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BREAKING: CMS Publishes CY 2019 Physician Fee Schedule/QPP Final Rule

November 1, 2018
by Heather Landi, Associate Editor
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The final rule includes provisions for reimbursement for virtual care; CMS modified its proposed changes to E&M coding

Late in the afternoon on Thursday, Nov. 1, the federal Centers for Medicare & Medicaid Services (CMS) published a final rule that provides updates to the Physician Fee Schedule and calendar-year 2019 Quality Payment Program (QPP), which encapsulates the Medicare Incentive-based Payment Program (MIPS) and Advanced Payment Models

In the proposed rule, which was released July 12, CMS recommended sweeping changes to MIPS measures, Evaluation and Management (E&M) coding and telemedicine reimbursement. At the time of the proposed rule’s release, CMS officials said the proposed changes will “fundamentally improve the nation’s healthcare system and help restore the doctor-patient relationship by empowering clinicians to use their electronic health records (EHRs) to document clinically meaningful information.”

In similar remarks about the finalized 2,378-page rule, CMS officials said changes to the Medicare Physician Fee Schedule and Quality Payment Program will shift clinicians’ time from completing unnecessary paperwork to providing innovative, high-quality patient care. The proposals in the final rule “address provider burnout and provide clinicians immediate relief from excessive paperwork tied to outdated billing practices,” CMS said in a press release.

CMS officials said the changes advance innovation, restore focus to patients and support moving the healthcare system to value-based care. A fact sheet on the final rule published Nov. 1 can be accessed here.

According to CMS officials, in Year 3 of the Quality Payment Program, CMS is continuing to use the framework established by the Patients Over Paperwork initiative, implement meaningful measures, promote interoperability, support small and rural practices, reduce clinician burden, and improve patient outcomes.

The changes in the CY 2019 PFS and QPP final rule establish Medicare payment for when beneficiaries connect with their doctor virtually using telemedicine to determine whether they need an in-person visit. Additionally, the QPP changes, set to take place in year three of the program, in 2019, would make changes to quality reporting requirements to focus on measures that most significantly impact health outcomes, CMS said.

The changes will encourage information sharing among healthcare providers electronically. And, the QPP final rule will make changes to the MIPS “Promoting Interoperability” performance category to support greater EHR interoperability and patient access to their health information, as well as to align this clinician program with the “Promoting Interoperability” program for hospitals, which was published as a final rule in August.

“The final 2019 Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) rule released today also modernizes Medicare payment policies to promote access to virtual care, saving Medicare beneficiaries time and money while improving their access to high-quality services, no matter where they live.” CMS stated. “It makes changes to ease health information exchange through improved interoperability and updates QPP measures to focus on those that are most meaningful to positive outcomes. Today’s rule also updates some policies under Medicare’s accountable care organization (ACO) program that streamline quality measures to reduce burden and encourage better health outcomes, although broader reforms to Medicare’s ACO program were proposed in a separate rule.”

CMS projects that the changes will save clinicians $87 million in reduced administrative costs in 2019 and $843 million over the next decade. The changes will result in 21 million hours saved for physicians over 10 years beginning in 2021, CMS said.

During a press call late Thursday afternoon to address the final rule, CMS Administrator Seema Verma said, “During the past year and a half, we have introduced several initiatives aimed at doing the things necessary to finally achieve the long talked-about goal of value-based care. With healthcare costs skyrocketing and the demands of Americans only increasing, value-based care isn’t something that we’d like to do, it’s something that we must do,” Verma said. “To that end, our initiates serve to do the things necessary to move our healthcare system towards one that pays for the value of service rather than the mere volume.”

Verma said CMS is working to put the patient at the center of the healthcare system. “We advanced several initiatives, including Patients over Paperwork, Meaningful Measures and MyHealthEData in our rules this week.”

Verma said Thursday’s announcement was another example of CMS is “putting action behind words.” “Today’s rules represent a big win, in terms of access to care in convenient and efficient ways by offering patients new choices in how connect they with doctors and caregivers. For the first time in 2019, Medicare will pay doctors for virtual check ins with their patients, virtual consultations between physicians, evaluation of remote pre-recorded images and video and an expanded list of telehealth services,” Verma said.

