, which actually tie payments more directly to performance on those measures. Next slide. So here are just some examples of CMS quality programs. This is by far not all of them. All of the payment systems that Bob was going through, each have their own quality programs tied to them. But some focus on physician-level measurement and are tied to Medicare Part B payments, such as the Merit-Based Incentive Payment System or MIPS, which I'll talk about in a minute. But there's also a variety of facility-level program that impact Part A payments. And these vary in terms of pay for reporting versus pay for performance, in terms of the measures used and in terms of how they actually impact payment. Next slide. And then other CMS initiatives focus more comprehensively on value-driven delivery and payment reforms. And these mostly fall under CMS's Center for Medicare and Medicaid Innovation Center, which is also referred to as CMMI or the Innovation Center. This was created under the Affordable Care Act in 2010 with the goal of testing innovative payment and delivery models under Medicare and Medicaid. And under the mandate, under the center, CMS has the ability to expand models without congressional approval if they reduce spending without reducing quality, improve quality without increasing spending, or if they improve quality and reduce spending at the same time. Over 50 models have been tested to date, but only about six have generated savings to Medicare and only four met the requirements for expansion. And additionally, there's been a lot of studies done showing that most have not shown significant improvements in quality. There's concern that very few of these models to date that have been tested are relevant to specialists. There's also concern that CMMI has tested too many models and maybe they're diluting the success of any one model. And then there's also pretty serious and ongoing concerns that CMMI could mandate participation in some of these models. Historically, most have been voluntary, but CMS has attempted a couple of times to mandate these and they've expressed interest in doing that some more in the future. But overall, CMS continues to test models through this Innovation Center. And they've actually set a goal of having 100% of traditional Medicare beneficiaries in accountable care relationships by 2030. Next slide. And then here just quickly are some examples of some of the models that the Innovation Center has been testing. I wanted to highlight the first one specifically, which is the Bundled Payment for Care Improvement Initiative. It's now in a phase called Advanced, but essentially it provides bundled payments for specific episodes of care. And you could see here that some of the episodes are related to your specialty. Next slide. And then finally, sort of a third leg of CMS's overall quality strategy is focused on interoperability of electronic health records and data access and exchange. CMS works closely with another department, U.S. Department of Health and Human Services Office known as the National Coordinator for HIT, also known as ONC to implement policies that promote better interoperability of HIT systems, more seamless and timely exchange of data. As I said, enhancing patient access and control over their data and also the broader use of electronic quality measures. And in fact, they've also set a goal to move to all electronic quality measures by 2030 as well. But overall, the aim here is to improve care coordination, quality and efficiency. Next slide. So I do wanna spend a couple of minutes discussing the quality payment program or QPP specifically, because it's the quality payment program that impacts physicians most directly. Before getting into this, I wanna emphasize that your employment situation doesn't necessarily dictate whether you're held accountable under this program. You might think that you're sort of immune to this program, but eligibility for MIPS is based on whether Part B fee schedule payments are billed through your group practice or institution. And so that data, whether you know it or not, is likely being reported on your behalf and impacting payments. And your performance actually is also potentially being showcased to the public through public reporting mechanisms. But the quality payment program was authorized under the macro legislation, which Bob referred to earlier, which as he noted was a broader Medicare payment reform package that repealed the SGR and aimed to more closely align Medicare physician payments with value. We're now in the seventh year of the program and most physicians will fall into one of two tracks, either the merit-based incentive payment system or MIPS or advanced alternative payment models. MIPS is a pay for performance program. It adjusts Part B payments both downwards in the form of penalties but also upwards in the form of bonuses based on how a physician performs in four performance categories listed here, quality, cost, promoting interoperability of EHRs, and clinical improvement activities. The second track is for physicians who participate sufficiently in what's known as an advanced alternative payment model. So this is not just any old alternative payment model. These are specific risk-based alternative payment models that rely on EHRs and also rely on MIPS-like quality measurements for accountability purposes. And so physicians who bill a sufficient percentage of their Medicare claims or see a sufficient number of Medicare patients through this type of APM are known as qualifying participants or QPs and they're exempt from MIPS. And instead, they have to date been eligible for a lump-sum Medicare incentive payment in addition to any bonuses or shared savings they received directly through the alternative payment model. And I did just want to point out