The editorial1Gloviczki P. Lawrence P. Appropriate management of patients with claudication.J Vasc Surg. 2022; 76: 23-24Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar preceding the far-reaching article on appropriate use criteria (AUC) goes too far in its declarations. Drs Gloviczki and Lawrence correctly identified the most important caveats of the AUC recommendations:•The importance of risk factor modification;•Claudication rarely progresses to chronic or critical limb-threatening ischemia (CTLI);•Proximal disease responds better to treatment than distal disease;•Patients should understand the natural history of intermittent claudication;•The AUC recommendations will change with changing technology, medications, etc. The leaders of the SVS and the authors of the AUC document2Woo K. Siracuse J.J. Klingbeil K. Kraiss L.W. Osborne N.H. Singh N. et al.Society for Vascular Surgery appropriate use criteria for the management of intermittent claudication.J Vasc Surg. 2022; 76: 3-22Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar correctly modified the original text of the recommendations at least partly due to the outcry from many stakeholders (personal communications with various members and leaders of the SVS). The words "appropriate" and "inappropriate" were struck from the body of the document because the terms "carry many different and often highly charged social connotations in the 21st century."2Woo K. Siracuse J.J. Klingbeil K. Kraiss L.W. Osborne N.H. Singh N. et al.Society for Vascular Surgery appropriate use criteria for the management of intermittent claudication.J Vasc Surg. 2022; 76: 3-22Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Additionally, the AUC "should be flexible."2Woo K. Siracuse J.J. Klingbeil K. Kraiss L.W. Osborne N.H. Singh N. et al.Society for Vascular Surgery appropriate use criteria for the management of intermittent claudication.J Vasc Surg. 2022; 76: 3-22Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar I and many others applauded these and other changes to the AUC recommendations publicly and privately. However, Drs Gloviczki and Lawrence ended their opinion piece poorly without considering the ramifications of the considerable weight of their words on our organization and public and private insurors. Drs Gloviczki and Lawrence advocate for using the AUC recommendations to "determine authorization and reimbursement policies," and "be used to deny reimbursement for physicians who repeatedly intervene . . .".1Gloviczki P. Lawrence P. Appropriate management of patients with claudication.J Vasc Surg. 2022; 76: 23-24Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar This is a wrong-headed advocation to use the AUC recommendations as a cudgel with which to batter those of us treating vascular patients in the trenches. The AUC panel and SVS correctly and significantly altered the original text of the AUC recommendations precisely because of the outcry regarding statements like those above. It is not possible for an insurance carrier to write guidelines for payment for claudication using the AUC recommendations because the physician and the patient are and should always be the final arbiters of treatment decisions. Furthermore, statements like those of Drs Gloviczki and Lawrence result in more attention by independent, for profit, auditing vendors for the Centers for Medicaid and Medicare Services (CMS) to practitioners who treat all vascular surgery. Attention equals an audit. It is generally not possible to beat an audit from CMS (whether you are clinically wrong or not), and an audit equals tens or hundreds of thousands of dollars in attorney's fees, refunds and fines. There are other ways to catch the few outliers in vascular intervention that do not involve wholesale change in the industry. The editors' words do great damage to our Society. The editorial published by Drs Gloviczki and Lawrence are harmful, they will offend many and most importantly, they fly in the face of the intent of the AUC recommendations. Appropriate management of patients with claudicationJournal of Vascular SurgeryVol. 76Issue 1PreviewTo improve healthcare, when the volume of published information on a topic is massive and advice regarding management appears to be conflicting, several processes have evolved to make sense of an overwhelming amount of information. First, "reporting standards" enable "apples to apples" comparisons of data in publications. Next, with a topic like claudication, its definition is particularly important, since many patients are at an advanced age, where leg pain is common and may have many different etiologies. Full-Text PDF ReplyJournal of Vascular SurgeryVol. 77Issue 5PreviewWe appreciate very much Dr Ryan's response to our editorial on the appropriate management of patients with claudication1 and thank him for his comments on what we "got right". We fully understand the impact of an audit for a perceived violation of a reimbursement policy. In fact, both of us have worked in clinical environments that are "in the trenches". We believe, though, that Dr Ryan misinterpreted our comments about the role of appropriate use criteria (AUC) in reimbursement policy. An AUC is intended to provide guidance to well-intentioned physicians who may not be aware of all of the published literature or of the opinions of expert leaders in the field, but it is not intended to be a set of inviolate rules. Full-Text PDF

