The Quality Payment Program Proposed Rule Has Arrived

CMS Quality Payment Program Proposed Rule Year 2:
MIPS Changes and How They May Affect You

The CMS Quality Payment Program (QPP) Year 2 proposed rule was released June 20 and will be open for public comment until August 21. To review the unpublished proposed rule, visit the Federal Register website.

Don’t want to read the 1,058 page document?

We have dissected the changes to the Merit-based Incentive Payment System (MIPS) and will provide an overview with explanation of what these change may mean to eligible clinicians (ECs) and groups below. As a reminder, these are currently proposed changes and may not become part of the Quality Payment Program Year 2 Final Rule.

APMs Proposed Rule Overview

Be sure to watch for our second proposed rule overview, which will review changes to Alternative Payment Models (APMs) and provide similar comment on what these changes may mean for organizations and ECs.

General Programmatic Changes

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The performance threshold may increase to 15 points
From the Proposed Rule What does it means?

The performance threshold may increase to 15 points, which is an increase from the 2017 transition year performance threshold of 3 points. CMS is seeking comment on where the performance threshold should be set for the 2018 program year, with consideration of 6 to 33 points as a performance threshold. The exceptional performer bonus threshold will remain at score of 70 MIPS total performance points and above.

ECs will need to report on more than a single quality measure in order to meet the increased performance threshold and avoid a negative payment adjustment, which will be 5% of Medicare Part B claims in 2018. Some suggested methods to achieve a 15 point performance score include: completing all required Improvement Activities (one to four based on practice size); report on six quality measures with a performance decile score of at least 3 on all measures; attest to the required base Advancing Care Information measures and a single quality measure; attest to implementation of two medium weight Improvement Activities (earn 20 category points) and report on two quality measures with performance decile score of at least 4 on both measures; attest to the required base Advancing Care Information measures and implement an Improvement Activity that utilizes the certified EHR for bonus points.

An increase to the low-volume threshold exclusion criteria
From the Proposed Rule What does it means?

An increase to the low-volume threshold exclusion criteria, the proposed rule sets the low-volume threshold at < $90,000 in Medicare Part B claims annually and < 200 Medicare beneficiaries annually.

For small and rural practices, a larger number of ECs may be excluded due to the low-volume threshold. Be sure to evaluate your Medicare Part B and Medicare beneficiaries cared for annually to determine if you may be included, the evaluation period is September 1, 2016 – August 31, 2017 with a 60-day claims runout, although CMS is considering a 30-day claims runout for 2018. CMS will also be updating the NPI participation status lookup tool on the QPP website. Additionally, CMS is seeking comment on a third element for calculating the low-volume threshold, which would include the number of items and services furnished under Medicare Part B by ECs during the specified reporting period.

Able to continue utilizing 2014 certified electronic health record (EHR) technology
From the Proposed Rule What does it means?

ECs and groups will be able to continue utilizing 2014 certified electronic health record (EHR) technology. If you are in the process of upgrading to or already have a 2015 certified EHR, you have the opportunity to receive a 10 percentage point bonus in the Advancing Care Information performance category.

ECs and groups do not need to rush to get a 2015 certified EHR implemented in their practice. While the burden of upgrading to 2015 certified EHR technology has been alleviated for the 2018 performance year, ECs and groups should plan to upgrade when their vendor is ready to make additional interoperability and data segmentation tools available.

Small practices & solo practitioners eligible for bonus of 5 points
From the Proposed Rule What does it means?

Small practices (solo practitioners and groups of 15 or fewer ECs) are eligible for a small practice bonus of 5 points that would be added to the final MIPS score. Practices seeking this bonus would need to report data in at least one performance category, such as: one Improvement Activity or two quality measures and one Improvement Activity. In order to be considered a small practice for the 2018 performance period, there will be a determination period that consists of practice size evaluation of 12-months prior to performance period (September 1, 2016 – August 31, 2017). While this method may not capture the real-time practice size, CMS is considering a second 12-month evaluation to take place during the performance period.

ECs that are solo practitioners and in groups (15 or fewer ECs) have the opportunity to receive bonus points based on a minimal level of participation in the MIPS program. In effort to provide incentives and reduce some of the burden to small practices, CMS has proposed this bonus which may assist these practices in avoiding a negative payment adjustment, if the performance threshold remains at 15, or possibly earn a more substantial positive payment adjustment.

Flexibility to submit data to CMS via multiple submission methods
From the Proposed Rule What does it means?

