The Centers for Medicare & Medicaid Services (CMS) issued on November 2nd its final rule with comment period for the MACRA Quality Payment Program (QPP) Year 2. With a continued focus on providing flexibility and reducing administrative burdens, CMS listened to stakeholders’ concerns and challenges by promising to:
- Go slow while preparing clinicians for full implementation in Year 3;
- Provide more flexibility to help reduce burden; and
- Offer new incentives for participation.
Several takeaways from the interim final rule are worth noting:
Merit-Based Incentive Payment System (MIPS)
- The low-volume threshold increase will allow even more eligible clinicians (ECs) to be exempt in Year 2 than in the Transition Year. For 2018, the low-volume threshold for excluding ECs or groups has increased to ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries.
- With changes in the 2018 performance category weighting, it’s even more important for ECs to utilize feedback provided by CMS & make improvements quickly, especially related to Cost performance. The 2018 performance category weighting will be: Quality—50%, Cost—10%, Improvement Activities (IA)—15%, and Advancing Care Information (ACI)—25%. This will affect how payments adjustments are calculated in 2020.
- ECs need to be strategic in choosing quality measures and should avoid those finalized as topped out for 2018. For the Quality performance category, the 3-point floor will remain, and topped-out measures will be removed and scored on 4-year phasing out timeline. CMS has finalized six topped out measures for 2018.
- The change to the Cost performance category will impact scoring in 2018, but it won’t require ECs to submit data. It will include two cost measures—Medicare Spending per Beneficiary (MSPB) and total per capita cost measures—to calculate the Cost performance category score for the 2018 performance period.
- CMS continues to maintain flexibility by allowing continued use of 2014 or 2015 Edition Certified EHR Technology (CEHRT) in 2018, and will grant a 10% bonus for using only 2015 Edition CEHRT. In addition, the 21st Century Cures Act will allow reweighting of the ACI performance category to 0% of the final score and reallocate the 25% to the Quality performance category for hardship exceptions, hospital-based MIPS Eligible Clinicians (ECs), ASC-based MIPS ECs, and for MIPS ECs whose EHR system is decertified.
- EC’s will have to report more in Year 2 to avoid a negative payment adjustment as CMS is raising the MIPS performance threshold from 3 points to 15 points for Payment Year 2020 The additional performance threshold stays at 70 for exceptional performance. In addition, the performance period for the ACI and IA categories will remain at a minimum 90-day period and the cost category will remain at measurement for 12 months. The performance period for the quality category has been finalized to a 12-month performance period. These policy changes continue to cause ECs have more skin in the game and to focus on cost control—since cost performance counts in the final score for Year 2—and high quality care—which is measured for a full 12 months instead of a minimum of 90 days in Year 2.
- Easing potential MIPS burdens, CMS has finalized a complex patients bonus for clinicians to earn up to five bonus points for the treatment of complex patients and a small practice bonus (15 or fewer ECs) of five additional points if they submit data on at least one performance category in an applicable performance period.
- CMS has allowed generous flexibility for clinicians due to extreme and uncontrollable circumstances, such as hurricanes, natural disasters, or public health emergencies. Clinicians may be exempted from MIPS reporting requirements or allowed to reweight certain performance categories for both the 2017 Transition Year and Year 2.
- Facility-based clinicians who are considered MIPS ECs will have to comply with MIPS reporting requirements for Year 2 and won’t have the option to convert the hospital’s VBPP score into a MIPS score. The proposal of a voluntary facility-based measurement option to convert a hospital Total Performance Score (based on the Hospital Value-Based Purchasing Program (VBPP)) into a MIPS Quality performance category and Cost performance category score will be delayed until Year 3.
- ECs will need to continue to weigh pros and cons of submission mechanisms in order to choose the most beneficial mechanism per performance category in Year 2. Only one submission mechanism performance category will be allowed for 2018, which is no change from the 2017 transition year. However, multiple submission mechanisms will be allowed in Year 3.
- Now clinicians have three choices for MIPS participation—individuals, groups, or virtual groups. Virtual Groups will be added as a participation option for Year 2 allowing two or more clinicians to come together virtually—regardless of specialty or location—to participate in MIPS for a performance year. If you are considering this new option for 2018, you must act quickly. The election process runs from October 11 -December 31, 2017.
Alternative Payment Models (APMs)
- Round 1 participants in the CPC+ Model will be exempt from the requirement that the Medical Home Model (MHM) financial risk standard applies only to APM Entities with fewer than 50 clinicians in their parent organization. In addition, CMS has finalized the change in requirements so that the minimum required amount of total potential risk for APM entity under the MHM nominal amount standard increases more gradually.
- CMS is making it easier for clinicians to be classified as Qualified Participants (QPs) and receive incentive payments by allowing participation in Advanced APMs that begin or end in the middle of a year. We expect this policy to encourage more clinicians to join APMs and become exempted from MIPS reporting requirements.
- To reduce the burden for MIPS APM participants who do not qualify as QPs, CMS has finalized several policies regarding the MIPS APM Scoring Standard, such as the addition of a fourth snapshot date and clarification around Virtual Group participants.
- Non-governmental and commercial payers are beginning to show interest in APMs and focus on value-based care, thereby providing even more opportunities for clinicians to participate in APMs. CMS provided clarity and additional information on the All-Payer Combination Option that will be available beginning in performance year 2019 and allow clinicians to become QPs through a combination of Medicare participation in Advanced APMs and participation in Other Payer Advanced APMs.
CMS listened to stakeholder feedback and used it to ensure that the QPP measures and activities are meaningful, administrative burden is minimized, care coordination for patients is improved, and clinicians have more clarity around participation in APMs. We see many of the Year 1 flexibilities retained in Year 2, with a focus on helping clinicians prepare for Year 3.
Don’t let CMS’s efforts to ease the transition lead to apathy or a lack of preparedness. Clinicians and groups need to familiarize themselves with these changes to be ready for the 2018 performance period. For more details of the QPP Year 2 final rule with comment period as well as a comparison of Years 1 & 2 policies, please refer to the CMS fact sheet on the Quality Payment Program final rule.
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