September 27, 2017

Quality Payment Program: Expansion and Flexibility

As the Quality Payment Program (QPP) moves into its second year, CMS has issued a proposed rule with updates and changes to improve policies and ensure meaningful measures going forward. According to CMS, the proposed changes continue to provide "many flexibilities that make it easy for clinicians to participate and that gradually prepare clinicians for full implementation." The final rule is expected to be released in Nov. 2017 and will take effect Jan. 1, 2018.

Read an ACR summary of the proposed rule »
Access the ACR comment letter on the proposed rule »

What's New for Radiology?

For radiologists, most of the provisions of QPP remain the same for both QPP tracks: Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). Here are a few highlights you should consider for the second and future years of the QPP.

MIPS Updates

"Pick Your Pace" concludes, but some flexibility continues. Under the QPP Year 2 rule, CMS will continue phasing in full MIPS requirements anticipated in the 2019 performance year. As proposed, the final score performance threshold would increase from 3 to 15 of 100 possible points required to earn a neutral payment adjustment. Those who score higher than the threshold can potentially earn a positive payment adjustment; those who score below will receive a potential negative payment adjustment.

Non-patient facing exemptions continue. In the proposed rule, CMS maintains the definition of a non-patient facing, MIPS-eligible clinician. In the second year of the QPP, many diagnostic radiologists will continue to benefit from potential exemptions available for two of the four performance categories: Advancing Care Information and Cost.

Small and rural practices. CMS included proposals to further ease the transition to the QPP for small and rural practices, including receiving five bonus points for participating in a small group practice. ACR has prepared a separate summary on the small and rural proposals in this rule.

Full year of data. CMS proposes increasing the performance period requirements to be a full calendar year for the Quality and Cost performance categories (for at least 50% of patients). In the Cost category, MIPS-eligible clinicians will receive feedback on their performance, but will not be held accountable as it will not count towards their MIPS final score. Cost may either be weighted at 0% or 10% for 2018 performance year, affecting 2020 payment. Clinicians will not be required to submit data for cost measures; it will be calculated from adjudicated claims. Clinicians can expect feedback on total per capita cost, Medicare Spending Per Beneficiary and episode-based measures, if applicable.

Multiple submission mechanisms. CMS proposes for the 2018 performance period and future years, to allow individual MIPS eligible clinicians and groups to submit data on measures and activities, as applicable, via multiple data submission mechanisms for a single performance category, as necessary, to meet the requirements of the quality, improvement activities or ACI performance categories. Previously, MIPS-eligible clinicians were required to use only one submission mechanism per performance category. This proposal will allow clinicians and groups the ability to select the quality measures most meaningful to them, regardless of submission mechanism: claims, qualified registry or qualified clinical data registry.

Topped-out measures. CMS defines a topped-out measure as one where median performance is 95% or higher and "meaningful distinctions and improvement in performance can no longer be made." CMS identified six "highly topped out" measures for 2018 that are proposed to be removed from the program in the next three years. Of the six topped-out measures for 2018, one is pertinent to radiology: "Optimizing Patient Exposure to Ionizing Radiation (OPEIR): Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging." For these measures, CMS proposes special rules for scoring, which involves a cap of six points. ACR recommended that CMS not remove the OPEIR measure due to limited reporting.

Improvement Activities (IA). In the proposed rule, improvement activities remain weighted at 15% for the 2018 MIPS performance year final score, and MIPS-eligible clinicians can continue attesting to IA. For radiologists, IA opportunities include several Qualified Clinical Data Registry activities as well as participating in the Radiology Support, Communication and Alignment Network (R-SCAN). New for 2018, radiologists and group practices can potentially earn full IA credit for supporting consultation of Appropriate Use Criteria (AUC) using clinical decision support when ordering advanced diagnostic imaging, as this activity has a high weighting and is eligible for the Advancing Care Information bonus. ACR supports inclusion of this new activity and encourages CMS to reword the activity so that radiologists can earn credit for supporting their referring clinicians in implementation of AUC through a qualified clinician decision support mechanism such as ACR Select®.

Virtual groups. 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 to participate in the MIPS program. Two types of practices can form virtual groups: MIPS-eligible solo practitioners who bill under a single Tax Identification Number (TIN) with a single National Provider Identifier (NPI); and 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.

APM Updates

CMS is keeping many of the policies finalized for the transition year, and is proposing changes and updates, including:

  • Extending the revenue-based nominal amount standard, which was previously finalized through performance year 2018, for two additional years (through performance year 2020). This standard allows an APM to meet the financial risk criterion to qualify as an Advanced APM if participants are required to bear total risk of at least 8% of their Medicare Parts A and B revenue.
  • Changing the nominal amount standard for Medical Home Models so that the minimum required amount of total risk increases more slowly
  • Giving more detail about how the All-Payer Combination Option will be implemented. This option allows clinicians to become Qualifying APM Participants (QPs) through a combination of Medicare participation in Advanced APMs and participation in Other Payer Advanced APMs. This option will be available beginning in performance year 2019.
  • Giving more detail on how eligible clinicians participating in selected APMs will be assessed under the APM scoring standard. This special standard reduces burden for certain APMs (MIPS APMs) participants who do not qualify as QPs, and are therefore subject to MIPS  

Prepare for Quality-Based Care in Radiology

Everything you need to know about MIPS and APMs is now at your fingertips via informative webinars, podcasts and videos. Learn how to meet requirements and prepare for the new era of patient care.

Read the CMS QPP Year 2 fact sheet »
Explore ACR MACRA resources »
Learn more about QPP »
Get answers to your QPP questions »