On March 23, 2010, the Patient Protection and Affordable Care Act, or Affordable Care Act (ACA) for short, was signed into law. This page provides information on regulatory issues related to the ACA, including proposed policies released by federal agencies and ACS letters to those federal agencies, advocating on general surgeons’ behalf.
Accountable Care Organizations (ACOs)
The Patient Protection and Affordable Care Act (ACA) requires the implementation of the Medicare Shared Savings Program. This program is intended to encourage physicians, hospitals, and other health care providers to come together voluntarily to form accountable care organizations (ACOs) to share the responsibility for providing cost-effective and coordinated care to their Medicare patients. Under the ACA, an ACO would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years. In the Medicare context, an ACO that meets established quality and performance standards and surpasses a minimum savings target will be able to share a percentage of savings (in addition to traditional fee-for-service payments under Medicare Parts A and B).
ACS Comment Letters
General Surgery Bonus Payment
The Affordable Care Act (ACA) authorizes a Medicare incentive payment program for major surgical procedures provided by general surgeons in Health Professional Shortage Areas (HPSAs). This new initiative is called the HPSA Surgical Incentive Payment program, or the general surgery bonus program. The bonus applies to major operations (defined as 10-day and 90-day global procedures) provided by a surgeon who is enrolled in Medicare with primary specialty code of 02 (General Surgeon). The major procedures must be provided in a geographic HPSA between January 1, 2011, and January 1, 2016. The bonus payment amount is 10 percent of the amount actually paid for service.
ACS Comment Letters
Medicare Claims Data
The Affordable Care Act (ACA) requires that certain Medicare claims data be made available for the purpose of allowing qualified entities (as defined by the Centers for Medicare & Medicaid Services) to prepare publicly available evaluations and comparisons of provider performance. The American College of Surgeons (ACS) advocacy efforts stress that appropriate safeguards must be put in place to guarantee the accuracy and validity of any performance reports that will be made publicly available. The ACS supports efforts to help physicians and patients better understand the quality and cost of their care and provide them with tools that will allow for the continuous improvement of care.
Availability of Medicare Data for Performance Measurement Rules
Physician Payment Sunshine Act
The Affordable Care Act (ACA) requires that, beginning in 2012, manufacturers of specified drugs, medical devices, and biologicals participating in U.S. federal health care programs must begin tracking any transfers of value or payments of $10 or more (as indexed by Consumer Price Index) to physicians and teaching hospitals. These reports must be submitted to the Secretary of the Department of Health and Human Services on an annual basis. The majority of the information contained in the reports will be available on a public, searchable website in 2013. In addition, the ACA mandates that manufacturers and group purchasing organizations must report ownership interests held by physicians and their close family members.
CMS Physician Sunshine Rule
Value-Based Payment Modifier
The Value-Based Payment Modifier (VM), authorized under the Affordable Care Act, provides either bonus payments, penalties, or no bonus or penalties (neutral adjustment) to a physician’s Medicare fee-for-service payments based on the quality and cost of the care they provide. The Centers for Medicare & Medicaid Services (CMS) began applying the VM to physician groups of 100 or more providers in 2015 based on their performance in calendar year (CY) 2013 and will begin applying the VM to all physicians in 2017 based on their performance in CY 2015.
To avoid 2017 VM penalties, surgeons must participate in the Physician Quality Reporting System (PQRS) in CY 2015. Lack of successful participation in the PQRS program in CY 2015 will result in a 2% PQRS payment penalty and may result in additional penalties up to 4% under the VM.
Components of the VM
There are two metrics used to calculate the VM: quality and cost.
The quality metrics are based in part on participation in the PQRS program as well as CMS selected claims-based outcomes measures, listed below. It is important that surgeons satisfy the PQRS program requirements in order to avoid additional VM penalties.
PQRS Measures Selected by the Provider
CMS will use the measures reported on by providers for the PQRS program as part of the quality composite score.
Claims-Based Outcomes Measures Selected by CMS
In addition to the PQRS measures, CMS will calculate performance on selected claims-based outcomes measures. CMS uses a two-step attribution process to associate beneficiaries to a provider’s tax identification number when assessing these measures. These measures include:
- Composite of rates of potentially preventable hospital admissions for heart failure, chronic obstructive pulmonary disease, and diabetes
- Composite rate of potentially preventable hospital admissions for dehydration, urinary tract infections, and bacterial pneumonia
- Rates of an all‐cause hospital readmissions measure
CMS will assess the quality measures for which there are a minimum of 20 eligible cases and equally weight them to calculate a quality of care composite score. If a provider does not have enough data on the quality measures (or if the quality measure does not apply to them), they will be deemed to be “average” for the quality component.