that for both of these tracks, there's a two-year gap between performance and payment. So performance under MIPS during this calendar year, the 2023 calendar year, won't impact payments until 2025. Next slide. So this slide just illustrates how the vast majority of physicians to date have participated in the MIPS track, although there has been a slight drop-off just likely due to COVID in recent years. But only about 20% of physicians or clinicians have qualified for the APM track to date, which is pretty problematic because the original intent of MACRA and the QPP was to really start to move clinicians out of these one-off quality reporting programs and into more comprehensive alternative payment models. And that's obviously not happening. Next slide, please. So this slide illustrates the timeline of Part B payment adjustments as authorized under the MACRA statute and some subsequent legislation. As Bob mentioned, MACRA attempted to replace the SGR with more stable updates over time. And although they're steady and predictable, as you can see in the row titled base update, they're pretty nominal and they still do fail to account for inflation. But the idea was to provide physicians with the opportunity to supplement these updates with value-based payment adjustments that are tied to the quality payment program. And these are outlined in the rows titled MIPS and APMs. The row labeled MIPS shows the maximum penalty amount, which is baked into MACRA. It's in statute each year for those who fail to participate or have the poorest performance each year. And then I've also indicated the maximum bonus that the highest performers have earned each year to date in terms of all the data we have to date. MIPS is a budget-neutral program. So the total amount of penalties fund the total availability of bonuses. So we don't yet know what the maximum bonus amounts are beyond the 2023 payment year. But the point I want to emphasize here is that the bonuses have been pretty nominal to date. And they don't make up for the lack of the fee schedule inflationary update or the high administrative costs of participating in the program. And then the bottom row labeled alternative payment model shows how physicians who qualified for this track have been rewarded with a 5% bonus up until 2022. And this is significantly more than what has been awarded under MIPS to date. So, Bob, if you just click that button. We're now in the seventh year of the program, as I mentioned. The maximum penalty is still 9% because, again, that's in statute. We don't yet know what the maximum bonus is, but we expect it, again, to be very, very small. But also note here that the 5% bonus is reduced for APM participants is now reduced to 3.5%. And then one more click. Starting next year, that APM bonus goes away completely under MACRA. And instead, these qualifying participants in APMs will be eligible for a slightly higher conversion factor update than those who participate in MIPS. But the MIPS participants will still be eligible for that up or down adjustment. So, again, problematic since so few physicians have had the opportunity to participate in this track. Next slide. So, this visualization just, again, emphasizes how small the maximum MIPS bonus payments have been to date represented by the blue bars compared to the maximum penalty represented by the orange bars. And you can see that the max bonus that's awarded to those with perfect performance has not even exceeded 2.5%. So, really, really small. And it's been frustrating when you compare that to the cost of participation, which has been on average estimated to be around $13,000. This is even more frustrating when you look at it in the context of physician payment updates each year, which is represented by the green line. And you can see here that physicians have mostly been facing cuts to Medicare payments each year. And these performance-based bonuses are not really filling that gap. One of the reasons why bonuses have been so nominal to date is because of the budget-neutral nature of the program. During the initial years of the program, CMS kept the bar pretty low in terms of compliance and performance thresholds. And then each year since 2019, they also started to offer a COVID hardship exception, which allowed basically anyone who didn't think they could comply with the program to take a year off without facing a penalty. So, there's been very little money available that's coming in on the penalty side available for upward adjustments. It's important to note, though, through the pandemic years, even though that hardship exception was offered, CMS continued to raise the bar on performance, and they adopted new policies that will make it increasingly challenging for physicians to avoid a penalty. And so, this could be problematic in the coming years as that hardship goes away and clinicians reenter the program. And sorry, I just wanted to highlight that in the yellow boxes, that's showing the percentage of clinicians that were receiving penalties each of those years. So, it's been very small to date, but that soon could change. And in fact, I'll just note that that's okay. CMS did recently estimate that if it did not – it's continuing to offer the COVID exception for 2023 for this year, but we expect that to be the last year. But they estimated that if they did not offer it this year, they would have expected 30 percent of clinicians to receive a penalty. So, if you compare that to the numbers in the yellow box, that's pretty staggering. Next slide. Just quickly, I wanted to show how the performance threshold, which is sort of the minimum number of points needed to avoid a penalty, has increased from year to year pretty drastically. It's more than doubled since the start of the program. So, that makes it harder to avoid a