August 04, 2017
9 min read

MACRA and gastroenterology: ACG pushes for ongoing focus on quality

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Costas H. Kefalas, MD, MMM, FACG, FASGE, AGAF
Costas H. Kefalas

The Medicare Access and Chip Reauthorization Act, which passed with bipartisan support in 2015, is poised to change the way Medicare pays physicians. MACRA repeals the Sustainable Growth Rate (SGR) formula for Medicare Part B reimbursement rates, and introduces the Quality Payment Program (QPP). The QPP will increase the proportion of physician payment that will be determined by value, which is defined by measures of quality and efficiency.

MACRA offers two tracks for clinicians to choose from: Merit-based Incentives Payment System (MIPS) and Advanced Alternative Payment Models (APMs). While most physicians will be required to choose one of these tracks starting in 2017, the CMS has designated 2017 as a “transition year.” During this year, physicians who make some effort toward quality reporting will not receive the 4% payment cut that will be taken from doctors who report no 2017 data.

According to Costas H. Kefalas, MD, MMM, FACG, FASGE, AGAF, current Chair of the Board of Governors of the American College of Gastroenterology, the ACG supports the aspects of MACRA that emphasize quality.

“The ACG especially stands behind the quality performance category; in our field, we have a number of very good, scientifically proven metrics,” Kefalas told Healio Gastroenterology. “Things like adenoma detection rate, cecal intubation rates, withdrawal times —  measuring these numbers, and having processes in place to improve these numbers, can actually impact patient care.”

Kefalas discussed what gastroenterologists should know about MACRA, its current flaws, and the ACG’s advocacy efforts toward addressing these issues.

Q: Which of the two QPP tracks will be more relevant to gastroenterologists?

Kefalas: Most gastroenterologists, at least in 2017 and probably even in 2018, are going to be participating in the MIPS program.

Q. Can you outline what is involved in the MIPS program?

Kefalas: The MIPS program has four performance categories: quality, cost, improvement activities, and advancing care information. Three of those four roll over from prior piecemeal programs that CMS had. The quality category comes from QPRS, the cost category replaces the value-based payment model, the improvement activities is the one new category created by the MACRA, and the advancing care information category replaces meaningful use.

Each of these categories is assigned a percentage score, and the MIPS total composite score is made up of the sum of the score for each of these categories for each individual provider or group, if reporting as a group practice. In the MIPS program, payments follow two years after the performance year. So for performance year 2017, the payment year is 2019.

In performance year 2017, CMS assigned a score of zero for cost; they basically took out the cost category for 2017. In the proposed rule for performance year 2018, which will likely be finalized in October or November of 2017, they propose to keep that score at zero for cost as well.

However, CMS’ ultimate goal over the next couple of years is to raise the cost category up from zero to 30% starting in performance year 2019. To do that, CMS proposes to decrease quality from 60% in 2017 and 2018 down to 30% in performance year 2019.

As far as the other two categories, improvement activities will be 15% for the next two years and advancing care information will be 25%. So, they bring in the cost category by taking away from the quality category. Of these four categories, cost is the one that clinicians — gastroenterologists included — have nothing to report on, because it is claims-based information. CMS will extract that information based on claims from billing submitted by providers. It is going to be automatic from CMS.

Q: What was the thinking behind these cost scores?

Kefalas: In late 2016, CMS, in their final rule for MIPS for 2017, said, “We’re not ready to measure cost,” and in fact, they aren’t. They have established multiple clinical committees and subcommittees from different specialties that are in the process of identifying and reviewing episodes of care.  I, along with three colleagues, represent the ACG on the CMS MACRA Episode-Based Cost Measures Clinical Subcommittee: Gastrointestinal Disease Management. There are also representatives from the American Society for Gastrointestinal Endoscopy, the American Gastroenterological Association, and non-GI representatives as well on this subcommittee.  CMS is trying to define what these episodes are, what the time window for the episode will be, what the clinical triggers of the episodes will be, and who will be the accountable provider. Once these specific disease states are defined, each of these attributes for these episodes will ultimately be approved by CMS and will be released as criteria for the cost category. As participants in the MIPS program, our claims-based data for this category will be compared against these CMS-defined episode parameters. For example, CMS will identify the attributable provider.  Is it the gastroenterologist? The hospital? The health system? Once they’ve found the attributable provider, one question will be, “Did they spend less than what we think should be the limit for caring for a patient with this disease for 30 days? Or did they go over?” If you go over, you’ll get your cost category points docked. If you go under, you’ll receive points.


Q: What has been the overall reaction to this in the field of gastroenterology?

Kefalas: Well, the ACG, which I represent, is a unique organization because of our Board of Governors, with representatives in each state. In April 2017, we conducted our annual advocacy fly-in in Washington, D.C., and one thing we did was speak to legislators about the fact that we feel the quality category should remain a high percentage, because that directly impacts patient care. We advocated that CMS shouldn’t take 30% away from quality and add that to the cost category of MIPS. In terms of providing quality care, most gastroenterologists do what we do whether the percent for quality is 60% or zero. Most of us have been doing quality gastroenterology for a decade or longer.

Our second advocacy point was that if they’re going to increase the cost category score from zero to 30% or higher, they should at least wait until the episodes of care have been defined and pilot-tested for some degree of accuracy.
And that is what CMS has done. The proposed rule that came out at the end of June delays the 0% cost until performance year 2019. So, we have another year to address the episodes and their specific features.

Q: In what other ways do you expect MACRA and the QPP to affect gastroenterologists?

Kefalas: There’s no question that if you come from a small practice, 15 or less for example, the burden is high. It’s higher than if you come from one of the larger practices. There are some very large mega-groups in Minnesota and Dallas and Atlanta. So, the larger practices are generally better equipped to handle the infrastructure, the staffing that is needed to enter the data to participate in this. This is especially true of practices that are not participating in GIQuIC, because GIQuIC covers a lot of these requirements.

