CMS is Testing new MIPS Resource Use Measures: Exploring possible benefits to LTPAC Medicine


In a September 2018 Blog post I opined on CMS’s Total Per Capita Cost (TPCC) methodology proposed for the CY 2019 Physicians Fee Schedule. The lead line pretty much summed up my opinion of the measure – “CMS Continues punishing Geriatric, LTPAC, and Palliative Medicine for serving the frail elderly nearing the end of life.”

CMS appears to be considering a major change in direction for its entire spectrum of Resource Use measures. If these changes are adopted, they definitely effect the MIPS program; if history is an indicator, they’ll also spill over into ACOs and other MSSPs.

The operative word in the title is ‘testing.’ CMS is accepting comments during October. If you provide care to the frail elderly, you have a big stake in this project.

September’s blog described major flaws in the CMS’s current methodology for determining TPCC if you provide primary or palliative care to the frail elderly.

In early October, CMS invited its audience to register for a webinar titled MACRA Cost Measures Field Testing. During the webinar, the narrators briefly described the new methodology CMS was testing for TPCC and the other cost measures.

Here are the important take-aways I heard:

  • Attribution – begins with a ‘candidate event’. The following is verbatim from CMS:
    1. Identify candidate events. Candidate events are defined as primary care evaluation and management (E&M) services that trigger the opening of a risk window, during which beneficiary costs are attributed to the TIN or TIN-NPI that performed the E&M service. Candidate events indicate that a clinician provided primary care to a beneficiary.
    2. Construct risk windows. For each candidate event, the risk window, during which a beneficiary’s costs are attributable to a clinician, begins on the date of the candidate event and continues until one year after the date of the candidate event.

This is a major change for LTPAC Medicine – it means you or your group are no longer responsible for any Hospitalization Costs that occurred prior to the ‘candidate event’. That’s important if you establish your initial patient relationship through a service in a Nursing Facility (POS 32), Assisted Living, or Home-based care.

This new methodology leapfrogs the considerable hurdles associated with trying to use Specialty Codes to adjust expected TPCC. As with most CMS methodological changes, they only give us the facts – rarely disclosing the change’s role in crafting future payment strategies. However, this seems to imply that beneficiaries/patients are going to be more accurately ‘priced’ in terms of expected costs or calculated monthly premiums in the Medicare Advantage market.  Let’s hope this strategy improves access to care for the costliest beneficiaries and ceases punishing those who serve them.

There’s a second major change that directly effects Nursing Facility Medical Groups: In the September Blog, we discussed RAFs (Risk Adjustment Factor).  Risk adjustment uses both demographics and diagnoses grouped into HCCs (Hierarchical Condition Categories). Under current TPCC modeling, beneficiaries ‘risk adjustment’ was based on the Community model. This ignored an existing Risk Adjustment model CMS maintains for I-SNPs (institutional special needs programs). I-SNPs are Medicare Advantage plans for beneficiaries residing in long-stay Nursing Facilities (90+ days). The testing model for TPCC is using:

“The institutional model is used for beneficiaries in long-term institutional settings. The institutional model includes demographic variables, clinical conditions as measured by HCCs, and various interaction terms.”

This is a major policy change that should benefit any medical group which captures new patients through POS 32 encounters. Without going into the complexities of HCC RAF calculations, it’s safe to say that the I-SNP model assigns a higher base RAF to beneficiaries qualifying for NF level care than those residing in the community. There is some corresponding offset in the HCC value assigned to diagnoses, so individual results may vary. However, the higher baseline for expected costs lessens the penalties for incomplete ICD-10 coding.

All groups subject to MIPS should review the Testing methodology, and individual reports.  The comment period is open through the end of October 2018. My assumption is that no changes in methodology could occur until CY 2020.

Here are the links:

  • Comments to CMS
  • Accessing a TIN’s Cost Measure Field Test Report – note, we’ve talked with several LTPAC medical groups that were/are subject to VBP and MIPS cost measures. They were unable to find Field Test Report as of 10/12/18.  That makes it difficult to make accurate predictions about how this new TPCC calculation compares to the current methodology.
  • TPCC Mock Report
  • Draft TPCC Measure Specifications (ZIP file) – look for the file titled Re-evaluated Total Per Capita Cost Measure Draft Cost Measure Methodology.pdf. It provides the detailed description of the new model.

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