“The historic reforms CMS finalized today move us closer to a healthcare system that delivers better care for Americans at lower cost,” Health and Human Services (HHS) Secretary Alex Azar, said in a statement. “Among other advances, improving how CMS pays for drugs and for physician visits will help deliver on two HHS priorities: bringing down the cost of prescription drugs and creating a value-based healthcare system that empowers patients and providers.” 

 “Today’s rule finalizes dramatic improvements for clinicians and patients and reflects extensive input from the medical community,” Verma said in a statement released with the final rule. “Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors. Today’s rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care. It also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort.”

The final CY 2019 PFS and QPP rule retains many of the dramatic changes to MIPS measures, E&M coding and telemedicine reimbursement contained in the proposed rule, but CMS officials did make some changes in the final rule in response to stakeholder concerns, Verma stated in the press release.

Speaking to Managing Editor Rajiv Leventhal at the CHIME Fall Forum in San Diego, Mari Savickis, vice president, federal affairs at the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), said in response to the final rule's release: "The biggest takeaway for us, and we’re still combing through the rule, is the telehealth part. [CMS] has done so many positive things here, that it's no longer one toe in the water; it’s definitely now one foot in the water. This is a great start for 2019, and it’s exceptionally promising that they are following through on many things we have seen from Congress.”

“And they appear to largely have aligned physicians [in this rule] with hospitals in the Promoting Interoperability rule. That is a huge burden reduction for our members. We also strongly support fewer measures and objectives. We have been advocating for that for years," Savickis said.

E&M Documentation Reforms

During the press call, Verma said coding requirements for physician services known as “evaluation and management” (E&M) visits have not been updated in 20 years. Verma said the final rule simplifies documentation so doctors can spend more time with patients. The final rule addresses longstanding issues and also responds to concerns raised by stakeholders when commenting on the proposed rule, Verma said.

Initially, in the proposed rule, CMS proposed major reforms to E&M payments including single blended payment rates for both new and established patients for office/outpatient E&M level 2 through 5 visits, essentially proposing to collapse the number of codes from five levels to two.

After listening to concerns from the provider community, CMS modified its proposals and will maintain a separate level of payment for the most complex patient care, or level 5 visits, Verma said.

The agency also is delaying implementation of E&M coding reforms until 2021, which will enable continued stakeholder engagement. “Physicians will see some immediate changes in 2019 that reduce burden and even more significant burden reduction in 2021, when broader changes to the E&M framework take effect,” Verma said. A CMS chart on E&M payment amounts can be found here.

Reimbursing for Virtual Care

As it relates to virtual care, CMS officials said that provisions in the CY 2019 Physician Fee Schedule would support access to care using telecommunications technology. Under the final rule, Medicare will pay providers for new communication technology-based services, such as brief check-ins between patients and practitioners, and pay separately for evaluation of remote pre-recorded images and/or video. CMS is also expanding the list of Medicare-covered telehealth services.

“This provides opportunities for patients around communicating with providers remotely. We’ve never had this in the program at large. There has been a telehealth benefit mostly for rural providers, but access to care is not just a rural issue, it’s something that patients struggle with across the country,” Verma said. “This is an historic change in terms of increasing access and it’s also a great example of some of the efforts that we’re trying to make around supporting innovation. This has been happening in the private market and I think the opportunities and the impact could be tremendous. We’re excited to be able to harness this innovation for Medicare beneficiaries.”

Changes to MIPS

Finally, regarding year three of MIPS, CMS made changes to remove MIPS process-based quality measures that clinicians have said are low-value or low-priority, in order to focus on meaningful measures that have a greater impact on health outcomes, agency officials said.

The rule also will overhaul the MIPS “Promoting Interoperability” (formerly called Advancing Care Information) performance category to support greater EHR interoperability and patient access to their health information, as well as to align this performance category for clinicians with the new Promoting Interoperability Program for hospitals. For the Promoting Interoperability performance category, CMS is requiring that MIPS-eligible clinicians to use 2015 Edition certified EHR technology beginning with the 2019 MIPS performance period.

