No Permanent Fix: MACRA, MIPS, and the Politics of Physician Payment Reform.

Organized medicine long yearned for the demise of Medicare's Sustainable Growth Rate (SGR) formula for updating physician fees. Congress finally obliged in 2015, repealing the SGR as part of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA established value-based metrics for physician payment and financial incentives for doctors to join alternative delivery models like patient-centered medical homes. Throughout the law's initial implementation, the politics of accommodation prevailed, with federal officials crafting final rules that made MACRA more favorable for physicians. However, the era of accommodation could be short-lived. The discretion that the Centers for Medicare and Medicaid Services had during the first two years of implementation is ending. Additionally, euphoria over the SGR's repeal has given way to concerns over the new program's value-based purchasing arrangements and uncertainty over their sustainability. MACRA eliminated the SGR, but not the politics of physician payment.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and the Merit-based Incentive Payment System.

As the implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Children's Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists.

Neurosurgeons' responses to changing Medicare reimbursement.

OBJECT: Medicare reimbursement for physician services has been declining even as the number of Medicare enrollees has been increasing. The number of Medicare participants will only continue to grow as the American population ages and the Patient Protection and Affordable Care Act goes into effect. Efforts to increase reimbursement for physician services through Medicare are often met with data showing that most neurosurgeons continue to participate in the program despite these cutbacks. To better understand this dichotomy, practicing neurosurgeons were surveyed to gauge their response to cutbacks in the Medicare program beyond just their participation status. METHODS: An Internet-based survey invitation was emailed to 3469 practicing neurosurgeons. Reminder emails were sent at intervals over several weeks to help increase the response rate. RESULTS: Among respondents, an overwhelming percentage (96.8%) participated in Medicare. The neurosurgeons indicated that about one-third of their patient population was covered by Medicare. They also reported limiting the number of Medicare patients they see through a variety of mechanisms: only seeing Medicare patients with a specific diagnosis or from certain referring physicians or limiting the number of appointment slots for Medicare patients. Many respondents stated that further declines in Medicare reimbursement would lead to a reduction in their participation. CONCLUSIONS: While most responding neurosurgeons do participate in the Medicare program, a substantial proportion modulates their participation through a variety of mechanisms. These barriers to care access for Medicare patients are only expected to become greater if further declines in reimbursement are implemented through the program.

Environmental, Social, Governance Risk and Corporate Sustainable Growth Nexus: Quantile Regression Approach.

Despite a huge body of literature revealing that the effect of environmental, social and governance (ESG) scores on a firms' financial performance and value, it lacks the empirical research on the nexus between corporate sustainable growth and ESG risk in the existing research. The paper aims to examine the nexus between ESG risk and corporate sustainable growth. This study utilizes a quantile regression approach to explore how ESG risk affects corporate sustainable growth (proxied by sustainable growth rate, SGR). The ordinary least squares estimation results confirm that ESG significantly negatively affects corporate sustainable growth. The quantile regression results reveal ESG risk has a significant negative effect on corporate sustainable growth in the upper quantiles of SGR, but not in the lower and median quantiles. The results show that the impact of ESG risk on the corporate sustainable growth is asymmetric and affected by the distribution of SGR. Furthermore, the research results identify that the negative relationship between ESG risk and corporate sustainable growth is particularly apparent for firms in environmentally sensitive industries. This study greatly contributes to existing literature, as with this detailed knowledge, managers can make decisions based on these associations and identify the most lucrative course of action.

The ACA Turns 10: Reflections Of Four Industry Leaders.

These leaders celebrate the ACA's successes, reflect on its shortcomings, and explain the politics that led to passage of the landmark act.

Trends in Medicare reimbursement for neurosurgical procedures: 2000 to 2018.

OBJECTIVE: There is currently a paucity of literature evaluating procedural reimbursements and financial trends in neurosurgery. A comprehensive understanding of the economic trends and financial health of neurosurgery is important to ensure the sustained success and growth of the specialty moving forward. The purpose of this study was to evaluate monetary trends of the 10 most common spinal and cranial neurosurgical procedures in Medicare reimbursement rates from 2000 to 2018. METHODS: The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for each of the top 10 most utilized Current Procedural Terminology codes in both spinal and cranial neurosurgery, and comprehensive reimbursement data were extracted. The raw percent change in Medicare reimbursement rate from 2000 to 2018 was calculated for each procedure and averaged. This was then compared to the percent change in consumer price index over the same time. Using data adjusted for inflation, trend analysis was performed for all included procedures. Adjusted R-squared and both the average annual and the total percent change in reimbursement were calculated based on these adjusted trends for all included procedures. Likewise, the compound annual growth rate was calculated for all procedures. RESULTS: When all reimbursement data were adjusted for inflation, the average reimbursement for all procedures decreased by an average of 25.80% from 2000 to 2018. From 2000 to 2018, the adjusted reimbursement rate for all included procedures decreased by an average of 1.59% each year and experienced an average compound annual growth rate of -1.66%, indicating a steady annual decline in reimbursement when adjusted for inflation. CONCLUSIONS: This is the first study to evaluate comprehensive trends in Medicare reimbursement in neurosurgery. When adjusted for inflation, Medicare reimbursement for all included procedures has steadily decreased from 2000 to 2018, with similar rates of decline observed between cranial and spinal neurosurgery procedures. Increased awareness and consideration of these trends will be important moving forward for policy makers, hospitals, and neurosurgeons as continued progress is made to advance agreeable reimbursement models that allow for the sustained growth of neurosurgery in the United States.

