Decoding Acronyms in Orthopedic Value-based Policies

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Source: Stryker Instance


Acronyms and abbreviations are used throughout healthcare in order to shorten clinical nomenclature, as well as condense the names of complex healthcare programs and policies. Within the past decade, the advent of health care reform has created an extensive—and often confusing—vocabulary of acronyms that directly affect the field of orthopedic surgery.1 This includes the introduction of programs focused on value-based payment models for lower joint arthroplasty, as well as major changes to Medicare reimbursement policies that incentivize cost-effective quality care through a risk-based system of penalties and rewards.2,3 What follows is a brief overview of the key value-based programs and reimbursement policies currently impacting joint arthroplasty, a listing of the most commonly used acronyms, and a discussion of why being able to understand, or decode, the meaning behind the acronyms and abbreviations matters.


 The Acronyms of Value-based Programs

The passage of the Affordable Care Act (ACA) in 2010, ushered in a series of initiatives aimed at improving healthcare quality, reducing costs, and accelerating the shift from traditional fee-for-service (FFS) to value-based (VB) alternative payment models (APM). Bundled payment programs have been a particular area of focus for the Centers for Medicare & Medicaid Services (CMS) since Medicare is the largest purchaser of healthcare in the U.S—and total hip arthroplasty (THA) as well as total knee (TKA) arthroplasty are the most common and costly inpatient surgeries for Medicare beneficiaries.4 While cost-containment efforts for total joint arthroplasty (TJA) have been in place for several decades, the Center for Medicare and Medicaid Innovation (CMMI), created by the ACA, broadened this process by implementing a series of bundled payment initiatives, including the 2013 Bundled Payments for Care Improvement (BPCI) Initiative.3 Based on the success of BPCI, the Comprehensive Care for Joint Replacement (CJR) program was introduced in 2016, a bundled payment initiative for lower extremity joint replacements (LEJR) that became mandatory in 67 metropolitan statistical areas (MSA) based on population density.3 In 2018, BPCI-Advanced (BPCI-A) was introduced, a substantially revised version of the original BPCI that, among other important changes for orthopedic surgeons, removed total knee arthroplasty (TKA) from the Medicare Inpatient Only (IPO) list.5


The Acronyms of Medicare Quality and Performance-based Reimbursement

Adding to the growing lexicon of program acronyms impacting Medicare reimbursement for orthopedic surgery, in 2015 the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) made extensive changes to the physician fee schedule, including the creation of a two-track Quality Payment Program (QPP).3 Through the QPP, orthopedic surgeons can chose to participate in one of two payment systems, the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). The QPP includes MIPS, a pay-for-performance (P4P) model that combines CMS's three existing programs—Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBPM), and Meaningful Use of Electronic Health Record (EHR) system and calculates a provider’s Composite Performance Score (CPS) MIPS score based on quality, promoting interoperability, clinical improvement activities (CPIA), and cost.6,7 Notably, according to the American Academy of Orthopedic Surgeons (AAOS), in 2019, the majority of orthopedic surgeons will follow the MIPS tract for participating in the MACRA Quality Improvement Program.


Sorting Out the Acronyms

Making sense of the “alphabet soup” of acronyms, and how the programs and policies behind the letters impact the operational and financial aspects of orthopedic surgery, can be challenging.1 Many of these programs undergo frequent revisions and updates, such as MACRA and BPCI-A due to the program design, or as a result of physician/provider group feedback.8 Many CMS programs are also difficult to bucket into one specific category, since they are multi-layered and overlap with other value-based initiatives. For example, the APM tract of MACRA includes the subset, Advanced APMs (AAPM), of which Bundled Payments for Care Improvement Advanced (BPCI-A) qualifies as an AAPM.9

What follows is a listing by groups of many of the most commonly used value-based acronyms in orthopedic surgery, with the proviso that the groupings overlap—and the list includes many—but not all—of the most relevant acronyms currently in use.