“This means that physician incentives are now directly tied to doctors updating their systems so that they are interoperable,” Verma said during the press call. “Today is an important milestone toward increasing the interoperability of electronic health records, which is critical to patient empowerment and driving toward a value-based healthcare system. We firmly believe health records belong to patients, and patients should control them and be able to share them with providers, researchers, caregivers, or whomever they want.”

CMS also introduced an opt-in policy so that certain clinicians who see a low volume of Medicare patients can still participate in MIPS, if they choose to do so, according to CMS. In addition, CMS is providing the option for clinicians who are based at a healthcare facility to use facility-based scoring to reduce the burden of having to report separately from their facility.

In addition, the rule continues CMS’s work to deliver on President Trump’s commitment to lowering prescription drug costs. Effective January 1, 2019, payment amounts for new drugs under Part B will be reduced, decreasing the amount seniors have to pay out-of-pocket, especially for drugs with high launch prices, CMS stated.

During the press call, Verma said the CMS initiatives announced in the past year and a half are a reflection of the agency’s “serious commitment to patient-centered care.” And, Verma noted that some industry stakeholders will have complaints about the changes to PFS and QPP programs. “This does not deter us. The status quo, where nearly one in five dollars will be spent on healthcare, is unacceptable. If we’re going to move our system to a patient-centered, value-based system, change is inevitable, and change is always hard for those whose livelihood is dependent on the status quo.”

 


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Healthcare Industry Could Save $12.4B With Full Adoption of Electronic Transactions

January 17, 2019
by Heather Landi, Associate Editor
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The healthcare industry continues to make progress automating business processes, but significant gaps remain, representing an opportunity for $12.4 billion in savings through further automation, according to new data from the 2018 CAQH Index.

Electronic adoption and transaction volume increased in 2018, with several common transactions reaching 80 percent electronic adoption across the sector, according to the latest CAQH Index. This progress resulted in a narrowing of the cost savings opportunity for the first time in CAQH Index history.

CAQH is a Washington, D.C.-based non-profit alliance of health plans and trade associations. The findings from the 2018 CAQH Index are based on voluntary nationwide surveys of providers, as well as commercial medical and dental health plans. Participating medical health plans represent over 160 million covered lives—nearly 49 percent of the commercially insured U.S. population—and 7.8 billion transactions conducted in 2018.

The sixth annual CAQH Index is an annual report tracking the adoption of HIPAA-mandated and other electronic administrative transactions between healthcare providers and health plans in the medical and dental industries. These transactions include verifying a patient’s insurance coverage, obtaining authorization for care, submitting a claim and supplemental medical information and sending and receiving payments. The CAQH Index also estimates the annual volume of these transactions, their cost and the time needed to complete them.

By benchmarking progress, industry and government can more easily identify barriers that may be preventing stakeholders from realizing the full benefit of electronic administrative transactions. These insights can prompt new initiatives to address and reduce barriers. For the report, data was submitted by medical and dental plans that cover roughly half of the insured population in the United States and providers representing a range of specialties.

After reporting modest progress over the past few years, the 2018 CAQH Index findings suggest more positive change is occurring in the industry overall. Healthcare industry stakeholders made progress on many fronts this year—in adoption of electronic transactions, reductions in the volume of manual transactions and reductions in the remaining savings opportunity.

“The results highlighted in the 2018 Index are encouraging,” Kristine Burnaska, director of research and measurement at CAQH, said in a statement. “Both providers and health plans are saving time and reducing administrative costs, but more effort is needed to significantly reduce the volume of expensive, time consuming manual processing.”

While the overall volume of transactions in the medical industry increased by 18 percent in the past year, the volume of manual transactions declined, falling 6 percent for health plans and 1 percent for providers, according to the CAQH Index.

Medical industry adoption of electronic eligibility and benefit verification increased six percentage points to 85 percent in 2018; adoption of electronic coordination of benefits rose to 80 percent in 2018, up from 75 percent in 2017. Adoption of electronic claim submission stands at 96 percent and 71 percent of healthcare organizations have adopted electronic claim status inquiries.