GIQuIC has become a QCDR — a Qualified Clinical Data Registry approved by CMS. If you participate in that registry, like many of us do, that hits three of the four performance categories. It doesn’t hit cost data, but it will hit the quality, it will hit the improvement activities, and the advancing care information category. So, GIQuIC is a good resource for reporting these data.

Q: How will smaller practices that haven’t enrolled in GIQuIC adapt?

Kefalas: CMS understands that MIPS implementation will be a burden on small practices, so in their proposed rule for 2018, there’s actually a small practice adjustment to account for those in smaller practices. In 2017, Medicare clinicians who use Medicare patients can be excluded from MIPS if they charge less than $30,000 a year and care for less than 100 Medicare patients.
The proposed 2018 rule becomes more liberal: the Medicare charge exclusion increases from $30,000 to $90,000 and the number of patients cared for requirement increases to less than 200 Medicare patients. So, they make it easier to opt out by increasing these two numbers.

The proposed rule also does a few more things to reduce the burden. They have an exemption for so-called “non-patient facing clinicians.” These are doctors who don’t see patients in the office. Like a pathologist, for example, or a radiologist. These people generally don’t see patients, so there’s an exemption for them in the proposed 2018 rule.

Another change that will be made is in the improvement activities category. In the new proposed rule, if you come from a group of 15 or fewer participants, a rural area or a health professional shortage area, you attest completion of up to two improvement activities for 90 days, rather than four.

Clearly, the CMS has heard the message loud and clear that they need to slow the pace down, figure out the details of some of these requirements, and offer hardship exemptions for those practices that are small or rural.

Q: We’ve been discussing MIPs so far. Can you tell me about the other QPP track, Advanced Alternative Payment Models, or APMs?

Kefalas: I think ultimately, CMS wants more of us to go into the direction of APMs There are APMs out there, but to be part of the quality payment program, an APM has to be an advanced APM. To be an advanced APM, there are three criteria that need to be met, according to CMS. To propose a new advanced APM for consideration by CMS, you have to apply to the PTAC (Physician-Focused Payment Model Technical Advisory Committee), the group that reviews such proposals.  PTAC then makes a recommendation to CMS on whether those APM proposals should become advanced APMs.

The three general criteria that CMS has outlined for an APM to be an advanced APM are: (1) there has to be certified EHR technology; (2) the quality criteria has to be MIPS comparable, meaning it has to have the same type of quality parameters that are found in MIPS; and (3) the APM has to accept some financial risk. There needs to be financial risk involved to become and advanced APM, and this has been defined by CMS.

Those are the three categories of criteria that need to be met to become an advanced APM.


Q: You said CMS ultimately wants more clinicians to go in that direction. Is that realistic?

Kefalas: Well, as of today, there are no GI advanced APMs out there. In 2017, CMS approved six advanced APMs. Most of them are internal medicine-based, and there’s an oncology one and a nephrology one, but there are zero GI advanced APMs.

But CMS ultimately wants that to happen. This past April, Lawrence R. Kosinski, MD, MBA, AGAF, a gastroenterologist who founded Project Sonar, an IBD specialty medical home initiative, took his proposal to the PTAC committee of CMS for consideration as an advanced APM. PTAC recommended limited scale testing of Project Sonar to CMS. I think we’re going to see more proposals. This is the first year, but I think 5 years from now, we’ll look back and there will be a number of GI advanced APMs that have been proposed.

Q: Would you say things are currently in transition?

Kefalas: They most certainly are. Right now, it’s mainly the cost category that has to be defined. We feel that it should not be a greater or equal component to quality, because quality is something we actually can measure, and that has been shown to affect patient outcomes.
In terms of the total composite scores, in performance year 2017, if your total composite score is 3 or higher, you will not receive the minus 4% penalty. Depending on how much higher your score is than 3, you may actually receive a bonus. For performance year 2018, CMS proposes to raise the threshold from 3 to 15.

The negative payment adjustment also is changing; as of now, the maximum is minus 9 starting in payment year 2022. That’s minus 9% of all one’s Medicare reimbursements. For payment year 2019, it’s going to be minus 4%, for payment year 2020, minus 5%, for payment year 2021 minus 7%, and for payment year 2022 minus 9%. That is how things stand as of right now.

Q: How will these changes impact GI clinicians?

Kefalas: So, in performance year 2017, CMS estimates that there are 12,168 MIPS-eligible GI clinicians. Of those 12,168 GI clinicians, 4.4% are going to receive the reimbursement cut in 2019; that’s 535 clinicians. That’s their estimate; I’m not sure how they arrived at that. For 2018, they estimate that there will be 10,900 MIPs-eligible GI clinicians, and 3.5% or 382 of them will receive the minus 5% cut in 2020. Are we really going to lose more than 1,000 MIPS-eligible GI clinicians? I think what’s going to happen is, as the proposed rule raises the Medicare charges exemption from $30,000 to $90,000, and raises the number of Medicare patients seen exemption from 100 to 200, there will be some GIs who don’t have to participate in MIPS because those exclusions are more liberal.

Look, this is a big burden, it’s a tremendous change. We’re looking at going from volume to value, and it’s not going to occur overnight, and this is only for Medicare. We’re not even talking about commercial payers yet. But Medicare is a trendsetter, so it’s not inconceivable to think that within a period of time, commercial payers are going to look at this as well. – by Jennifer Byrne

For more information:

Costas H. Kefalas, MD, MMM, FACG, FASGE, AGAF, can be reached at 570 White Pond Drive, #100, Akron, OH 44320; email:

Disclosure: Kefalas reports no relevant financial disclosures.