On July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) issued the Calendar Year 2019 Quality Payment Program (QPP) proposed for the third transition year for physicians to begin participation in either the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs). The third transition year increases the MIPS payment adjustments to +/- 7 percent in payment year 2020. The final rule has a 60-day comment period ending on September 10, 2018. These policies become effective on January 1, 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. If an individual radiologist or group falls below this threshold, they are exempt from participating in the Quality Payment Program.
CMS proposes to increase the weight of the cost category to 15 percent which would reduce the weight of the quality category to 45 percent of the performance score, with the promoting interoperability (formerly called advancing care information) and improvement activities remaining at 25 percent and 15 percent respectively for patient-facing clinicians. CMS is proposing to increase the MIPS performance threshold for neutral adjustments from 15 to 30 points in 2019.This performance threshold defines the total points required to earn a neutral payment adjustment and avoid a negative payment adjustment. MIPS-eligible clinicians who score higher than the threshold (31 points and above) may earn a positive payment adjustment for 2021. CMS is proposing to increase the exceptional performance bonus threshold from 70 points to 80 points.
CMS will continue to apply the small practice bonus, but proposes to add three points to the quality performance category, rather than adding five points to the MIPS final score. CMS defines small practices as 15 or fewer clinicians.
CMS proposes modifying the definition of a MIPS-eligible clinician by including the following types of clinicians for the 2021 payment year: physical therapists, occupational therapists, clinical social workers, and clinical psychologists. As there are several proposed MIPS quality measures that may be finalized for removal, CMS will reassess whether 4 additional clinician types (qualified speech-language pathologists, qualified audiologists, certified nurse midwives, and registered dietitians or nutrition professionals) are eligible after consensus on the quality measures and will include these types only if they have at least six MIPS quality measures available to them.
CMS seeks comments on adding these additional types of clinicians as MIPS-eligible clinicians beginning with payment year 2021. All the new MIPS-eligible clinicians are proposed to be exempt from the Promoting Interoperability performance category.
There are various determination periods currently in place to identify MIPS-eligible clinicians for different applicable policies, such as non-patient-facing and low-volume threshold. CMS would like to consolidate several of these policies into one MIPS determination period that includes low-volume threshold, non-patient-facing, small practice, hospital-based and ambulatory surgical center (ASC)-based.
CMS is proposing that for 2019, the determination period would be a 24-month assessment period consisting of two 12-month analyses of claims data; the first 12-month segment would begin on October 1, 2017 and would end on September 30, 2018 and the second period would begin on October 1, 2018 and would end on September 30, 2019. The first period would include a 30-day claims run out and the second segment would include quarterly snapshots for informational purposes. These quarterly snapshots would allow new TIN/NPIs and TINs to be aware of their eligibility status sooner.
There are no changes proposed for the eligibility of non-patient facing clinicians. For the 2021 MIPS payment year, non-patient facing status will still be extended to individual MIPS-eligible clinicians who bill 100 or fewer patient facing encounters (including Medicare telehealth services) during the non-patient facing determination period. The same will be true of groups or virtual groups for which more than 75 percent of the NPIs billing under the group’s TIN (or virtual group’s TINs) meet the definition of non-patient facing individuals. Non-patient facing clinicians will continue to be exempt from the promoting interoperability performance category; the 25 percent weight of that category will be reweighted to the quality performance category. For the improvement activities performance category, non-patient facing clinicians may submit either one high-weighted improvement activity or two medium-weighted improvement activities for full credit.
For the 2020 MIPS payment year and future years, the low-volume threshold has been defined as an individual eligible clinician or group that has Medicare Part B allowed charges less than or equal to $90,000 or provides care for 200 or fewer Part B–enrolled Medicare beneficiaries. Eligible clinicians or groups who do not meet this definition are automatically excluded from MIPS. CMS proposes to add a third criterion for determining MIPS eligibility in 2019. To be excluded from MIPS, clinicians or groups would need to meet one of the following three criterion: 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 (PFS). If a clinician meets or exceeds one of the three determinations, then the clinician is not required to participate but may opt-in to MIPS by making an affirmative election.
