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Our first review of the 2018 Cost Measure Field Testing

Oct 12, 2018 10:13:59 AM

While there are many measures under review, the one that effects a majority of our clients is the Total Cost per Capita measure (TPCC). Our thoughts after reviewing these reports is that if these changes are implemented, specialists will continue to get attributed in the TPCC measure. Here are some notes on what we have found so far:

  • The current TPCC measure attributes patients to the primary care provider that provided the most primary care services (think E&M visits). If no primary care provider provided primary care services, patients would be attributed to your practice if you provided the most primary care services to that patient in the calendar year. If you and another specialist provided the name number of primary care services, the attribution would go to the practice with the most recent encounter.
  • The revised TPCC measure attributes patients to you if you provide an E&M visit and any other non-E&M primary care services are provided +/- 3 days from you or any other provider (even ones outside of your practice), or if you bill another primary care service within 90 days from the initial encounter. This is called the "candidate event".
  • To weed out specialists from this methodology, surgeons are excluded if 15% or more of your "candidate events" also have a 10-day or 90-day global surgery performed within +/- 180 days of the event. There are a few other exclusions, but I don't think they apply to you.
  • All services provided to that beneficiary from that "candidate event" and one year out will be attributed to your TIN in monthly chunks called "episodes". All episodes are payment and risk adjusted, then summed and divided by the total number of episodes attributed to you. This is your TPCC score.

Our own review shows that compared with the old attribution method, this new method affects 5x the amount of our clients than before. There are many flaws with this new method:

  • In regards to the first candidate event, I believe the +/- 3 day window of capturing other primary care services around the E&M visit is to catch if primary care providers are ordering testing, labs, and radiology around the visit from outside groups. This makes sense, but if you happen to see the patient around that time, you will get looped in. 
  • The other candidate event filter, on if another E&M visit is billed within 90 days makes sense, as I find it rare for my customers to use an E&M more than once (usually on the first visit). However because each filter is either or, there is an issue. I would reccomend that CMS use both filters together to determine "candidate events".
  • The exclusion out of the attribution based on surgery is a great addition, but it doesn't do anything for specialists that do not always perform surgery. 
  • This already complex measure has become even more complex, and we are continuing to learn more about it and bring you more information.

Randy Marsden

Written by Randy Marsden

Randy Marsden is the founder of the MIPS consulting firm MarsdenAdvisors.

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