However, the healthcare industry made little progress in the adoption of other electronic administrative transactions—only 12 percent of organizations have adopted electronic prior authorization, although that is up from 8 percent the year before. Adoption of electronic claim payment stands at 63 percent and less than half of healthcare organizations (48 percent) have adopted electronic remittance advice processes.

However, continued efforts are needed to significantly reduce the volume of expensive, time-consuming manual transactions and adapt to the changing administrative needs of the healthcare system, according to the CAQH Index. The Index estimates that the medical and dental industries could save an additional $12.4 billion annually with full adoption of electronic administrative transactions, particularly through greater automation by providers, which could save an additional $8.5 billion.

During a period of rising transaction volume, the medical industry shaved $1.3 billion from its savings opportunity, bringing it to $9.8 billion.

The Index also highlights a substantial rise in overall transaction volume, growing in parallel with industry complexity. As these trends persist, the Index finds that the industry would benefit from updated standards, operating rules, infrastructure and functionality that can accommodate the increase in volume and growing complexity associated with the need to connect administrative and clinical data elements in value-based payment models.

“The industry is making progress,” April Todd, senior vice president, CORE and Explorations at CAQH, said in a statement. “But, we are at an inflection point where processes and technology must adapt to a healthcare system that is transitioning to value-based payment and becoming increasingly complex.”

The CAQH Index notes that industry complexity is growing in parallel with transaction volume. “As these trends persist, the industry will benefit from standards, operating rules, infrastructure and functionality that can accommodate both the increase in volume and the growing complexity associated with varying plan and payment models designed to increase the value and quality of healthcare for consumers. There is a need for all stakeholders to support initiatives that lay the groundwork for the future,” the report authors wrote.

The CAQH Index also issued a number calls to action for the healthcare industry, including focusing efforts to address cost savings opportunities. Several transactions offer the greatest potential for savings and should be the subject of attention—transactions include eligibility and benefit verification, claim status, remittance advice and prior authorization. The medical industry could save an additional $4 billion on eligibility and benefit verifications and $2.6 billion on claim status transactions by fully adopting electronic transactions, according to the CAQH Index.

CAQH also recommends accelerating standards and operating rule development and encouraging timely vendor adoption of standards and operating rules.

 

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Has CMS Just Tipped the Scales Towards Provider Alienation, in its ACO Final Rule?

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CMS’s release of its final rule on MSSP ACO participation has pushed the healthcare industry into a very fraught moment in the ongoing evolution of the ACO experiment

As Healthcare Informatics Associate Editor Heather Landi reported on Dec. 21, that morning, “The Centers for Medicare & Medicaid Services (CMS) on Friday morning published a final rule that makes sweeping changes to the Medicare Shared Savings (MSSP) Accountable Care Organization (ACO) program, with the goal to push Medicare ACOs more quickly into two-sided risk models.”

Indeed, as Landi noted in her report, “Referred to as ‘Pathways to Success,’ the Trump Administration’s overhaul of Medicare’s ACO program will redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase in higher levels of risk; and the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.”

And, Landi noted, “Currently, the MSSP model includes three tracks and is structured to allow ACOs to gain experience with the program before transitioning to performance-based risk. The vast majority of Shared Savings Program ACOs have chosen to enter and maximize the allowed time under Track 1, which is an ‘upside-only’ risk model. MSSP Tracks 2 and 3 involve downside risk, but participation in these tracks has been limited thus far.”

One of the biggest points of contention in recent months as centered on how aggressive a push on the part of CMS to compel providers forward into two-sided risk would be desirable, or even wise. Some in the industry tried to put a positive spin on the “low-income” element of the program, with that term referring to smaller physician groups choosing to participate in the MSSP. On Friday morning, in response to the final rule, Travis Broome, vice president of policy at Aledade, a Bethesda, Md.-based company focused on physician-led ACO development, tweeted, “One more change to Basic. Low-revenue ACOs will be able to stay in 1-sided risk for 3 years. Difference [between] 2 & 3 years is big. The decision to take risk is made summer before the year starts. So 2 years of 1-sided risk meant making the risk decision before year 1 results even came in.”