The Bipartisan Budget Act of 2018 provides that the MIPS adjustment factor and, if applicable, the additional MIPS adjustment factor will apply to Part B payments for covered professional services furnished by the MIPS-eligible clinician during the year. The adjustment factors will not apply to Part B drugs and other items. CMS proposes to make this change beginning with the 2019 payment year.
CMS offers further flexibility in helping small and rural practices to transition into participating in APMs and MIPS. CMS proposes to maintain a small practice bonus, but modifies its application by adding three points to the quality performance category score rather than adding 5 points to the final MIPS score. CMS also proposes to allow small groups to use claims as a collection type beginning in the 2019 performance year.
CMS proposes to maintain the complex patient bonus for the 2021 payment year.
In the CY 2018 QPP final rule, CMS established the potential for a facility-based measurement scoring option for clinicians that meet certain criteria beginning with the 2019 MIPS performance period/2021 MIPS payment year. CMS proposes the 2019 MIPS performance year as the first year physicians can choose to use a facility-based scoring option for the MIPS quality and cost performance categories. CMS proposes to limit facility-based reporting to the inpatient hospital in the first year. CMS also limits measures applicable for facility-based measurement to those used in the Hospital Value-Based Purchasing (VBP) Program.
The Hospital 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. In the 2018 Final Rule, CMS discussed moving forward with allowing MIPS-eligible clinicians who are facility-based to use their institution’s performance in the Quality and Cost categories. Although many hospital-based clinicians provide a majority of services in the on-campus outpatient hospital, CMS believes that a significant portion of services in the on-campus outpatient hospital are reflected in the quality captured by the Hospital VBP Program.
To qualify for facility-based scoring, physicians must perform 75 percent of their services in inpatient, on-campus outpatient or emergency room settings, and must have at least one service billed with the place of service (POS) code used for inpatient (21) or emergency room (23). For groups, 75 percent or more of the National Provider Identifiers (NPIs) billing under the group’s Tax Identification Number (TIN) must be eligible for facility-based measurement as individuals. CMS is now proposing to add the on-campus outpatient hospital (POS 22) as a site of service used to determine facility-based measurement eligibility.
Facility-based scoring will automatically be applied to MIPS-eligible clinicians and groups who qualify and would benefit by having the facility-based score for their quality performance, as long as they submit data under the Improvement Activity (IA) or Promoting Interoperability (PI) categories. CMS maintains the 30 percent floor, so any physician who scores below 30 percent via the facility-based reporting option would have their score reset to 30 percent in the quality performance category. CMS is also seeking comment on possibly expanding the facility-based scoring option to other settings in future years, specifically to post-acute care and end-stage renal disease settings.
CMS proposes to maintain performance periods for 2019 and future years as follows:
CMS proposes to maintain the 60 percent data completeness threshold for QCDRs, qualified registries, EHRs and claims-based data submissions with the expectation that this threshold will increase over time. The quality performance category weight is proposed to be 45 percent of a clinician’s final score for the 2019 MIPS performance year.
CMS proposes using the following measures to assess performance: CMS’ final list of MIPS quality measures, QCDR measures, facility-based measures, and MIPS APM measures. Measure requirements remain the same: MIPS-eligible clinicians must submit 6 quality measures, one of which must be a high priority or outcome measure or a specialty set, provided that the set includes 6 measures. If the specialty measure set does not have 6 measures, then the clinician should report additional measures as applicable.
CMS defines a topped out measure as one whose median performance is 95 percent 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 has established a 4-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. In the proposed rule, CMS is suggesting a new criterion for removing measures identified as “extremely topped out,” that is, measures with an average performance within the 98th to 100th percentile. For these measures, regardless of where they are in the topped out measure lifecycle, CMS may propose to remove them in the following year’s rulemaking cycle.
Beginning with the 2020 payment year, measures identified as topped out for two or more consecutive years will be eligible for no more than 7 points. It is important to note that a measure could be deemed topped out in one 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 for which it has been deemed topped out.
Two measures reportable by diagnostic radiologists have been proposed for removal:
Measure #359 has been proposed for removal because it is duplicative of the currently adopted Measure #361: Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry. The use of standardized nomenclature within this measure is intended to enable reporting to Dose Index Registries to allow comparison across radiology sites and does not require the submission to a Dose Index Registry as indicated in Measure 361.