 Acronyms Used in Value-Based and Bundled Payment Programs3

  • ACA – Affordable Care Act or PPACA – Patient Protection and Affordable Care Act
  • BPCI – Bundled Payment for Care Improvement
  • BPCI-A Bundled Payment for Care Improvement Advanced
  • CJR– Comprehensive Care for Joint Replacement
  • CMS – Centers for Medicare and Medicaid Services
  • CMMI– Center for Medicare and Medicaid Innovation
  • HRRP – Hospital Readmissions Reduction Program (quality measure for TJA)
  • MJRLE– Major Joint Replacement of The Lower Extremity
  • MSA– Metropolitan Statistical Area (for CJR)
  • IPO– Medicare inpatient-only (for TKA)
  • THA-Total Hip Arthroplasty
  • TJA-Total Joint Arthroplasty
  • TKA-Total Knee Arthroplasty

 

Acronyms Used in Medicare Reimbursement3

  • APM – Alternate Payment Model
  • AAPM – Advanced Alternate Payment Model
  • CPS – Composite Performance Score (for MIPS)
  • CEHR – Certified Electronic Health Record (for APMs)
  • HRRP –Hospital Readmissions Reduction Program (hospital quality measure)
  • FFS – Fee for Service
  • MACRA – Medicare Access and CHIP Reauthorization Act of 2015
  • MIPS – Merit-based Incentive Payment System
  • MS-DRG – Medicare Severity-Diagnosis Related Group ((Medicare fee schedule for inpatient claims)
  • PQRS – Physician Quality Reporting System
  • MSSP – Medicare Shared Savings Program, also known as the ACO program
  • ACO – Accountable Care Organization, also see MSSP
  • P4P– Pay for Performance
  • QPP– Quality Payment Program
  • VM or PVBM – Value-based Payment Modifier


Why Understanding Value-based Acronyms Matters

Given the ongoing changes to bundled payment programs, along with Medicare’s latest quality and performance-driven reimbursement frameworks, it is increasingly essential that orthopedic surgeons, practice administrators, and other orthopedic stakeholders understand what these acronyms signify in order to navigate the complex payment models and quality measures impacting orthopedic surgery.3 In today’s value-based, quality-driven reimbursement frameworks, acronyms have become more than just abbreviations; providers must be able to effectively understand and make decisions regarding how they will participate in programs such as BPCI-A, MIPS, and APMs; all of which require increasing levels of financial risk for performance, as well as far more focus on quality and outcomes reporting.3 Practices that are able to master the new vocabulary of these volume-based programs and payment models are more likely to benefit from the potential economic opportunities they present, as well as the cost-effective, quality patient care the programs and policies are designed to deliver.1,3

 

This material and/or presentation is provided for guidance and/or illustrative purposes only and should not be construed as a guarantee of future results or a substitution for legal advice and/or medical advice from a healthcare provider. Stryker Performance Solutions does not practice medicine and assumes no responsibility for the administration of patient care.
The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.
©2019 Stryker Performance Solutions, LLC.

 

 


 
References
  1. Seven scariest acronyms of healthcare explained, Medical Economics, December, 2016. https://www.medicaleconomics.com/health-law-and-policy/7-scariest-acronyms-healthcare-explained, Accessed June 17, 2019.
  2. CMS value-based programs, Centers for Medicare & Medicaid Services, May, 2019. https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/value-based-programs.html, Accessed June 17, 2019.
  3. Medicare reimbursement and orthopedic surgery: past, present, and future. Curr Rev Musculoskelet Med. 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435637/ Accessed February 20, 2019.
  4. Bundled Payments in Total Joint Replacement: Keeping Our Care Affordable and High in Quality, Curr Rev Musculoskelet Med. 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5577424/ Accessed February 21, 2019.
  5. The Shift to Outpatient Large-Joint Replacement Surgeries, Decision Group Resources, December, 2018. https://decisionresourcesgroup.com/drg-blog/shift-outpatient-large-joint-replacement-surgeries/ Accessed December, 2018.
  6. MACRA, MIPS, and APMS, Centers for Medicare & Medicaid Services, June, 2019. https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html Accessed June 19, 2019.
  7. Breaking down the MACRA final rule, Health Affairs, November, 2017. https://www.healthaffairs.org/do/10.1377/hblog20171109.968225/full/ Accessed June 21, 2019.
  8. CMS releases proposed rule for quality payment program year 2, AAOS Now, American Academy of Orthopaedic Surgeons, August, 2017. https://www.aaos.org/AAOSNow/2017/Aug/Advocacy/advocacy03/?ssopc=1 Accessed June 22, 2019.
  9. APMs and BPCI Advanced: what they mean for orthopaedists. AAOS Now, American Academy of Orthopaedic Surgeons, May, 2018. https://www.aaos.org/aaosnow/18046/ Accessed June 22, 2019.