ECs and groups will have the flexibility to submit data to CMS via multiple submission methods within one performance category. The QPP Year 1 Final Rule stipulates that ECs and groups may submit data via multiple methods across the four performance categories, but must choose a single method within each performance category.

ECs and groups that may struggle to identify the adequate number of measures to report on utilizing a single submission method will now be able to mix and match measures to best meet their practice type and patient population. Keep in mind that each submission method and data to support measure performance should be tracked and monitored, which may increase administrative burden if each performance category is spread across several submission methods.

Virtual group participation option
From the Proposed Rule What does it means?

CMS will be offering a virtual group participation option, which will be available to solo practitioners and those in groups of 10 or fewer ECs. ECs and groups interested in assembling and participating as a virtual group would need to choose this as their participation option prior to the start of the 2018 performance period, likely be December 1st. Virtual groups seeking to take advantage of the rural and underserved group options would need to demonstrate that at least 75% of the group TINs are in rural and health provider shortage areas (HPSAs). If the entire virtual group is comprised of 15 or fewer unique NPIs, the virtual group would be provided small practice status when reporting to MIPS. Virtual groups will receive the same reporting options as standard groups with regard to performance category requirements, scoring and submission methods.

Small, rural and underserved ECs that may struggle to meet participating requirements on their own will have the ability to work with other similar ECs to take advantage of data aggregation and group reporting. Keep in mind that when a group decides to work with another group(s) or solo practitioner to create a virtual group, all ECs under the group TIN will be part of the virtual group. CMS is seeking comment for future years of rulemaking which may provide increased flexibility for sub-group reporting. It is important to note that much like reporting as a group in 2017, ECs that decide to participate as a virtual group in 2018 for the for the performance year and must participate as a group for all performance categories. Additionally, groups interested in forming a virtual group with others will have their TIN size evaluated on a five month rolling basis, with determination set at a relative point during this five-month period. Finally, CMS is allowing solo practitioners and groups of 10 or fewer ECs with the opportunity to elect participation in a virtual group prior to the release of the QPP Final Rule and would require participants to establish a formal written agreement between all participants prior to the start of the 2018 performance year.

ECs that care for complex patients may earn up to 3 bonus points
From the Proposed Rule What does it means?

ECs that care for complex patients, which is determined by their patient population’s average Hierarchical Conditions Category (HCC) risk score to the final score, may earn up to 3 bonus points. ECs that care for patients that fall into the 79 categories of HCC codes, which identifies individuals with serious or chronic illness and assigns a risk factor score to the individual based on a combination of the individual’s health conditions and demographic details, would receive a bonus towards their final score. Use of the HCC scores is an effective estimate of how the individual’s Fee-for -Service spending will compare to the overall average for the entire Medicare population. CMS has also proposed to evaluate patient complexity, including social determinants, which would take into account dual eligible beneficiaries in computing a possible bonus.

ECs with a complex patient panel or who can for underserved populations can receive a bonus simply for the routine patient care efforts. This bonus is intended to ensure that complex patient continue to have access to high quality care providers and to avoid placing ECs caring for complex patients at a potential disadvantage.

Demonstrate performance improvement and earn up to a 10 percentage point bonus
From the Proposed Rule What does it means?

ECs and groups that demonstrate performance improvement at the quality performance category level, which is based on the rate of improvement from previous reporting periods, can earn up to a 10 percentage point bonus. Additionally, consideration has been proposed for evaluation of the cost performance category improvement against historical performance at a measure level and could afford ECs and groups beneficial data regarding overall performance.

Does your practice seek continuous quality and process improvement? Use this to your advantage, improve the care provided to your patients through quality measure performance and receive a bonus for your efforts. It is crucial to consider what overall quality category performance is for 2017 in order to see adequate improvement in 2018. CMS sought to implement improvement evaluation methodologies that allowed for continued flexibility within the quality performance category, such that ECs and groups could move between measures and submission methodologies as desired.

ECs in ASCs, HHAs, HOPDs may be included in MIPS
From the Proposed Rule What does it means?

EC who practice in ambulatory surgical centers (ASCs), home health agencies (HHAs), hospice facilities and hospital outpatient departments (HOPDs) may be included in reporting to MIPS if they furnish other items or services in one of the mentioned locations and bill for those items separately, outside of billing that falls under the facilities all-inclusive payment or prospective payment methodology, under the Physician Fee Schedule (PFS) and meet the low-volume threshold criteria.