Alternative payment models: can (should) trauma care be bundled?

BACKGROUND: Recent legislation repealing the Sustainable Growth Rate mandates gradual replacement of fee for service with alternative payment models (APMs), which will include service bundling. We analyzed the 2 years' experience at our state-designated level I trauma center to determine the feasibility of such an approach for trauma care. METHODS: De-identified data from all injured patients treated by the trauma service during 2014 and 2015 were reviewed to determine individual patient injury profiles. Using these injury profiles we created the 'trauma bundle' by concatenating the highest Abbreviated Injury Scale score for each of the six body regions to produce a single 'signature' of injury by region for every patient. These trauma bundles were analyzed by frequency over 2 years and by each year. The impacts of physiology and resource consumption were evaluated by determination of the correlation of the mean and SD of calculated survival probability (Ps) and intensive care unit length of stay (ICU LOS) for each profile group occurring more than 12 times in 2 years. RESULTS: The 5813 patients treated over 2 years produced 858 distinct injury profiles, only 8% (71) of which occurred more than 12 times in 2 years. Comparison of 2014 and 2015 profiles demonstrated high frequency variation among profiles between the 2 years. Analysis of injury patterns occurring >12 times in 2 years demonstrated an inverse correlation between the mean and SD for Ps (R2=0.68) and a direct correlation for ICU LOS (R2=0.84). DISCUSSION: These data indicate that the disease of injury is too inconsistent a mix of injury pattern and physiologic response to be predictably bundled for an APM. The inverse correlation of increasing SD with increasing ICU LOS and decreasing Ps suggests an opportunity for measurable process improvement. LEVEL OF EVIDENCE: Economic and value-based evaluations, level IV. STUDY TYPE: Economic/decision.

Repeal of the Sustainable Growth Rate: an overview for surgeons.

BACKGROUND: The Medicare sustainable growth rate (SGR) formula is used to control Medicare spending on physician services. Under the current SGR formula, physicians face an almost 24% cut to the Medicare fee schedule on April 1, 2015. The US House Way & Means and Energy & Commerce Committees and the Senate Finance Committee released jointly proposed legislation to permanently repeal the SGR, and transition Medicare physician payment to a value-based payment method. This review summarizes the key components of the proposed legislation, and discusses some of the political challenges ahead. DATA SOURCES: House Committees on Energy & Commerce and Ways & Means, and the Senate Committee on Finance staff write-ups. CONCLUSIONS: Physician Medicare reimbursement will move from a volume-based model to a value-based model over the next decade. Surgeons should remain engaged with the political process to ensure repeal of the SGR.

The evolution of ambulatory ECG monitoring.

Ambulatory Holter electrocardiographic (ECG) monitoring has undergone continuous technological evolution since its invention and development in the 1950s era. With commercial introduction in 1963, there has been an evolution of Holter recorders from 1 channel to 12 channel recorders with increasingly smaller storage media, and there has evolved Holter analysis systems employing increasingly technologically advanced electronics providing a myriad of data displays. This evolution of smaller physical instruments with increasing technological capacity has characterized the development of electronics over the past 50 years. Currently the technology has been focused upon the conventional continuous 24 to 48 hour ambulatory ECG examination, and conventional extended ambulatory monitoring strategies for infrequent to rare arrhythmic events. However, the emergence of the Internet, Wi-Fi, cellular networks, and broad-band transmission has positioned these modalities at the doorway of the digital world. This has led to an adoption of more cost-effective strategies to these conventional methods of performing the examination. As a result, the emergence of the mobile smartphone coupled with this digital capacity is leading to the recent development of Holter smartphone applications. The potential of point-of-care applications utilizing the Holter smartphone and a vast array of new non-invasive sensors is evident in the not too distant future. The Holter smartphone is anticipated to contribute significantly in the future to the field of global health.