July 06, 2017

Medicare Proposes Further Expansion and Flexibility for the Second Year of the Quality Payment Program

On Tuesday, June 20, 2017, CMS issued the Calendar Year 2018 Quality Payment Program (QPP) proposed rule for the second transition year for physicians to begin participation in either the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs). CMS now refers to the 2018 year as QPP Year 2. CMS is offering further flexibility and easing of requirements to help physicians to make the transition to the new payment systems. The proposed rule has a 60-day comment period ending on August 21, 2017. If finalized, policies in the proposed rule generally would take effect on January 1, 2018.

The most significant change in the QPP year 2 is the expected continued partial phase-in of the eventual full MIPS requirements anticipated in the 2019 performance year, and started in transition year 1 of the QPP under the CMS pick-your-pace program. CMS proposes to increase the final score performance threshold from 3 to 15 of 100 possible points. This performance threshold defines the total points required to earn a neutral payment adjustment - with those who score higher than the threshold potentially earning a positive payment adjustment, and, those who score below the threshold earning a potential negative payment adjustment. This proposed action combined with lowering the achievement point floor for those who do not meet the 50% data completeness requirement in the “Quality” performance category from 3 points to 1 translates into an escalation of minimum reporting requirements for MIPS eligible clinicians in QPP year 2. CMS concomitantly increased the reporting period for the “Quality” performance category to one full calendar year, while maintaining 90-day reporting periods for the “Advancing Care information” and “Improvement Activities” performance categories. The “Cost” performance category has once again been proposed to be reweighted to zero, which means MIPS eligible clinicians will receive feedback on their performance in this category, but will not be held accountable as it will not count towards their final score.

The table below summarizes the potential reweighting scenarios of the four MIPS performance categories proposed for the QPP performance year 2 (2018) determining the final score for adjustment year 2020. Many diagnostic radiologists will continue to benefit from the potential exemptions available to them for the “Advancing Care Information” performance category.


As above, the “Quality” performance category is proposed to be measured over the full 2018 calendar year. CMS would maintain the 50% data completeness threshold for QCDRs, qualified registries, EHRs and claims-based data submissions, despite a previously finalized policy of 60% for the 2018 performance period. However, CMS proposes to raise it to 60% in 2019 and anticipates it will increase over time.

Practices should be aware of changes impacting the quality performance category scoring. CMS will maintain the 3-point floor for measures that can be reliably scored against a benchmark, Measures that do not meet data completeness will receive 1 point, except small practices which will receive 3 points per measures. Measures submitted that do not have a benchmark or do not meet the case minimum will receive 3 points, as long as they meet the 50% data completeness threshold. Bonus points continue to be available for reporting high priority and outcome measures. Additionally, bonus points can be added to the final scores of MIPS eligible clinicians who are in small practices (defined as 15 or fewer clinicians) or care for complex patients. ACR will comment about potentially applying bonus points to rural areas.

Previously, MIPS eligible clinicians were required to use only 1 submission mechanism per performance category. To allow more flexibility for clinicians in Year 2 individual MIPS eligible clinicians and groups would be allowed to submit measures and activities through multiple submission mechanisms to meet the requirements of each performance category Quality, Improvement Activities or Advancing Care Information.

Facility-based Measures

In the 2018 Proposed Rule, CMS proposed allowing MIS eligible clinicians who are facility-based to use their institution’s performance in the Quality and Cost categories. Although for most clinicians, facilities-based measures cannot be used for outpatient departments, items and services furnished by radiologists as well as emergency physicians and anesthesiologists in the hospital outpatient setting are eligible to use facilities-based measures.

The Value-Based Purchasing (VBP) is an existing program under Medicare that provides adjustments to bundled payments based on facility-wide quality measures. There are currently 13 quality and efficiency measures defined under VBP. CMS is proposing allowing eligible clinicians to report facility-wide measures under this program for the appropriate MIPS categories (mostly Cost category) beginning in the 2020 payment year (2018 performance period).

Somewhat different from the “hospital-based” designation used in the ACI performance category, CMS proposes defining the “facility-based” designation for when the clinician furnished 75% or more of their services in either an inpatient hospital or emergency room, but not hospital outpatient departments. ACR will comment on potentially lowering the 75% threshold so more radiologist could choose this option if they desire. Individuals or groups that are eligible for facility-based measurement would be required to elect to do so. CMS estimates that approximately 20% of eligible facility-based clinicians will participate in facility-based measures reporting.