penalty as well. Next slide. And then, without getting into too many details, I just wanted to demonstrate how the four categories work. Each category is prescribed a weight in statute. There's different reporting mechanisms for each one. There's different reporting requirements in terms of the number of measures or activities that must be reported in traditional MIPS, which is the middle column there. However, starting this year, CMS approved this new reporting pathway for MIPS known as the MIPS Value Pathway, or MVPs, which is shown in the right column. And it's essentially the same in terms of the four categories with their weights, but it offers a slightly reduced reporting burden. What these MVPs are are smaller subsets of more sort of defined measures that focus on a specific specialty or condition. And if you choose to report from that set, you are not required to report on as many measures as you would be under traditional MIPS. So, it's supposed to result in a more sort of cohesive and meaningful participation experience, but also a reduced burden. Next slide. I just wanted to highlight that the MIPS measure, quality measure inventory includes over 200 measures. There's a ton of measures in there. There are only two that are specific to cardiac electrophysiologists, which are listed on the left side here. These are measures that HRS originally developed and spent significant resources doing so. Unfortunately, even though they've been in the program since pretty much the beginning, they have not been used much by clinicians. And as a result, they don't have benchmarks, which is problematic because they could be removed from the program and they also don't provide clinicians with any points. I wanted to highlight on the other side that these are the measures that are most commonly reported by cardiac electrophysiologists. And you can see here that some are not even related to your specialty. And what's going on here is that the program allows for reporting at the group level or even at the APM level. And so your group practices are reporting measures on your behalf that might not even impact you, but you're sort of being swept up in that larger group and receiving their performance score and their payment adjustment. Next slide. Really quickly, these are a list of the cost measures. We're running out of time, so I'm not going to go through them, but there are very few that apply directly to cardiac electrophysiologists. And as I mentioned, CMS is offering these MVPs starting this year and the Advancing Care for Heart Disease is one that's being offered that does include the two EP measures. So I think that could be an opportunity for your members to participate more meaningfully. Next slide. And I just wanted to quickly mention that under MVPs, CMS is offering this new subgroup reporting option where you can sort of peel off from the rest of your group and form a subgroup for purposes of reporting. So I only mentioned this because this might give EPs an opportunity to report on their more focused measures and maybe accrue some of those benchmarks that are needed. Next slide. And then last two slides, there are lots of ongoing challenges with MIPS regarding the siloed performance categories, constantly shifting goalposts. The quality measures are problematic since they're not all meaningful. And the program is very burdensome. A recent survey showed that physicians consider it the third most burdensome regulatory requirement. So lots of things that need to be fixed in this program. Next slide. This just shows CMS's national quality strategies for the coming years in terms of their long-term goals. But we can, in the interest of time, skip over that and go to the last slide. And then finally, in terms of seeing more foundational and meaningful reforms for the quality payment program and for Medicare physician payments in general, as Bob discussed earlier, much of this activity is going to have to take place through Congress. And while we continue to work with CMS to make changes that are possible through regulation, we've almost sort of hit a wall where some of this CMS continues to say that their hands are tied by the macro statute. So we're now looking, physician groups are looking more heavily to Congress to reform not only the quality payment program, but physician payments more broadly. There is legislation that's been introduced in the House, H.R. 2474, which would tie physicians' annual updates to the Medicare Economic Index. And doing so could also have the effect of providing more resources to physicians to invest in value-based care. There is also the House Energy and Commerce Committee's oversight subcommittee on oversight is holding a hearing next week on MACRA. It's not clear if it's going to focus more on the quality or the payment aspects of it, but this is another opportunity to sort of shed some light on the problems that we've been having with the program. And then there are different things that are being floated around as congressional reforms, potentially if this MEI proposal did go through, you know, tying the MIPS payment adjustment to that to put less of physician payments at risk and possibly extending the APM incentive payment. But I'll wrap up by just saying that I, it's, we really, we hope to sort of tonight lay the foundation for all these programs because it's your advocacy and your involvement in all these issues is going to be extremely important in the coming years, especially as this moves over to Congress. So we hope this presentation, and I apologize that the last few slides were sort of rushed through, but we hope this presentation sort of gave you a foundational basis for some of these issues. I believe HRS is interested in doing more focused webinars in the future on some of these topics, but we