Measure #363 has been proposed for removal because the quality action does not completely attribute to the radiologist submitting the measure and does not require a quality action that links to improved outcomes when the search is completed prior to the study.
Three measures pertinent to radiation oncologists which have been proposed for removal in 2019 due to being evaluated as “extremely topped out”:
CMS will maintain the 3-point floor for measures that can be reliably scored against a benchmark, with 10 points being the highest score for a measure. 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 60 percent data completeness threshold. Measures that do not meet data completeness will receive 1 point; however, CMS notes they are considering assigning 0 points starting in the 2020 performance period (excluding small practices, who would continue to receive 3 points). Measures that are identified as topped-out will receive a maximum of 7 points; CMS is also proposing that QCDR measures will no longer qualify for the topped out measure cycle through rulemaking process but may not be approved through the QCDR measure approval process. Bonus points continue to be available for reporting high priority and outcome measures as well as end-to-end reporting and will be capped at 10 percent of the quality performance denominator. CMS is considering eliminating bonus points for high priority measures and end-to-end electronic reporting for the 2020 performance year.
CMS did not propose to significantly modify the options available to ACR members for reweighting the Promoting Interoperability (PI) MIPS performance category in performance year 2019/payment year 2021. MIPS-eligible clinicians determined to be non-patient-facing or hospital-based will continue to be automatically reweighted for the PI category unless they report PI participation data. For simplification purposes, CMS proposed to unify the various determination periods used for certain special statuses such as non-patient-facing, hospital-based, small practice, etc., into a single “MIPS determination period.”
As before, eligible clinicians who reweight PI would continue reallocating its 25 percent of the total MIPS score to the Quality category. CMS again seeks comments on a potential alternate paradigm in which 15 percent would be reallocated to Quality and 10 percent would go to IA.
For those radiologists who plan to participate in ACI, CMS proposed to require implementation of 2015 Edition certified EHR technology (CEHRT), which is aligned with the agency’s proposal for the hospital-specific Promoting Interoperability program (formerly the EHR Incentive Program) in the 2019 Inpatient Payment System proposed rule. CMS proposed to change the scoring methodology for the PI performance category by eliminating the paradigm of separate “base” and “performance” scores. Instead, CMS will score PI participants based on calculated performance on the individual measures, each having different weights/maximum points:
Max Points 2019
Max Points 2020
|Query of Rx drug monitoring program (PDMP)||5 bonus||5|
|Verify opioid treatment agreement||5 bonus||5|
|HIE||Support electronic referral loops by sending health information||20||20|
|Support electronic referral loops by receiving and incorporating health information||20||20|
|Provider-to-Patient Exchange||Provide patients with electronic access to their health information||40||35|
|Public Health and Clinical Data Exchange||
Choose two the following:
The numerator and denominator for a given measure would be used to calculate a “performance rate” which would then be calculated against the maximum available points for that measure to determine the actual awarded points for the measure in question. The participant’s awarded points for all measures are then tallied and calculated against the 100 total available PI points to determine the PI performance score for the year (i.e., up to 25 percent of the MIPS score in performance year 2019).
Meeting the exclusion criteria of certain measures would result in reallocating the points to other measures. For example, if excluded from the eRx measure in 2019 (< 100 permissible prescriptions during the performance period), the maximum 10 points from eRx would be reallocated to increase the maximum points for the two health information exchange (HIE) measures, increasing both to 25 maximum points each. As another example, the HIE measure for “support electronic referral loops by receiving and incorporating health information” has an exclusion that would result in its 20 maximum points being reallocated to the other HIE measure (“support electronic referral loops by sending health information”), making it worth 40 maximum points.
CMS proposed to eliminate several measures requiring action by patients as well as measures the agency believes do not support interoperability: patient-specific education, view/download/transmit, patient-generated health data, and secure messaging. The HIPAA/security risk analysis measure would be eliminated as a separate measure, but would still remain as a mandatory requirement for PI reporting. CMS also proposed to essentially combine concepts from the 2018 “request/accept summary of care” measure with the 2018 “support electronic referral loops – receiving and incorporating health information” measure to create the proposed 2019 HIE measure of “support electronic referral loops by receiving and incorporating health information.”
CMS proposed to eliminate the previously available 10 percent bonus for completing one of several specified Improvement Activities using CEHRT.