Topped-out Measures

CMS defines a topped out measure as one whose median performance is 95% or higher. CMS describes topped out measure performance as “so high and unvarying that meaningful distinctions and improvement in performance can no longer be made.” CMS proposes a 3-year timeline for identifying and removing topped out measures. For a measure to be “topped out” it must be identified as such for 3 consecutive years and be available for comment prior to rule-making for the 4th year. Starting from year 2, special scoring considerations will be used for topped out measures, namely there will be a maximum score of 6 points. For most current measures, determination of “topped out” will be based on comparison to the 2018 performance period. Thus, the earliest most measures can be removed is 2021. It is important to note that a measure could be deemed topped out in on reporting mechanism, but not reach topped out status in another. In this scenario, the measure would only undergo topped out methodology within the reporting mechanism it has been deemed topped out.

There are however, 6 quality measures that CMS proposes to regard as “topped out” for the 2018 performance period. Of these, one is pertinent to radiology: “Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging”. For these 6 measures, CMS proposes using special rules for scoring which involves a cap of 6 points for these measures.

There are likely to be many measures that will become “topped out” and subject to being removed starting in 2021. Based on 2015 benchmark data, CMS estimates that, 45% of current quality measures will meet the criteria to be topped out.

Advancing Care Information (ACI) Category

Reweighting/Exempting ACI

CMS proposed to continue offering the various options for reweighting (i.e., exempting) the Advancing Care Information (ACI) category in performance year 2018/payment year 2020, including automatically reweighting “non-patient-facing” MIPS-eligible clinicians. Most importantly for radiology, the calculation used by CMS to determine “hospital-based” eligible clinicians would be expanded to include off-campus-outpatients hospital settings (POS 19), thus significantly expanding the number of “patient-facing” radiologists who would be determined hospital-based.

CMS also proposed adding several new ACI reweighting options—most notably a manual application option for MIPS-eligible clinicians in small practices (15 or fewer clinicians and solo practitioners) who faced an overwhelming barrier to ACI compliance. CMS proposed a deadline for applications to reweight ACI of December 31 or later, as specified by CMS, for the performance period in question (2017 as well as 2018). The proposed rule indicated that the manual application process is planned to be detailed in mid-2017.

Though eligible clinicians who reweight ACI would continue reallocating ACI’s 25% of the total MIPS score to the Quality category, CMS is also inviting public comments on a new alternate option by which 15% would be reallocated to Quality and 10% would go to IA.

Participating in ACI

For those radiologists who plan to participate in ACI, CMS proposed to continue allowing use of 2014 Edition certified EHR technology (CEHRT) as well as the alternative/transitional ACI measures during the 2018 performance year. CMS would provide a 10% ACI bonus for those participants who used 2015 Edition CEHRT, thereby increasing the total possible ACI bonus points from 15 to 25% (including the 5% bonus for reporting to a public health agency/clinical data registry and 10% bonus for doing an identified CPIA activity using CEHRT).

The ACI measures and alternative/transitional measures in 2018 would remain essentially the same as 2017 with a few administrative changes and error corrections. Exclusions with base score credit from the e-prescribing and health information exchange-related ACI measures would be available for certain participants. Additionally, those unable to report to immunization registries would be able to make up the 10 available performance score points by reporting to two public health and/or clinical data registries (worth 5 percentage points each).

Improvement Activities

CMS defines improvement activities as those that support broad aims within healthcare delivery, including care coordination, beneficiary engagement, population management, and health equity. In the proposed rule, improvement activities remain weighted at 15% for the 2018 MIPS performance year final score. CMS asserts that MIPS-eligible clinicians can continue attesting improvement activities. However in future years, CMS intends to score the improvement activities based on performance and improvement, rather than simple attestation. CMS seeks comment on how they could measure performance and improvement without imposing additional burden on eligible clinicians (ECs), such as by using data captured in eligible clinicians’ daily work.

In addition, CMS proposes no changes to the number of activities (two high-weighted or four medium-weighted) that MIPS-eligible clinicians have to report to reach the total of 40 points to receive full credit. CMS also maintains the policy that the weight for any activity selected is doubled for small, rural, health professional shortage area practices, and non-patient facing MIPS-eligible clinicians, so that these practices and ECs only need to select one high-weighted or two medium-weighted improvement activities to achieve the highest score of 40 points. Also, under the MIPS APM scoring standard, all clinicians identified on the Participation List of an APM will receive at least one-half of the highest score applicable to the MIPS APM with the opportunity to report additional improvement activities to add points to achieve the full 40 points.

In the rule, CMS retains the current inventory of 92 improvement activities, however, CMS proposes to modify 27 improvement activities and add an additional 20 new improvement activities, to include Appropriate Use Criteria (AUC). The AUC improvement activity will allow MIPS eligible clinicians to earn a high-weighted improvement activity by attesting that they are using AUC through a qualified clinical decision support mechanism for all advanced diagnostic imaging services ordered. The list of improvement activities with their relative weightings is available on the QPP website. Of relevance to radiologists, several QCDR-based activities continue to be included as medium-weight activities as well as the 7 medium-weighted improvement activities that may be obtained by participation in the ACR’s Radiology Support Communication and Alignment Network program (R-SCAN).

