On June 20, 2017, the Centers for Medicare & Medicaid Services (CMS) released its proposed updates outlining the changes to the Quality Payment Program (QPP) for 2018. The QPP, established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), began offering an incremental implementation approach for the new payment program in 2017. The proposed updates provide further implementation rules for the payment program’s second year, maintain the incremental approach and extend provider flexibility and support for clinicians.
Key takeaways regarding the Merit-based Incentive Payment System (MIPS) reporting track from the proposed rule include:
- Increases low-volume threshold – CMS proposes to raise the low-volume threshold from less than $30,000 in Part B-allowed charges or fewer than 100 Part B patients to less than $90,000 in Part B-allowed charges or fewer than 200 Part B patients. This increase is estimated to exclude an additional 134,000 clinicians from MIPS reporting. CMS estimates a majority of the excluded clinicians are in small and rural practices.
- Reweights cost category to 0 percent in the 2018 performance year – Although clinicians won’t be scored on cost in year two, the law requires that CMS weighs cost at 30 percent in performance year 2019. CMS will provide clinicians and groups with cost performance data for MIPS clinicians to prepare for cost in 2019.
- Raises the bar for MIPS performance – CMS proposes to raise the composite performance threshold from three to 15 points to avoid a negative payment adjustment on Medicare professional revenues. CMS also will require eligible participants or groups to report 12 months of quality performance data in year two.
- Establishes virtual groups – CMS has provided guidance for establishing virtual groups, which were mentioned in the final rule but not implemented for the transition year. Virtual groups allow group practices of 10 or fewer clinicians to join with other solo or small practices to qualify for MIPS.
- Delays 2015 CEHRT requirement – CMS has delayed the requirement to only use 2015 edition Certified Electronic Health Record Technology (CEHRT) for year two. This delay means clinicians and groups may continue to use 2014 CEHRT during the 2018 performance year.
- Provides facility-based measures option – CMS could allow hospital-based clinicians and groups to report their hospital’s Value-Based Purchasing (VBP) program performance to satisfy MIPS quality and cost categories.
- Offers MIPS bonus points for:
- Complex patients – CMS will use Hierarchical Condition Category risk scores to assess the complexity of a provider’s patient population and award between one and three bonus points.
- Small practices – Practices with 15 or fewer clinicians will be awarded five points on their final MIPS scores.
- Using only 2015 CEHRT – Clinicians and groups using only 2015 edition CEHRT to report data will receive bonus points.
- Rewards improvement on quality metric performance – CMS will calculate an improvement score by comparing clinicians’ current performance period to their previous performance period. Clinicians and groups may receive up to 10 percentage points.
- Maintains MIPS performance category weights –Quality will remain 60 percent of the total composite score if cost is reweighted to 0 percent. The Improvement Activities category will remain 15 percent and the Advancing Care Information category will remain 25 percent of the total composite score.
Key takeaways regarding the Alternative Payment Model (APM) participation track from the proposed rule include:
- Estimates increase in Advanced APM participation – CMS estimates that participation will double—from 120,000 qualified participants in 2017 to 245,000 in 2018—due to the addition of Medicare Shared Savings Program Track 1+, reopening of the Next Generation Accountable Care Organization program and expansion of the number of regions participating in the Comprehensive Primary Care Plus (CPC+) program.
- Extends risk-based nominal standard for APM designation under MACRA – The Advanced APM 8 percent revenue-based qualification standard may be extended for another two years under the proposed updates. CMS is maintaining all other existing APM qualification criteria.
- Provides details about the All-Payer Combination Option – The All-Payer Combination Option will be available to clinicians beginning in 2019.
Next steps may include:
- Conducting a holistic review of your organization’s performance under the Hospital and Physician VBP program – Since CMS has proposed the adoption of the facility-based measures reporting option, organizations now have an opportunity to align and focus their performance and reporting strategies across multiple CMS value-based reimbursement programs.
- Assessing opportunities to form virtual groups or partnerships with solo or small practices – With the addition of virtual groups in 2018, solo and small practices may increasingly look to form groups—or partner—with other organizations in an attempt to improve performance and reduce reporting costs associated with MIPS compliance.
- Identifying and refining your organization’s value-based reimbursement strategy – APMs are becoming an increasingly popular tactic for track selection and participation under the QPP. In the proposed rule, CMS has estimated that Advanced APM participation will grow by 104 percent between performance years 2017 and 2018. With the potential increase in the number of clinicians excluded from MIPS reporting, and the uptick in Advanced APM participation, the MIPS track is becoming more competitive. Organizations should begin to evaluate current capabilities to manage payment risk, assess timing and feasibility of potentially entering into risk-based reimbursement strategies and assess how it will affect their QPP strategy.
CMS accepted comments until August 21, and a final rule is expected to be released in the fall. Additional resources and tools for the QPP can be found at the CMS Quality Payment Program website. CMS developed a MIPS lookup tool for clinicians to verify eligibility and identify whether the clinician or group qualifies for special status, which may result in bonus points or preferential scoring for 2017 performance. For more resources related to MACRA, MIPS, CPC+ and other CMS Innovation initiatives, visit our Payment Reform Resource Center.