ECs practicing in ASCs, HHAs, hospice and HOPDs would need to be mindful of their billing practices and should evaluate the potential for inclusion in MIPS reporting. At this time, this is a proposal, so these ECs would not be able to utilize the CMS NPI participation status lookup tool.

Performance Category Changes

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Quality will remain 60% of MIPS score in 2018
From the Proposed Rule What does it means?

Quality will remain 60% of MIPS score in 2018; however the reporting period may be increased to 12-months. Numerous measures have updated specifications and some additional measures have been added. Additionally, for quality measure submissions that do not meet the data completeness criteria of 50% of the patients seen during the reporting period (50% of Medicare Part B patients only is using claims-based reporting), those measures will only receive 1 point instead of 3 points towards the quality category score; except in the case of small practices, who will continue to get 3 points for these measures. CMS proposes to use a cap of 6 points for the following six topped out measures, with a plan for phased removal of such topped out measures over the course of future years of the program: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin; Melanoma: Overutilization of Imaging Studies in Melanoma; Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis; Image Confirmation of Successful Excision of Image-Localized Breast Lesion; Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description; and Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy. No changes have been made to the requirements for groups planning to utilize the CMS web interface (groups of 25 ECs or more) for quality measures reporting. Where applicable, CMS is seeking comment on ways in which to increase the reporting of data for all-payer methods under all submission methods, although some methods are currently limited to Medicare Part B data, such as claims-based reporting and utilization of the CAHPS survey.

Much of the quality performance category requirements remain unchanged as we head into the 2018 performance year. ECs and groups should evaluate their previous performance and identify ways in which to demonstrate improvement as bonus points are now available for this. Additionally, ECs and groups that are unable to meet the data completeness requirements or are reporting on topped out measures, should consider identifying other quality measures that may be reported on that could increase performance, validity and progress to outcome measures to enhance their overall performance score.

Advancing Care Information will remain 25% of MIPS score in 2018
From the Proposed Rule What does it means?

Advancing Care Information will remain 25% of MIPS score in 2018 and the reporting period will also continue to be at least a consecutive 90-day period. For 2018, the Advancing Care Information measures and percentage scores will remain the same. A new exclusion for the Health Information Exchange measure has been included, ECs and groups that complete 100 or fewer transfers during the reporting period will be excluded from reporting; this will also take effect for the 2017 performance year. In place of immunization registry reporting performance measure, ECs may potentially earn 5% each for reporting to any of the Public Health and Clinical Data Registry Reporting options, with a max of 10% bonus. ECs that experience significant hardship in the implementation of certified EHR technology will have until December 31, 2017 to submit a hardship exemption application; this will be the case for future years of the program as well. CMS is also considering adding a new Advancing Care Information hardship exception for clinicians in small practices, which would allow for Advancing Care Information category to be reweighted to 0% and quality increased to 85%.

Overall, there will be greater flexibility in the requirements of the Advancing Care Information performance category. CMS received overwhelming numbers of comments on the struggles many ECs and groups are having and has made an increased number of hardship exemptions available as well allowed for flexibility in certified EHR technology utilization. What you should keep in mind if you are considering the hardship exemptions: 1) evaluate your EHR systems capabilities and determine if a hardship is applicable; 2) if you determine that an exemption is applicable, watch for the hardship application, to be made available by CMS mid-2017; 3) submit application to CMS no later than December 31, 2017.

21st Century Cares Act
From the Proposed Rule What does it means?

21st Century Cares Act, which was enacted in 2016 following the publication of the QPP Final Rule, focuses mainly on behavioral health and substance abuse funding, medical research, FDA drug approval process and healthcare access includes some additional flexibility options with regard to Advancing Care Information reporting. With many of the EHR vendors struggling to meet the increased certification requirements as the QPP progresses, CMS will be adding a decertification exception for ECs who’s EHR was decertified, this exception will be retroactively effective to performance periods in 2017. Under this exception, the EC or group must also demonstrate that they have made a good faith effort to adopt and implement another certified EHR prior to the performance period. ECs that are ambulatory surgical center-based (furnishing at least 75% of their covered services in place of service 24) will receive flexibility and have their Advancing Care Information category reweighted to 0% and quality increased to 85%. There is also an allowance for significant Advancing Care Information hardships for hospital-based clinicians, which includes ECs that furnish at least 75% of their covered services in place of service 21 – inpatient hospital, 22 – on campus outpatient hospital and 23 – emergency department. In 2018, CMS is seeking comment on including covered services rendered in place of service 19 – off-campus outpatient hospital in the calculation of hospital-based clinicians. Facility-based clinicians may also take advantage of the utilization of the hospital value-based payment program performance rates (Fiscal Year 2019 data), with an option for these ECs to convert the hospital total performance score into their MIPS quality and cost performance category score.