Cost Performance Category

In order to improve clinician understanding of cost measures and continue the development of episode-based measures that will be used in the cost performance category, CMS proposes to continue to weigh the cost performance category at zero percent of the final score for the 2018 MIPS performance period and 2020 MIPS payment year. Clinicians expressed their desire to down-weight the cost performance category to zero percent for an additional year with full knowledge that the cost performance category weight is set at 30% under the statute for 2019 which affects the 2021 MIPS payment year. CMS still seeks comments on whether CMS should continue with assigning 10% to the cost performance category for 2018 (affecting the 2020 MIPS payment year) or whether eligible clinicians will actively be prepared for full cost performance category implementation at the 30% statutory weight for the cost performance category for the 2021 MIPS payment year.

CMS is also proposing to adopt the total per capita costs for all attributed beneficiaries measure and the Medicare Spending per Beneficiary (MSPB) measure that were implemented for the 2017 MIPS performance period. In addition, CMS is proposing to not use the 10 episode-based measures that were adopted for the 2017 MIPS performance period. Rather, CMS is in the process of developing new episode-based measures with significant clinician input and believes it would be more prudent to introduce these new cost measures over time.

Virtual Groups

Definition of a Virtual Group

In the 2017 final rule, CMS defined two ways to participate in MIPS: an individual or as a group. In the 2018 proposed rule, CMS proposes the creation of a new, third category, the so-called “virtual group” in order to assist small, independent practices. There are two types of practices that can form virtual groups: (1) MIPS-eligible solo practitioners who bill under a single Tax Identification Number (TIN) with a single NPI; and (2) a group with 10 or fewer eligible clinicians. In the virtual group option, two or more of either of these types of practices can voluntarily come together as a group to participate in MIPS. There are currently no proposed restrictions in terms of geography, specialty of the practices, or number of practices that can form a virtual group as long as the criterion for the size of each practice is met. MIPS performance measures for the virtual group will be assessed on the basis of the combined performance of the entire group, payment adjustments will be made on an individual TIN/NPI level. Eligible practices may only be a part of one virtual group. CMS plans to make technical assistance available for the 2018 and 2019 performance years for practices implementing virtual groups.

Participation in a virtual group will not change the financial relationship between a clinician and/or group and an entity furnishing health services for the purposes of self-referral.

Non-patient Facing MIPS-Eligible Clinicians

In the proposed rule, CMS maintains the definition of a non-patient facing MIPS-eligible clinician for MIPS as an individual MIPS-eligible clinician that bills 100 or fewer patient-facing encounters and a group that provided more than 75 percent of the NPIs billing under the group’s TIN meet the definition of a non-patient facing individual MIPS-eligible clinician during the non-patient facing determination period. CMS proposes to modify the definition of a non-patient facing MIPS-eligible clinician to apply to virtual groups starting in the 2018 MIPS performance year.

CMS proposes to continue re-weighting of the advancing care information performance category for non-patient facing MIPS-eligible clinicians. Specifically, MIPS-eligible clinicians and groups who are considered to be non-patient facing will have their advancing care information performance category automatically reweighted to zero for the 2018 MIPS performance year and future years. CMS also maintains the policy that the weight for any improvement activity selected is doubled for non-patient facing MIPS-eligible clinicians, so that these practices and ECs only need to select one high-weighted or two medium-weighted improvement activities to achieve the highest score of 40 points to receive full credit for the improvement activities performance category. CMS is seeking comment on these proposals. The list of patient facing encounter codes for 2018 will be published at the end of 2017. The 2017 codes can be found here: qpp.cms.gov/resources/education.

Advanced Alternative Payment Models (APMs)

APMs that meet the criteria to be Advanced APMs provide the pathway through which eligible clinicians, who would otherwise fall under the MIPS, can become Qualifying APM Participants (QPs), thereby earning incentive payments for their Advanced APM participation. QPs who have met a threshold of 25% of revenues earned or 20% of patients treated through an Advanced APM would be excluded from MIPS for 2018, and receive a 5% APM Incentive Payment. This 5% bonus is applicable for each year they are QPs beginning in 2019 through 2024.

For Advanced APMs that start or end during the Medicare QP Performance Period and operate continuously for a minimum of 60 days during the Medicare QP Performance Period for the year, CMS is proposing to change the QP determinations by using payment or patient data only for the dates that APM Entities were able to participate per the terms of the Advanced APM and not for the full Medicare QP Performance Period of which is a minimum of 90 days. Eligible clinicians who participate in Advanced APMs but do not meet the QP or Partial QP thresholds of are subject to MIPS reporting requirements and payment adjustments.