Closure devices are available in a range of different schemata to close the percutaneous arteriotomy. Although they may contribute to room turnover and increased time to ambulation, they carry the risk of dissection, thrombosis, failure, and expense that may bring a patient back for an avoidable operation, causing undue stress to a patient who elected to avoid the hospital to seek office-based care. In addition, there is hardship of a foreign object in the skin, increasing inflammation and scarring should the groin need to be reaccessed or exposed.

Background The U.S. healthcare system is undergoing a broad transformation from the traditional fee-for-service model to value-based payments. The changes introduced by the Medicare Quality Payment Program, including the establishment of Alternative Payment Models, ensure that the practice of vascular surgery is likely to face significant reimbursement changes as payments transition to favor these models. The Society for Vascular Surgery Alternative Payment Model taskforce was formed to explore the opportunities to develop a physician-focused payment model that will allow vascular surgeons to continue to deliver the complex care required for peripheral arterial disease (PAD). Methods A financial analysis was performed based on Medicare beneficiaries who had undergone qualifying index procedures during fiscal year 2016 through the third quarter of 2017. Index procedures were defined using a list of Healthcare Common Procedural Coding (HCPC) procedure codes that represent open and endovascular PAD interventions. Inpatient procedures were mapped to three diagnosis-related group (DRG) families consistent with PAD conditions: other vascular procedures (codes, 252-254), aortic and heart assist procedures (codes, 268, 269), and other major vascular procedures (codes, 270-272). Patients undergoing outpatient or office-based procedures were included if the claims data were inclusive of the HCPC procedure codes. Emergent procedures, patients with end-stage renal disease, and patients undergoing interventions within the 30 days preceding the index procedure were excluded. The analysis included usage of postacute care services (PACS) and 90-day postdischarge events (PDEs). PACS are defined as rehabilitation, skilled nursing facility, and home health services. PDEs included emergency department visits, observation stays, inpatient readmissions, and reinterventions. Results A total of 123,180 cases were included. Of these 123,180 cases, 82% had been performed in the outpatient setting. The Medicare expenditures for all periprocedural services provided at the index procedure (ie, professional, technical, and facility fees) were higher in the inpatient setting, with an average reimbursement per index case of $18,755, $34,600, and $25,245 for DRG codes 252 to 254, DRG codes 268 and 269, and DRG codes 270 to 272, respectively. Outpatient facility interventions had an average reimbursement of $11,458, and office-based index procedures had costs of $11,533. PACS were more commonly used after inpatient index procedures. In the inpatient setting, PACS usage and reimbursement were 58.6% ($5338), 57.2% ($4192), and 55.9% ($5275) for DRG codes 252 to 254, DRG codes 268 and 269, and DRG codes 270 to 272, respectively. Outpatient facility cases required PACS for 13.7% of cases (average cost, $1352), and office-based procedures required PACS in 15% of cases (average cost, $1467). The 90-day PDEs were frequent across all sites of service (range, 38.9%-50.2%) and carried significant costs. Readmission was associated with the highest average PDE expenditure (range, $13,950-$18.934). The average readmission Medicare reimbursement exceeded that of the index procedures performed in the outpatient setting. Conclusions The cost of PAD interventions extends beyond the index procedure and includes relevant spending during the long postoperative period. Despite the analysis challenges related to the breadth of vascular procedures and the site of service variability, the data identified potential cost-saving opportunities in the management of costly PDEs. Because of the vulnerability of the PAD patient population, alternative payment modeling using a bundled value-based approach will require reallocation of resources to provide longitudinal patient care extending beyond the initial intervention.