Much like the flexibilities noted above, CMS has sought to enable ECs in all practice settings to identify the means and methods for reporting that best suit them. As such, alterations to hardship application dates and excluded population definitions will further alleviate the burden of implementing a certified EHR for many ECs. What is imperative to consider if you are in an excluded population is how to remain actively engaged in the utilization of certified EHR technology and how to improve interoperability between your fellow practitioners.

Improvement Activities will remain 15% of MIPS score in 2018
From the Proposed Rule What does it means?

Improvement Activities will remain 15% of MIPS score in 2018 and the reporting period will also continue to be at least a consecutive 90-day period. Roughly 10 Improvement Activities have been added and numerous changes have been made to the existing activities. In particular, a new activity will include a focus on Appropriate Use Criteria (AUC), specifically as it relates to the utilization of qualified clinical decision support mechanisms for all advanced diagnostic imaging services ordered. Additionally, practices seeking to use Patient-Centered Medical Home (PCMH) accreditation as an Improvement Activity must meet the threshold of 50% of the total number of practices within a TIN are PCMH recognized for the TIN to receive full credit in the performance category. Additionally, there is consideration for adjusting the weight of two high weighted improvement activities to be medium weight for program year 2018 and beyond, this includes: participation in the Transforming Clinical Practice Initiative (TCPi) and providing 24/7 access. CMS is seeking comment on how to better connect the use of certified EHR technology with improvements in clinical practice and patient engagement.

Emphasis continues to be places on improving care across the continuum, patient engagement, care planning and implementation of processes to address appropriate utilization of resources. With the performance threshold potentially being increased to 15 points, ECs and groups concerned with meeting this requirement should consider ways in which to utilize current programs, initiatives or affiliations as Improvement Activities to receive full credit for the category. Furthermore, identifying ways in which to leverage certified EHR technology, whether through portal utilization, integration of patient reported outcomes or bi-directional communication with fellow clinicians can earn an EC or group Improvement Activity performance points as well as Advancing Care Information performance and bonus points.

Cost may remain at 0% of the MIPS score in 2018
From the Proposed Rule What does it means?

Cost may remain at 0% of the MIPS score in 2018 versus previous rate of 10%; however the proposed rule notes that the value will quickly jump to 30% of the MIPS score in 2019 and beyond. If the category is included in the MIPS score for 2018, there will be a 12-month reporting period and CMS will only use the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures in calculating cost performance category score. The 10 episode-based measures that were previously finalized in the 2017 QPP Final Rule have been removed and CMS is seeking comment on ways in which to achieve increased reporting accuracy through the development of new episode-based measures. Feedback on previous episode-based measures will be discontinued after 2017 and feedback for newly developed episode-based measures is expected mid-2018.

With the cost performance category score likely remaining at 0% of the MIPS score for 2018, but with the potential to increase to 30% in 2019, ECs and groups should carefully evaluate their overall cost and utilization rates at the present time. While the data is limited, review of the Quality and Resource Use Reports (QRUR) can shed some light on areas where performance could be improved prior to category performance inclusion in the MIPS score.

Feedback Reports

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Feedback reports may become available at least annually
From the Proposed Rule What does it means?

CMS is proposing to make feedback reports available at least annually for performance related to the quality and cost categories, with discretion on providing feedback on performance in Advancing Care Information and Improvement Activities categories as applicable. Feedback reports will likely be in the form of a web-based application and are anticipated to available around July 2018. Feedback reports made available in 2018 would include measures specified for program year 2017 as well as MIPS final score. Cost data is available via claims and feedback reports are expected in the fall 2017 for the most recent 12-month period. CMS is encouraging the submission of quality, Advancing Care Information and Improvement Activity data to be submit via registry or qualified clinical data registry to ease feedback reporting.

ECs and groups seeking to identify their performance based on CMS provided reports should plan to evaluate the included data as soon as it becomes available. With significant MIPS program performance points assigned to the quality performance category and the potential increase of the cost performance category to 30% in 2019, it is crucial for ECs and groups to understand how they are performing, utilization of resources and how they stack up to their peers. Additionally, public data reporting coming soon, ECs and groups should be aware of how their performance will appear on the Physician Compare website and be interpreted by consumers.

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