July 12, 2018

CMS Proposes Changes to Quality Payment Program (QPP)

On July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) released its proposed rule on the 2019 Quality Payment Program as part of the Physician Fee Schedule proposed rule. In this rule CMS describes changes to policies for implementation of the third year for the Merit-Based Incentives Payment System (MIPS) and for Advanced Alternative Payment Models (APMs).

CMS has proposed to weight the cost category under MIPS for 2019 at 15%. In addition, the quality category will be weighted at 45% while promoting interoperability (formerly called advancing care information), and improvement activities will remain at 25% and 15% respectively. If a MIPS eligible clinician is scored on fewer than two performance categories, a final score equal to the performance threshold will be assigned and the MIPS eligible clinician will receive a payment adjustment of 0%.

CMS proposes to increase the MIPS performance threshold for neutral adjustments to 30 points in 2019, and the exceptional performance bonus threshold is proposed to increase to 80 points. CMS is proposing to move forward with increasing the minimum MIPS penalties and maximum MIPS base incentives from -5%/+5% in 2018 to +7%/-7% for 2019.

CMS has added a third criterion for determining MIPS eligibility with respect to the low-volume threshold. To be excluded from MIPS in 2019, clinicians or groups would need to meet one of the following three criteria: have ≤ $90K in Part B allowed charges for covered professional services, provide care to ≤ 200 beneficiaries, or provide ≤ 200 covered professional services under the Physician Fee Schedule.

CMS proposes to continue the small practice bonus, but intends to add these five points to the Quality performance category, rather than to the MIPS final score.

CMS is proposing to maintain a data completeness standard of 60% for quality measures. This number defines the minimum subset of patients within a measure denominator that must be reported. For 2019, CMS proposes to allow eligible clinicians and groups to submit a single measure via multiple collection types (e.g. MIPS CQM, eCQM, QCDR measures and Medicare Part B claims measures). Individuals and groups were previously restricted to a single submission mechanism.

CMS is proposing to move forward with the inclusion of eight recently field-tested episode based cost measures for Knee Arthroplasty, Elective Outpatient Percutaneous Coronary Intervention (PCI), Revascularization for Lower Extremity Chronic Critical Limb Ischemia, Routine Cataract Removal with Intraocular Lens (IOL) Implantation, Screening/Surveillance Colonoscopy, Intracranial Hemorrhage or Cerebral Infarction, Simple Pneumonia with Hospitalization and ST-Elevation Myocardial Infarction (STEMI) with PCI. These cost measures will be attributed to clinicians who provide a trigger service for procedural episodes or bill inpatient Evaluation and Management claims for the acute inpatient episodes.

Recognizing the importance of appropriate use criteria (AUC) for diagnostic imaging, CMS proposes to continue offering high-weighted improvement activity (IA) credit for those referring physicians who are early adopters by participating in clinical decision support for 2019. Additionally, CMS is proposing to maintain participation in R-SCAN as a medium-weighted IA. Under MIPS, non-patient-facing physicians are required to earn two medium-weighted IAs or one high-weighted IA to receive full credit in this category. CMS proposed 98 IAs for 2019, many of which can be used by radiologists to meet the performance requirements in this category. CMS is proposing the addition of six new improvement activities, the modification of five existing improvement activities and the removal of one in this rule.

CMS also provided further explanation for their recent change in the name of the Advancing Care Information Category to Promoting Interoperability (PI). This category is designed to promote both patient engagement and the electronic exchange of information using certified electronic health record technology (CEHRT). CMS proposes a new scoring methodology for this category and will require participants to use 2015 edition CEHRT. Qualification for reweighting of PI will remain the same as for ACI, and includes non-patient facing and hospital-based status.

CMS is proposing to implement facility-based scoring for 2019. The measure set for the fiscal year Hospital Value-Based Purchasing (VBP) program that begins during the applicable MIPS performance period would be used for facility-based clinicians. A facility-based group would be defined as one in which 75 percent or more of the MIPS eligible clinicians NPIs billing under the group’s TIN are eligible for facility-based measurement as individuals. There are no submission requirements for individual clinicians in facility-based measurement but a group must submit data in the Improvement Activities or Promoting Interoperability performance categories in order to be measured as a group under facility-based measurement. CMS will automatically apply facility-based measurement to MIPS eligible clinicians and groups who are eligible for facility-based measurement and who would benefit by having a higher combined Quality and Cost score.

CMS is proposing to allow eligible clinicians to become Qualifying APM Participants (QP) utilizing the All-Payer Combination and Other Payer Options given that they are also participating in Advanced APMs with Medicare. CMS proposes to allow QP determinations to be requested at the tax ID number (TIN) level in addition to the APM Entity and individual eligible clinician levels. If the proposal is finalized, the QPP will allow for two options regarding how a physician becomes eligible to become a Qualifying APM Participant, the Medicare option, which only takes into account participation in Advanced APMs with Medicare, and the combination of being a QP with Medicare and Other Payers who meet the CMS criterion. The requirements for these APMs include the use of CEHRT, base payments for covered professional services on quality measures that are comparable to those used in the MIPS quality performance category with some modification, and a requirement that participants bear financial risk, which CMS is proposing to continue to define as 8% of revenues or 3% of expenditures.

ACR’s MACRA Committee and staff are reading and digesting this rule and will prepare a more detailed summary for publication in the near future. In the meantime, read CMS’ extensive fact sheet on the major changes in this rule for the third year of Medicare’s Quality Payment Program for physicians who are required to participate in either APMs or MIPS.