Medicare publishes a list of qualifying Advanced APMs each year. They anticipate that new Advanced APMs will be available for participation in 2018 including the Medicare ACO Track 1 Plus (1+) Model, and expanded participation in current Advanced APMs, such as the Next Generation ACO Model and Comprehensive Primary Care Plus Model. CMS anticipates the amount of QPs to grow in subsequent years of the program and estimates that approximately 180,000 to 245,000 eligible clinicians may become QPs for payment year 2020 based on Advanced APM participation in performance year 2018.

To be considered an Advanced APM the APM must meet all three of the following criteria: (1) over 50% of its participants must be using CEHRT; (2) The APM must provide for payment for covered professional services based on quality measures comparable to those in the quality performance category under MIPS and; (3) The APM Entities must bear more than nominal amount of financial risk, or be a Medical Home Model.

For QP Performance Periods in 2017 and 2018, the total amount of risk must be equal to at least either 8% of the average estimated total Medicare Parts A and B revenue of participating APM Entities (the revenue-based standard); or for all QP Performance Periods, 3% of the expected expenditures for which an APM Entity is responsible under the APM (the benchmark-based standard). CMS is proposing to maintain the generally applicable revenue-based nominal amount standard at 8% for 2019 and 2020 and seeks comment as to whether this amount should continue in future years.

CMS proposes policies as to how other payer participation in APMs may be considered in order for QPs to meet their percentage thresholds beginning in 2019. There are a few major differences to be highlighted: 1) To become a QP through the All-Payer Combination Option, an eligible clinician must participate in an Advanced APM with CMS, as well as an Other Payer Advanced APM. 2) Other Payer Advanced APM participation may be identified by information submitted by eligible clinicians, APM entities, and in some cases by payers, including states and Medicare Advantage Organizations. 3) The other payers must meet the same three criteria as Medicare APMs as noted above, and 4) CMS is proposing to conduct all QP determinations under the All-Payer Combination Option at the individual eligible clinician level since it would be difficult to track eligible clinicians by group in various payer combination arrangements.

Physician-Focused Payment Models (PFPMs)

Section 101 (e)(1) of MACRA created the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to make comments and recommendations to the Secretary of the Department of Health and Human Services on proposals for Physician-Focused Payment Models (PFPMs) submitted by individuals and stakeholders. The Secretary is required by MACRA to establish criteria for PFPMs and to review the comments and recommendations on proposed PFPMs and to post a detailed response to those comments and recommendations on the CMS website.

In the proposed rule, CMS discusses broadening the definition of PFPMs to include payment arrangements that involve Medicare, Medicaid or the Children’s Health Insurance Program (CHIP) (or some combination of these) as a payer. CMS believes that broadening the definition of PFPMs would complement the All-Payer Combination Option and could provide an opportunity for stakeholders to propose PFPMs to the PTAC that could be Other Payer Advanced APMs. Additionally, participation in Other Payer Advanced APMs would contribute to an eligible clinician’s ability to become a Qualified Participant (QP) through the All-Payer Combination Option.

CMS does not go into specifics about PFPM Criteria, however CMS is seeking general comments on the Secretary’s criteria and whether the criteria are appropriate for evaluating PFPM proposals and are clearly articulated. In addition, CMS is seeking feedback on stakeholders’ needs in developing PFPM proposals that meet the Secretary’s criteria. In particular, CMS would like to know whether stakeholders believe there is sufficient guidance available on what constitutes a PFPM, the relationship between PFPMs, APMs, Advanced APMs, and how to access data, or how to gather supporting evidence for a PFPM proposal.

MIPS APM Scoring Standard

The MIPS APM scoring standard is designed for MIPS-eligible clinicians participating in certain types of APMs to reduce participant reporting burden of submitting data for both MIPS and their respective APMs. In the proposed rule, CMS adds a fourth “snapshot” assessment date of December 31 to identify MIPS-eligible clinicians (ECs) who participate in a full TIN APM (ECs who reassign their billing rights to a TIN participating in a full APM, such as a Medicare Shared Savings Program (MSSP) ACO) to ensure ECs who join the full TIN APM late in the performance year would be scored under the APM scoring standard. CMS notes that the fourth “snapshot” assessment date is not used for determining Qualifying APM Participant (QP) status and will not extend the QP performance period beyond August 31.

Small and Rural Practice

CMS offers further flexibility in helping small and rural practices to transition into participating in APMs and MIPS. ACR has prepared a separate summary on the small and rural proposals in this rule. Click here to read more.

The ACR’s MACRA Committee and staff are further analyzing and digesting this rule for the membership to prepare future tools and materials. They also are preparing to develop comments on how this rule affects the specialty of radiology and its subspecialties for 2018.