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 percent for the 2019 MIPS performance year final score. The submission process for activities is proposed to remain the same; clinicians would still be able to attest to activities by indicating a “yes” response for each completed activity using their submission method of choice.
In the rule, CMS proposes to retain nearly all the 112 activities from the 2018 inventory while adding 6 new activities, modifying 5 existing activities and removing one activity. CMS has also proposed a new criterion for the consideration of new improvement activities related to items that have been declared a public health emergency by the HHS Secretary, such as the opioid epidemic. 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).
CMS is not proposing any changes to the number of activities (two high-weighted or four medium-weighted) that MIPS-eligible clinicians are required 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. Lastly, CMS is proposing to remove the provision for receiving bonus points toward the Promoting Interoperability performance category if certain improvement activities are completed using CEHRT.
CMS is proposing that the cost performance category would increase to 15 percent of a MIPS-eligible clinician’s final score for the 2021 MIPS payment year and anticipates increasing the weight of the cost performance category by 5 percentage points each year until reaching the required 30 percent weight for the 2024 MIPS payment year. CMS will continue to utilize the total per capita cost and Medicare spending per beneficiary (MSPB) measures, established for the 2017 MIPS performance period, for the 2019 MIPS performance period and future performance periods. CMS plans to reevaluate cost measures every 3 years to ensure that they continue to meet measure priorities and to analyze measure performance rates and reassess the reliability and validity of the measures.
Additionally, beginning with the 2019 MIPS performance period, CMS is proposing to add 8 episode-based measures to the cost performance category and notes that they will continue to develop additional episode-based measures for future rulemaking. Episode-based measure specifications differ from total per capita cost and MSPB measures in that they include items and services related to the episode of care for a clinical condition or procedure, and not all services provided to a patient over a given timeframe.
CMS reports that episode-based measures are developed to inform attributed clinicians regarding the cost of the care clinically related to their initial treatment of a patient provided during the episode’s timeframe. CMS defines cost as based on the allowed amounts on Medicare claims, which include both Medicare payments and beneficiary deductible and coinsurance amounts. Episode-based measures are calculated using Medicare Parts A and B fee-for-service claims data and are based on episode groups. Episode groups represent a clinically cohesive set of medical services rendered to treat a given medical condition, aggregate all items and services provided for a defined patient cohort to assess the total cost of care and are defined around treatment for a particular condition or the performance of a particular procedure. The episode-based 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. CMS proposes a case minimum of 10 for procedural measures and 20 for inpatient episodes.
The Bipartisan Budget Act of 2018 now requires information on cost measures in use under MIPS, cost measures under development and the time-frame for such development, potential future cost measure topics, a description of stakeholder engagement, and the percent of expenditures under Medicare Part A and Part B covered by cost measures, to be posted on the CMS website. The eight proposed episode-based cost measures as well as their measure type can be found below.
|Elective Outpatient Percutaneous Coronary Intervention (PCI)||Procedural|
|Revascularization for Lower Extremity Chronic Critical Limb Ischemia||Procedural|
|Routine Cataract Removal with Intraocular Lens (IOL) Implantation||Procedural|
|Intracranial Hemorrhage or Cerebral Infarction||Acute inpatient medical condition|
Simple Pneumonia with Hospitalization
|Acute inpatient medical condition|
|ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)||Acute inpatient medical condition|
CMS proposes to change the terminology used for MIPS data submission to reflect the experience users have when submitting data more concisely. Therefore, they would like to define “collection type” as a set of quality measures with comparable specifications and data completeness criteria. These include eCQMs; MIPS Clinical Quality Measures (MIPS CQMs); QCDR measures; Medicare Part B claims measures; CMS Web Interface measures; the CAHPS for MIPS survey; and administrative claims measures. CMS proposes to replace the term “registry measures” with “MIPS CQMs,” as other entities besides registries may submit data on these measures. MIPS-eligible clinicians or third-party entities that submit data on behalf of MIPS-eligible clinicians would be referred to as “submitter types.” “Submission type” would refer to the type of mechanism by which a submitter type submits data to CMS. The submission types include direct, log in and upload, log in and attest, Medicare Part B claims and the CMS Web Interface.