The Society for Vascular Surgery Alternative Payment Model (APM) Taskforce document explores the drivers and implications for developing objective value-based reimbursement plans for the care of patients with peripheral arterial disease (PAD). The APM is a payment approach that highlights high-quality and cost-efficient care and is a financially incentivized pathway for participation in the Quality Payment Program, which aims to replace the traditional fee-for-service payment method. At present, the participation of vascular specialists in APMs is hampered owing to the absence of dedicated models. The increasing prevalence of PAD diagnosis, technological advances in therapeutic devices, and the increasing cost of care of the affected patients have financial consequences on care delivery models and population health. The document summarizes the existing measurement methods of cost, care processes, and outcomes using payor data, patient-reported outcomes, and registry participation. The document also evaluates the existing challenges in the evaluation of PAD care, including intervention overuse, treatment disparities, varied clinical presentations, and the effects of multiple comorbid conditions on the cost potentially attributable to the vascular interventionalist. Medicare reimbursement data analysis also confirmed the prolonged need for additional healthcare services after vascular interventions. The Society for Vascular Surgery proposes that a PAD APM should provide patients with comprehensive care using a longitudinal approach with integration of multiple key medical and surgical services. It should maintain appropriate access to diagnostic and therapeutic advancements and eliminate unnecessary interventions. It should also decrease the variability in care but must also consider the varying complexity of the presenting PAD conditions. Enhanced quality of care and physician innovation should be rewarded. In addition, provisions should be present within an APM for high-risk patients who carry the risk of exclusion from care because of the naturally associated high costs. Although the document demonstrates clear opportunities for quality improvement and cost savings in PAD care, continued PAD APM development requires the assessment of more granular data for accurate risk adjustment, in addition to largescale testing before public release. Collaboration between payors and physician specialty societies remains key.

The Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) was passed by a bipartisan vote of Congress in 2015. MACRA repealed the sustainable growth rate that threatened to reduce Medicare physician payments by >20% yearly. At the same time, MACRA created the Quality Payment Program (QPP), which requires that most physicians who submit claims to the Centers for Medicare and Medicaid Services (CMS) participate in one of two programs: the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM). There is currently no approved vascular condition-specific APM, so many vascular surgeons will participate in MIPS. Medicare physicians who do not perform adequately in an APM or MIPS in 2020 will be subject to a 9% reimbursement penalty in 2022. CMS has finalized the rules for MIPS reporting Year 4, which runs from January 1 to December 31, 2020.12020 Quality Payment Program final rule FAQs.https://qpp-cm-prod-content.s3.amazonaws.com/uploads/739/2020%20QPP%20Final%20Rule%20FAQs.pdfDate accessed: December 1, 2019Google Scholar The performance categories and the weight that they contribute to the final score remain unchanged from Year 3: Quality (45%), Cost (15%), Promoting Interoperability (25%), and Improvement Activities (15%). In the Quality performance category, data on 70% of eligible patients for any given measure must be reported for the measure to be considered complete (up from 60% in Year 3) for the purposes of contributing to the MIPS quality category score. Quality measures eligible for use in MIPS are available on the CMS website in the QPP Resource Library. Topped-out measures that CMS considers to be maximized out on their potential for quality improvement may now be removed from MIPS eligibility in the future, and these are published on the website along with their historical quality benchmarks for all measures. In general, for all measures, historical quality benchmarks are used for scoring performance. In the Improvement Activities category, 2 new activities are available, 7 were modified, and 15 were removed. These can also be viewed on the CMS website in the QPP Resource Library. In the Promoting Interoperability category, the requirements remain unchanged from Year 3 with one set of required objectives and measures based on the 2015 Edition Certified Electronic Health Record Technology. The four required objectives are e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. Clinicians are required to report certain measures from each of the four objectives unless an exclusion is claimed. There is language in the final rule that implies changes will be made to the Promoting Interoperability category in future rulemaking, possibly as soon as for 2021 reporting. In the Cost category, 10 new episode-based cost measures were added to compare costs among clinicians for treating common conditions. Hemodialysis Access Creation is the only cost measure among the new measures that applies to vascular surgery. The Management of Chronic Critical Limb Ischemia cost measure used in Year 3 that is relevant to vascular surgery will be continued in Year 4. The Total Per Capita Cost and Medicare Spending Per Beneficiary cost measures will also remain in use. Hospital-based clinicians who choose to report as a group or virtual group are eligible for reweighting when >75% of the National Provider Identifiers in the group or virtual group meet the definition of a hospital-based individual MIPS-eligible clinician. The performance threshold to avoid a penalty is increased to 45 points from 30, and the exceptional performance threshold is increased to 85 points from 70. The MIPS changes outlined here will have an impact on vascular surgery and should be considered in a surgeon's strategy for reporting the MIPS program components to CMS in 2020.