But in a statement from the National Association of ACOs (NAACOS), an association comprised of more than 360 ACOs, Clif Gaus, Sc.D., NAACOS’s president and CEO expressed concern that CMS retained the two-year limit for other ACOs. “Becoming a well-functioning ACO takes time and requires building of IT infrastructure, hiring care coordinators, changing the culture of providers, among other tasks. Under CMS’s proposed rule, many ACOs would have just a single year of performance data available to them before evaluating the required move to risk in their third year of the program,” Gaus stated.

Gaus did include a conciliatory note in his statement, saying that "We appreciate CMS' effort in the final rule to provide greater stability to the Medicare Shared Savings Program with five-year agreement periods and more flexibility through waivers for telehealth and skilled nursing facility stays. We look forward to working with CMS to ensure that the Medicare Shared Savings Program, which has a track record of saving taxpayer hundreds of millions of dollars while demonstrably improving care for patients, continues to attract new participants and reap savings." NAACOS has been among the most vocal of healthcare professional associations this year, as CMS Administrator Seema Verma has intensified her call for providers to move forward quickly into more advanced forms of alternative payment models.

But, choosing not to sound any notes of conciliation on Friday, was the Chicago-based American Hospital Association, the largest U.S. hospital association, representing nearly 5,000 hospitals nationwide. A statement attributed to Tom Nickels, AHA vice president, on Dec. 21, said, “Today’s final rule will not be helpful in the move toward value-based care. None of the actions taken today will better empower ACOs to maximize their contribution to patient care and are not pathways for improving the value of the program for patients. We remain opposed to CMS drastically shortening the length of time in which ACOs can participate in an upside-only model. Hospitals and health systems have asked for a more gradual pathway because building a successful ACO that is able to take on financial risk requires significant investments in time, effort and finances.”

Further, the AHA statement said, “While CMS made some improvements to its shared savings rate policies from the proposed rule, they still are not sufficient to appropriately reward ACOs for improving quality and reducing costs. We are particularly concerned about the impact of these and other policies on high-revenue ACOs. We do appreciate that CMS took certain steps to expand participants’ ability to provide care to beneficiaries – for example, via telehealth and longer agreement periods.”

And, the AHA said, “As a whole, the policies in the rule will likely result in a significant decrease in program participation. That would be unfortunate, as we seek to transform care to better serve our patients and communities.”

While the Centers for Medicare & Medicaid Services (CMS) finalized some improvements to the Medicare Shared Savings Program (MSSP), the Premier healthcare alliance is extremely concerned that these are overshadowed by unrealistic expectations of the speed at which providers can transition to risk-based tracks, the un-level playing field created for hospital-led vs. physician-led ACOs and the imbalance of risk vs. reward.

Meanwhile, leaders at the Charlotte-based Premier Inc. were equally critical. In a statement released on Friday, Blair Childs, Premier’s senior vice president of public affairs said that while “Premier appreciates that CMS finalized the extension of waivers and the longer agreement period and heard our concerns about the reduction in shared savings,” “We are extremely disappointed, however, that CMS has moved forward in creating an unlevel playing field that disadvantages high-revenue ACOs—primarily hospital-led ACOs. Premier and other stakeholders, including MedPAC, oppose this policy,” the statement read. “Hospital-led ACOs in Premier’s Population Health Management Collaborative performed twice as well as all the other ACOs nationally. CMS should be taking steps to enhance, not limit, the inclusion of all innovative providers that are seeking to move to value-based care. For an Administration that has been outspoken in advocating for market solutions and level playing fields among competitors, it’s an enormous mistake to finalize a policy that pits providers against each other rather than focusing on collaboration, as the model intends.”

So, where does this leave the industry? Quite possibly, at an important inflection point, now that what was a proposed rule is now a final rule. One could argue this situation from a number of standpoints, but the bottom line is simple: in her desire to push providers forward quickly and decisively into two-sided risk—and even with the carrot-like incentives for smaller physician groups that have been added—Administrator Verma is now strongly risking a massive wave of defections from the MSSP.