hope this helps you in your advocacy efforts. And with that, I will open it up to the moderators for questions. Wow. Thank you, Rachel and Bob. That was amazing and incredibly informative. I've been working in this space, you know, learning from both of you for 10, 12 years, but that puts a lot of the pieces together for me. We are close to the end of the hour and I want to respect everyone's time. I don't see a lot of questions from the audience. I know that I have one broad one and Sandeep has one as well. So I'll just start off since time's limited. You know, from a big picture perspective, listening to Bob, you explain how just the Medicare fee schedule, the physician fee schedule is so tightly budget neutral and Rachel you explaining these complex, you know, quality improvement payment models all for scraps, yet we see, you know, reimbursement for all the other components of the healthcare arena increasing at rates greater than inflation, or at least close to inflation. Is there a philosophy or is this the philosophy of CMS and Congress to shift payment from individual providers to organizations, or is this a lack of advocacy on the physician's part? I'm just wondering if there's an underlying strategy. Obviously our members are going to have to get engaged and we're going to have to advocate, but I'm curious to hear your thoughts on the big picture, why this is the way it is. I can start and then Rachel may have some thoughts to add to. I think a lot of it is just sort of coincidence. The one, you know, piece of it is that, you know, what we, what we highlighted, which is each of these pieces of Medicare operate on different systems. And I think that, you know, we have been under reimbursement update mechanisms that are difficult at sort of the wrong moment in time. And it's too expensive for Congress to change it. So I think in that way, it's a problem. I also think though, that there is this thought that consolidation might not be bad. So to the extent that this is leading to consolidation, I think that there are some folks who think, you know, on the Hill that think that's not a big, big idea. And then the last thing where I think advocacy is really important is there is this assumption that if the hospital is making more money, then it trickles down to you. And I think that educating folks on Capitol Hill and the staffers, that that's not how it works, is going to be important to trying to change the trajectory here. The only thing I'll add on the quality side is there is interest in aligning all, you know, EPs who are practicing in a facility are held accountable to MIPS. They're indirectly held accountable to these institutional level programs. So there's so many different programs that they have to comply with. And so there is interest in bringing it all together and, you know, maybe having where, you know, you've received credit for one program and that applies across all of them, or even just streamlining the number of programs because it really is administratively burdensome and results in sort of flawed data. Well, that's great. I just had one more question. If we have the time, maybe a quick 30 second response, but from the standpoint of the individual provider, is there a portal that the individual provider or provider groups can go to to see what their sort of MIPS report card is like or what particular parameters are being reported on their behalf? That might be an interesting question for individual members to kind of go and see their own organizations reporting activities on their behalf. Yeah, there's a portal that will show you basically your eligibility for the program that's available to the public. And then there are portals that will also provide performance feedback, but it is sort of password protected and you would have to go through an administrator, but I could definitely work with HRS staff to get that information out to participants or the membership. Thank you. I think, Sandy, I'll turn it over to you in a second. You know, we did want to explain that if the audience has questions, you can follow up with us at HRS. I believe we were going to show an email, but I don't see that. But if you go to the HRS website and go under health policy, you'll see the contact information. So please feel free to follow up with any specific questions and you can follow up with Rachel and Bob, you know, as needed. I'll turn it over to you. Thank you. So, you know, it's been a very informative hour. I can say certainly for myself as an individual provider, for me to see the complexities that are involved in, you know, the data that goes to CMS and kind of the complicated formulae that go into our reimbursements and how the evolution has been, especially over the past decade or so in the reimbursements. This was very insightful. This was very informative. And I thank both Bob and Rachel for taking the time and putting this presentation together. I'm sure our membership will be very, very appreciative of this information and, you know, go back to their administrators and their organizations and try to identify opportunities for both advocacy and hopefully action based on some of the information that was presented today. So again, on behalf of the HRS Digital Education Committee and the Health Policy Committee, Dr. Slott Weiner, I thank both Bob and Rachel for their time and for all the information that you provided. As Dr. Slott Weiner said, feel free to reach out to us at HRS with any questions or feedback that you have with regard to the information presented today, but also the BEAT series. And we'd love to hear from you guys and girls and appreciate your time. Thank you so much.

The Beat

CMS

Medicare

fee-for-service

value-based payment

Quality Payment Program

MIPS

physician payments

advocacy

healthcare delivery