The cost metrics used by CMS to calculate the cost performance include five total per capita cost measures and the Medicare Spending per Beneficiary measure. CMS uses a two-step attribution process to associate beneficiaries to a provider’s tax identification number (TIN) when assessing these measures. The cost measures include:
- Total per Capita Costs for All Beneficiaries evaluates all Medicare Part A and B costs associated with any beneficiary over a year. Beneficiaries are attributed to the group that provided the plurality of primary care services to that individual
- Total per Capita Costs for Select Conditions evaluates Part A and B costs for patients with specific conditions (heart failure, coronary artery disease, chronic obstructive pulmonary disease, and diabetes). Beneficiaries are attributed to the group that provided the plurality of primary care services to that individual
- Medicare Spending per Beneficiary evaluates Part A and B costs spanning three days prior to and 30 days after an inpatient hospitalization. Beneficiaries are attributed to the group that provided the plurality of Part B services during the inpatient stay
Similar to the quality measures, CMS will assess the cost measures for which there are a minimum of 20 eligible cases and equally weight them to calculate the cost composite score.
Both the quality and cost composite scores will be equally weighted to determine the VM score as shown in the graphic created by CMS below.
CMS will then divide each physician and physician group’s quality and cost composite scores into three tiers based on whether the score is above, at, or below the mean. This is known as “quality tiering” and this will determine whether they will receive a bonus, penalty, or no bonus or penalty under the VM.
2017 VM (for Performance Year 2015)
The 2017 VM will be applied to all physicians based on how they perform on their overall cost and quality performance in CY 2015.
Solo practice physicians and groups up to nine physicians will avoid VM payment penalties, but may see either of the following:
- Bonus payment
- Neutral adjustment (no bonus or penalty)
Groups of 10 or more providers will be subject to one of the following:
- Bonus payment
- Neutral adjustment (no bonus or penalty)
The graphic below shows how the 2017 VM will be applied to solo surgeons and physician groups of various sizes for CY 2015.
Groups of 10 or more have two options in CY 2015 to avoid the 2017 VM penalty:
Option 1: Consider participating in PQRS as a group through the Group Practice Reporting Option. Assuming successful PQRS participation, this will be the best way to ensure that all members of the group avoid the PQRS penalty. To determine whether your group has already been enrolled to participate in PQRS in this manner, contact the CMS Quality Net Help Desk and provide them with your group tax identification number (TIN). They can be reached at: 1-866-288-8912. Note that PQRS measures chosen for this option may or may not be relevant to surgeons in the group. Additionally, based on CMS’ determination of the groups cost and quality performance for the VM, groups may also avoid the VM penalty, but may also be at risk for a VM penalty.
Option 2: Ensure that at least 50% of the group’s members are participating in PQRS through one of the Individual Reporting Options. This PQRS reporting method will allow individual surgeons to choose which measures to report on and therefore allow them to choose what is most applicable for their practice. Depending on CMS’ determination of the group’s quality and cost, this option may allow all members of groups of 10+ to avoid receiving a penalty under the VM. However, in this situation, those providers who did NOT submit PQRS data and those who did NOT successfully report for PQRS, will still be subject to a 2% PQRS payment penalty.
Resources for VM
2013 Quality and Resource Use Reports
CMS VM Website
VM Attribution Process
The Affordable Care Act (ACA) made several changes and created several mandates with the intention of protecting the integrity of Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) and preventing waste, fraud, and abuse. Among other issues, the ACA addressed provider screening, application fees, and temporary moratoria on enrollment under Medicare, Medicaid, and CHIP. The Centers for Medicare & Medicaid Services (CMS) implemented these changes via notice and comment rulemaking. The American College of Surgeons (ACS) prepared a joint comment letter for submission to CMS in response to the CMS Medicaid Integrity Program proposed rule, and 13 surgical specialty societies signed on to this letter.
CMS Program Integrity Rules
Reporting and Returning of Overpayments
The Affordable Care Act (ACA) requires that Medicare providers and suppliers report and return Medicare overpayments within a certain time period. The overpayments must be reported and returned to the Secretary of the Department of Health and Human Services, the State, an intermediary, a carrier, or a contractor, as appropriate. The overpayment must be reported and returned by the later of: (1) 60 days after the date on which the overpayment was identified or (2) the date any corresponding cost report is due. Failure to meet the deadline for returning an overpayment exposes the provider or supplier to civil monetary penalties under the federal False Claims Act.
Rules Implementing ACA Provision
For further information, please contact Vinita Ollapally at firstname.lastname@example.org, or Neha Agrawal at email@example.com.