The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 repealed the Sustainable Growth Rate (SGR) formula and created the Quality Payment Program (QPP) – the framework for a new value-based system that intends to stabilize Medicare payments to physicians. Under the QPP, clinicians are incentivized to provide high-quality and high-value care through Advanced Alternative Payment Models or the Merit-based Incentive Payment System (MIPS). MIPS eligible clinicians can receive a performance-based adjustment to their Medicare payments based on four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability.
To develop new MACRA episode-based cost measures for use in MIPS, the Centers for Medicare & Medicaid Services (CMS) contracted with Acumen, LLC to seek input from clinicians, patients, caregivers and other relevant stakeholders. The effort is now working in Wave 4, which includes the development of cost measures related to chronic heart failure.
Earlier this year, three HFSA members — Paul Heidenreich, MD, Marvin Konstam, MD, and Maria Rosa Costanzo, MD — were selected to serve on the Wave 4 workgroup to provide input and help ensure clinicians have relevant and valid measures that accurately reflect the care they are providing. Dr. Heidenreich serves as chair of the Wave 4 workgroup, and all three HFSA members previously assisted in the development of cardiology-focused cost measures during previous Waves.
“These decisions heavily impact heart failure specialists and their pay, so it’s critically important that HFSA members are driving the discussions in this way,” Dr. Konstam said. “I can see that our perspective is really having an impact. And, I’ve gained a great deal of respect for the Acumen team, who have been thoughtful and clearly value our input.”
The first Wave 4 workgroup meeting took place in late June to begin discussing several of the defining issues within the chronic heart failure cost measure, including:
- What triggers and defines an episode window
- What services and costs should be included in a chronic heart failure episode
- Which clinician is attributed to the patient
- The challenges of patient heterogeneity
- The importance of matching cost episodes with quality metrics
Each Wave is an iterative process whereby following each workgroup meeting, participants receive lengthy questionnaires detailing the items discussed and must confirm or clarify their feedback and recommendations. Acumen analyzes the responses and reflects them back to the workgroup, getting more granular each round.
The Wave 4 workgroup will continue to refine the measure through the end of the year. Initial measures developed will be field tested this fall. Data is then provided back to the workgroup to discuss and help shape practical decisions within the cost measure. At the end of the process, Acumen provides recommendations to CMS and the agency ultimately makes the final determination, through rulemaking, before implementing the new cost measure.
“Episodes of care for chronic heart failure are very complex. For example, we’re working to determine when a chronic episode begins. All three HFSA members were of the opinion that we should not include anything related to the hospitalization or a routine visit that occurs within 7 days of the hospitalization – however we did not have agreement on this among all workgroup participants,” said Dr. Costanzo. “We’re also working to determine attribution – which caregiver begins chronic heart failure treatment. These discussions don’t have easy answers, but the most important point is that heart failure specialists went from having zero input into measures like these, to now having 3 HFSA members at the table throughout the process.”
The final chronic heart failure cost measure is likely to be completed in the spring of 2022, at which point it would be proposed, through rulemaking, in order to be adopted under MIPS. The final measure is projected for use beginning in the 2024 performance year.
“There are significant challenges in creating a cost metric for a chronic disease like heart failure. We want to ensure the metrics appropriately attribute costs and excludes unimportant costs.” said Heidenreich. “HFSA members have been actively advocating for our specialty throughout each Wave of this process. And, HFSA continues work to strengthen coalitions with other cardiology stakeholder groups to help appropriately advocate for and influence the CMS decision-making that impacts our work.”
Ultimately, investing in more specialty, procedure-specific episodes of care will better capture what physicians have control over and provide a fairer evaluation of healthcare spending. HFSA members are invested in this process to help determine how heart failure patient care will be defined. Stay tuned, HFSA will provide additional updates as this process continues.