The Centers for Medicare and Medicaid Services (CMS) has published its proposed rule for the Medicare Physician Fee Schedule (PFS) for the year 2022. This rule also includes ideas for improvements to the Quality Payment Program (QPP).
Since it went into effect in 2017, the Quality Payment Program (QPP) has included two participation paths for doctors who are qualified to receive Medicare Part B payments. Under the Quality Payments Program (QPP), healthcare providers had the option of participating in one of two value-based reimbursement pathways.
The Merit-based Incentive Payment System (MIPS), or the advanced alternative payment models (APMs). 2 With close to 100% of MIPS-eligible clinicians engaged in these value-based quality payment programs,3 plans proposed by CMS to begin transitioning the traditional MIPS program to MIPS Value Pathways (MVPs) in 2023, and the signaled intent to move completely to digital quality measures (potentially as early as 2025),4 the Biden administration has indicated its intent to continue with value-based reimbursement models, with modifications based on “lessons learned.”
Proposed Changes MIPS in 2022
However, more immediate are the suggested adjustments that might take effect as early as the following year. These changes include alterations to quality metrics and activities geared toward improvement. Quality, cost, interoperability, and improvement activities are the four performance criteria that may have an effect on compensation under the Quality Payment Program (QPP).
Depending on the model physicians participate in, performance on Quality will be weighted 30% to 55% (e.g., 30% for traditional MIPS) in a calendar year (CY) 2022, while improvement efforts will be weighted 15% to 20%)e.g., 15% for traditional MIPS. 5 Stakeholders (pharmaceutical manufacturers, clinicians, health plans, and systems) should take note of the proposed changes in quality measures and improvement activities, identify the potential impacts (challenges and opportunities) upon their practices and relevant therapeutic areas, and formulate strategies and tactics to support access and alignment with the Quintuple Aim (Population Health, Care Team Well-Being, Patient Experience, Equity & Inclusion, Reducing Cost) (Population Health, Care Team Well-Being, Patient Experience, Equity & Inclusion, Reducing Cost). 6
Measurements of Quality: Planning the Next Steps
The Centers for Medicare & Medicaid Services (CMS) has proposed 195 quality measures for the 2022 performance period,1,5, which include the following:
There have been significant alterations made to all 84 of the existing MIPS quality measures.
Alterations to the specialized (more than 40 in 2021), including the deletion of certain measures contained within certain sets, as well as the incorporation of new outcome and intermediate outcome measures
Two new subspecialty groups have been added.
- Certified nurse midwife and the specialty measurement set that corresponds with this role
- As part of the planned modifications to the specialty set, clinical social work is also being considered as a new MIPS-eligible clinician.
Elimination of 19 quality control measures
Addition of 5 quality measures, which include 2 new administrative claims measures, as well as a call for public comment on the draught of the COVID-19 vaccination by clinicians, measure specifications.
The continuing concerns that CMS has with hospital admission rates are reflected in the administrative claims measures that are now being proposed, which are as follows:
Admission Rates for Acute Cardiovascular Emergencies That Were Not Planned That Were Risk-Standardized for Patients Who Suffer from Heart Failure According to the MIPS (applicable to MIPS eligible clinicians, groups, virtual groups)
Risk-standardized hospital admission rates for patients with several chronic conditions, broken down by clinician as well as by clinician group (applicable to MIPS eligible groups with at least 16 clinicians)
The following actions are recommended for manufacturers to take:
- Determine if existing as well as suggested new or updated quality metrics are pertinent to your therapeutic area and can be found in relevant data sets such as the Quality Payment Program (QPP), the Health Effectiveness Data and Information Set (HEDIS), and Medicare Stars Parts C and D.
- Conduct a literature review on the topics that are pertinent to your portfolio in search of evidence to support quality measure performance (e.g., readmission reduction)
- Identify and resolve any data gaps in the quality measures (e.g., plan for real-world data collection and analyses.
- Create a strategy to communicate product performance in a way that is supportive of key quality measurements, including the regular updating of value message frameworks.
- In addition to this, if quality metrics that reflect care gaps are not yet available, look for opportunities for multi-stakeholder collaborations to develop quality measure concepts with the goal of accelerating the closing of care gaps through the use of evidence-based practices and therapies.