Beginning with the 2019 performance period, CMS proposes to allow individuals, groups and virtual groups to submit measures using multiple collection types CMS would like to move away from Medicare Part B claims reporting and proposes to limit Part B claims collection type only to individuals in small practices beginning with the 2021 MIPS payment year (2019 performance year) and to also allow small practices to report using claims as a group.
In the 2018 final rule, CMS defined three ways to participate in MIPS: as an individual, as a group, or as a new category called a “virtual group” in order to assist small, independent practices. In the virtual group option, two or more solo practitioners or groups made up of 10 or fewer eligible clinicians 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.
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. 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. The virtual group election process will not change from 2018; physicians or groups who wish to report as part of a virtual group for 2019 must apply through CMS by December 31, 2018.
One proposed change to virtual group eligibility in 2019 is related to the determination of group size. In the 2018 reporting year, the size of a TIN was determined by analyzing claims over a 5-month period from July 1 to November 30 of the year preceding the performance period. CMS is now proposing to change this to a 12-month period beginning on October 1 of the previous year through September 30 of the calendar year preceding the performance period. This analysis will be used to determine a group’s eligibility to participate as a virtual group.
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.
CMS proposes changes to the three criteria to qualify as an Advanced APM:
However, CMS requests comments on whether they should consider raising the revenue based nominal amount standard to 10 percent, and the expenditure-based nominal amount standard to 4 percent starting for QP Performance Periods in 2025 and later.
CMS is proposing to allow eligible clinicians to become Qualifying APM Participants (QP) by utilizing the All-Payer Combination of participating in Medicare’s Advanced APMs and with Other Payers. To be consistent and reduce burden, CMS proposes that other payers meet the same criteria as Medicare APMs with one exception. CMS proposes to phase in the CEHRT requirement by requiring at least 50 percent in each APM Entity use CEHRT to document and communicate clinical care with patients and other health care professionals and then 75 percent for 2020 and beyond.
CMS also 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. In this instance, all clinicians under the TIN will have reassigned billing rights to the APM Entity. CMS clarifies that, in making QP determinations using the All-Payer Combination Option, eligible clinicians may meet the minimum Medicare threshold using one method, and the All-Payer threshold using the same or a different method.
CMS proposes that for each of the three QP determinations (March 31, June 30, and August 31), they will allow for claims run-out for 60 days (approximately 2 months), before calculating the Threshold Score so that the three QP determinations will be completed approximately 3 months after the end of that determination time period. CMS proposes to shorten the claims run-out period by 30 days so that eligible clinicians are notified of their QP status more quickly after each of the three QP determination snapshot dates, and prior to the beginning of the MIPS data submission period after the last determination. This offers clinicians the option of electing to report under MIPS for the reporting year if they do not receive a QP status.
CMS also propose that when an eligible clinician is determined to be a Partial QP for a year at the individual eligible clinician level, the individual eligible clinician can make an election whether to report to MIPS. If the eligible clinician elects to report to MIPS, they will be subject to the MIPS reporting requirements and payment adjustment. In the absence of an explicit election to report to MIPS, the eligible clinician will be excluded from the MIPS reporting requirements and payment adjustment. CMS proposes this to ensure that no actions other than the eligible clinician’s affirmative election to participate in MIPS would result in that eligible clinician becoming subject to the MIPS reporting requirements and payment adjustment.
The All-Payer Combination Option allows eligible clinicians to become QPs by meeting the QP thresholds through a pair of calculations that assess a combination of both Medicare Part B covered professional services furnished through their Advanced APMs and services furnished through Other Payer Advanced APMs. CMS will use the Threshold Score that is most advantageous to the eligible clinician toward achieving QP status, or if QP status is not achieved, Partial QP status, for the year.
Other APM Entities or eligible clinicians working with them must submit all of the payment amount and patient count information to CMS in order for them to make QP determinations by December 1 of the calendar year that is 2 years to prior to the payment year, which is referred to as the QP Determination Submission Deadline. CMS requires this because they do not have access to the Other APM Entities data since private payer data is not usually shared in the public domain.
For a side-by-side comparison of CY 2018 final rule and CY 2019 proposed rules, please refer to CMS’ Fact Sheet.
The ACR’s MACRA Committee and staff are further analyzing and digesting this rule for the membership to prepare future tools and materials. ACR will also submit comments on the proposed rule before the September deadline.