The Quality Payment Program, established by the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 (MACRA), requires Medicare providers to participate in either the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model to avoid a 7% payment penalty in 2021 Medicare reimbursements.1 Understanding the MIPS final score calculation can help providers minimize penalties and maximize positive payment adjustments in 2021.

The Medicare Access and Children's Health Insurance Program Reauthorization Act is a bipartisan legislation signed into law in 2015. The Medicare Access and Children's Health Insurance Program Reauthorization Act requires all providers (physicians, dentists, podiatrists, chiropractors, nurse practitioners, certified nurse anesthetists) who bill Medicare to participate in the Merit-Based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model to avoid a 7% penalty in 2021 Medicare reimbursements.

The Quality Payment Program, established by the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA), requires Medicare providers to participate in the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (AAPM). No AAPM is currently approved for vascular surgery, and most vascular surgeons will participate in MIPS. Failure to participate adequately in MIPS in 2019 will result in a 7% penalty in 2021 reimbursements. The Quality category will account for 45% of the final MIPS score in the 2019 reporting year. Not only is measurement of Quality in health care required by MACRA, it is also variably required by third-party payers, accreditation bodies, and even specialty boards for physician maintenance of certification. As a result, measurement of processes of clinical care and outcomes has become an essential component of medical practice, occupying significant blocks of physician and staff time as well as institutional resources, for the purpose of self-directed and mandated quality improvement. Few specialties are affected more than vascular and endovascular surgery. Clinical data registries have emerged as sophisticated tools for measuring processes of care and clinical outcomes. Registry data can be used to facilitate changes in practice that drive quality improvement. Widespread participation at the regional and national level allows identification of areas for systemic improvement, provides a mechanism for individual practitioners and institutions to assess the quality of their care against regional or national benchmarks, and facilitates adoption of best practices when improvement is needed. The Society for Vascular Surgery (SVS), American College of Surgeons, and American College of Cardiology have each responded to the need for clinical process and outcome measurement tools with the development of data registries for vascular care. Although the registries described here cannot be used for MIPS reporting, they can be included in the design of an AAPM to satisfy the Quality requirement. The objectives of this series of articles are to provide an overview of existing registries that capture vascular and endovascular procedures and to describe how hospitals and physicians are using these registries to satisfy requirements for quality improvement activities, measurement of value-based care, and achievement of full reimbursement imposed by regulators and payers. This first article will focus on the SVS Vascular Quality Initiative (VQI). In 2011, the VQI was formed as a national quality improvement project of the SVS, based on the pioneering work of the Vascular Study Group of Northern New England. The VQI offers 12 procedural registries: carotid artery stent, carotid endarterectomy, endovascular aneurysm repair, open abdominal aortic aneurysm repair, hemodialysis access, inferior vena cava filter, infrainguinal bypass, suprainguinal bypass, lower extremity amputation, peripheral vascular intervention, thoracic and complex endovascular aneurysm repair, and varicose vein. The VQI has 18 regional quality groups that meet in person twice a year. The VQI captures consecutive cases audited by billing data. In-hospital outcomes and follow-up between 9 and 21 months for key outcomes are captured, and long-term survival after procedures is monitored through linkage to the Social Security Death Index. Participating institutions receive regular reports showing institutional outcomes relative to regional and national benchmarks. Ongoing development includes a vascular medicine registry for release in 2019 (in conjunction with the American Heart Association and Society for Vascular Medicine), a venous stent registry for release in 2019, and a vascular ultrasound registry that is currently in the pilot stage. Cost includes a $5000 one-time setup fee and $2515 annual fee per registry.

The Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) established the Quality Payment Program (QPP). The QPP requires that most physicians who submit claims to the Centers for Medicare and Medicaid Services (CMS) participate in one of two programs: Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Model (APM). There is currently no approved vascular APM, so most vascular surgeons will participate in MIPS. The MIPS final score is calculated from four component category scores: Quality, Advancing Care Information (ACI), Clinical Practice Improvement Activities, and Cost. Providers have a number of options for participating in MIPS. This article details the experience of one solo private practice vascular surgeon, Dr Patrick Ryan, with MIPS. Dr Ryan is a Vascular Quality Initiative (VQI) participant and took advantage of VQI's status as a qualified clinical data registry (QCDR). Dr Ryan used VQI's QCDR certification to easily submit high-value data that are relevant to vascular surgery to satisfy the quality category. Within the VQI, there are multiple process and outcomes measures across all registries. The provider selects the measures that will yield the highest performance scores. Being a participant in eight VQI registries provided a large number of measures for Dr Ryan to choose from, but even participating in one or two registries would have been adequate. Dr Ryan selected four outcomes measures and two process measures where he was a high performer. Reporting for the ACI category was completed using the practice's certified electronic health record technology (CEHRT) and attestation. Several of the ACI measures are dependent on patient participation, which requires patients to create an account for the electronic portal, to log in, and to perform specific activities including viewing of medical records and sending messages to the provider. Despite aggressive encouragement from Dr Ryan and his staff, patients' response rate to portal use was low. As a result, Dr Ryan's practice scored poorly on these measures. Reporting for Clinical Practice Improvement Activities also was done using the CEHRT. The minimum 2017 reporting requirement was two medium-weight and one high-weight measure. Dr Ryan's practice reported on 10 medium- and 2 high-weight measures, well above the minimum but below the maximum possible. All of the activities were related to participating in a QCDR, another benefit of being a VQI member. MIPS Cost category performance is calculated using claims data and does not require reporting. The practice's CEHRT and use of the VQI QCDR allowed the submission process to take less than 30 minutes and was done through the QPP website. The 2017 MIPS performance scores will result in bonus, penalty, or neutral payment adjustments in 2019. This information is available on the QPP website. In checking the website, it was discovered that CMS considered Dr Ryan's practice to be part of a local APM even though the practice had never submitted any claim through that APM and had never seen any documentation regarding participation in the APM. Thus, CMS disregarded the data reported by Dr Ryan's practice. This emphasizes the importance of reviewing feedback reports that are available through CMS. The practice is in discussions with CMS to correct the error.

The Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) established the Quality Payment Program (QPP), which shifts Medicare from a fee-for-service to a pay-for-performance program. The QPP requires that most Medicare providers participate in the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM). As there are no approved vascular APMs, most vascular surgeons will participate in MIPS. Providers who do not meet 2018 minimum participation requirements will receive a 5% penalty in 2020 reimbursements. The first performance year was 2017, and feedback reports for participating providers are available through the Centers for Medicare and Medicaid Services (CMS) website: https://qpp.cms.gov. QPP participants are required to obtain Enterprise Identity Management (EIDM) credentials to obtain their feedback reports. The EIDM credentials are used to submit and to review data for MIPS reporting. Clinicians submitting data as an individual already have EIDM credentials, whereas someone within small group submissions will also have EIDM credentials or know who in their practice does. Partcipation in QPP as part of a large health care organization or academic institution may present challenges in finding the proper department to help you provide access to your data/feedback reports. Institutions participating as an MIPS APM1White P.W. Sales C.M. Johnson B. Rathbun J. Woo K. What is an MIPS APM?.J Vasc Surg. 2018; 67: 353Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar (distinct from an Advanced APM) are responsible for distributing feedback data to clinicians; CMS will not directly provide feedback data to individuals.2Merit-based Incentive Payment System (MIPS) 2017 Performance Feedback Guide.https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2017-Performance-feedback-user-guide.pdfDate accessed: August 23, 2018Google Scholar If you do not have EIDM credentials, the first step in obtaining your QPP performance report is to create an account within the CMS Enterprise portal (https://portal.cms.gov). Select “PV: Physician Quality and Value Programs” from the application drop-down menu. Enter your demographic information, select a user name, and answer three challenge questions that can later be used to verify your identity. Submit the form, and you should receive an e-mail acknowledging successful account creation with your EIDM user ID. If you are in a large group and need to find out if your practice or organization is already registered in the EIDM, contact the Quality Payment Program by phone (1-866-288-8292/TTY 877-715-6222) or by e-mail ([email protected]). You will need to provide the group's Tax Identifier Number and the name of the group. Again, if your practice has submitted data to QPP, then someone in your group has EIDM credentials and should be able to provide your feedback report to you. With your EIDM credentials, you will be able to log into the CMS Quality Payment Program website, https://qpp.cms.gov. Select the “View Performance Feedback” button to obtain your report and to review all of the practice sites to which data were submitted under your National Provider Identifier and Tax Identifier Number. Based on your EIDM credentials, you may be able to review performance feedback for your entire group or be restricted to individual data. Detailed instructions on accessing performance feedback reports are available in the MIPS 2017 Performance Feedback Guide2Merit-based Incentive Payment System (MIPS) 2017 Performance Feedback Guide.https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2017-Performance-feedback-user-guide.pdfDate accessed: August 23, 2018Google Scholar with examples of reports and interpretations. According to CMS, 91% of MIPS-eligible clinicians successfully submitted data in 2017. High performers will receive up to a 4% bonus in their 2019 reimbursements. A final score of 70 or greater qualifies a provider for an additional bonus adjustment for exceptional performance from a $500 million incentive pool.

OBJECTIVE:Carotid endarterectomy (CEA) has been shown to be an effective treatment for patients with asymptomatic carotid artery stenosis when perioperative stroke rates are low and patients survive long enough to benefit from the intervention. Our objective was to develop and to validate a simple risk prediction model for 30-day stroke and 1-year mortality to guide optimal selection of patients for CEA. METHODS:Asymptomatic patients undergoing first-time elective CEA within the Vascular Quality Initiative (VQI) from 2010 to 2015 were selected. Outcome measures included any 30-day postoperative stroke and 1-year mortality. Patient demographics, comorbidities, carotid artery disease burden, and provider characteristics were evaluated to select a parsimonious clinical model for risk prediction using multivariable logistic regression. Internal validation was performed for stroke and split sample validation was done for 1-year survival to ensure generalizability. RESULTS:We identified 31,939 patients for inclusion in the stroke analysis (2010-2015) and 24,086 patients for the mortality analysis (2010-2014). Both the 30-day stroke rate (0.9%) and 1-year mortality rate (3.4%) varied substantially across 265 VQI centers (range, 0%-8.3% and 0%-20%, respectively). Eleven significant factors were selected for the 30-day stroke risk prediction model (area under the receiver operating characteristic curve [AUC], 0.67). Internal validation demonstrated good discrimination (bias corrected AUC = 0.652; calibration intercept and slope of 0.03 and 1.01, respectively). Similarly, 10 significant factors were selected for the 1-year mortality risk prediction model (AUC, 0.764). External validation demonstrated excellent discrimination and calibration (AUC, 0.764; 95% confidence interval, 0.72-0.80). CONCLUSIONS:Stroke and 1-year mortality rates after CEA for asymptomatic stenosis vary across VQI centers. We have developed a preoperative risk model that can be used to accurately estimate risk of perioperative stroke and 1-year mortality and to assist providers in selecting patients with asymptomatic stenosis who are most likely to benefit from CEA.

Under the Medicare Access and CHIP Reauthorization Act (MACRA), providers who receive payment from Medicare must participate in either the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM) in 2017 in order to avoid a 4% payment penalty in 2019. As there are currently no vascular APMs available, the majority of vascular providers will participate in MIPS in 2017.