As NAACOS’ Gaus noted in his statement, “Under CMS's proposed rule, many ACOs would have just a single year of performance data available to them before evaluating the required move to risk in their third year of the program.” Perhaps similarly importantly, he noted, "Although we are pleased that CMS finalized a new, limited exception to its high-low policy, we remain concerned that the high-low revenue ACO distinction could deter providers who want to embark on the path of value-based care and could unintentionally harm physician-led ACOs. We urged CMS in the rulemaking process to provide an equal playing field for all ACOs and will continue to advocate for changes to this policy. A NAACOS analysis of how ACOs would be classified under CMS's proposed definitions found almost 20 percent of physician-led ACOs would be considered high revenue ACOs. Furthermore, federally qualified health centers and rural health clinics would also have a fair proportion of high revenue ACOs.”

So, here we come to a very tricky set of issues. First, the entire point of adding in the “low-income ACO” distinction was to encourage more physician groups to join the MSSP; and that would be very important for the survival and thriving of the program, since the participation of hospital-based organizations has been slow to date, and one key way to encourage participation by all types of patient care organizations would be to be able to boast about rapidly increasing participation. But if, as Gaus has noted, NAACOS’ analysis finds that nearly 20 percent of physician-led ACOs would actually end up being “high-revenue ACOs,” that could indeed complicate CMS’s attempts to quickly gain new participants.

Further, the short period of time between initial participation and having to decide whether to stay in the voluntary program and take on mandated two-sided risk, poses one of the most serious barriers to increased participation; and therein lies the real rub for CMS, because if this final rule ends up causing mass defections in the next two years, the agency’s signature and largest federal ACO program could begin to fall apart, precisely at the time that Administrator Verma, Health and Human Services Secretary Alex Azar, and all their fellow senior federal healthcare policy officials, would be hoping to accelerate the shift from volume to value in U.S. healthcare, and prove that the broad ACO experiment is working.

On the other hand, it’s also true that if CMS allows the forward evolution of the MSSP program to progress too slowly, that could cause members of Congress and their staffs to determine that voluntary programs simply aren’t cutting it, and move towards massive Medicare cuts instead, in an attempt to get better control of overall U.S. healthcare inflation, at a time when all discretionary spending in the federal budget is increasingly becoming politically fraught.

For the time being, there is no simple answer to any of this. It’s as though the levers of power and influence must be used in an exquisitely calibrated way. There seems to be no “Goldilocks pace” of change here that will both maximize new participation, and ongoing participation, in the MSSP program, on the part of wary providers, and yet also fulfill all the demands and desires of senior federal healthcare policy officials. Only time will tell, but this moment feels more fraught than ever, in the ongoing evolution of the ACO experiment. There’s no doubt that 2019 could be a determinative year for MSSP.

 

 

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CMS: 93% of Clinicians Get Positive Payment Adjustments for MIPS Year 1

November 8, 2018
by Rajiv Leventhal, Managing Editor
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Ninety-three percent of MIPS (Merit-based Incentive Payment System)-eligible clinicians received a positive payment adjustment for their performance in 2017, and 95 percent overall avoided a negative payment adjustment, according to a CMS (Centers for Medicare & Medicaid Services) announcement today.

The first year of MIPS under MACRA’s Quality Payment Program (QPP) was dubbed by CMS as a “pick your pace year,” which essentially enabled clinicians to avoid payment penalties as long as they submitted at least the minimum amount of quality data. As such, in its announcement, CMS did admit that the overall performance threshold for MIPS was established at a relatively low level of three points, and the availability of “pick your pace” provided participation flexibility through three reporting options for clinicians: “test”, partial year, or full-year reporting.

CMS said that 93 percent of MIPS-eligible clinicians received a positive payment adjustment for their performance in 2017, and 95 percent overall avoided a negative payment adjustment. CMS specifically calculated that approximately 1.06 million MIPS-eligible clinicians in total will receive a MIPS payment adjustment, either positive, neutral, or negative. The payment adjustments for the 2017 program year get reflected in 2019.

Breaking down the 93 percent of participants that received a positive payment adjustment last year, 71 percent earned a positive payment adjustment and an adjustment for exceptional performance, while 22 percent earned a positive payment adjustment only. Meanwhile, just 5 percent of MIPS-eligible clinicians received a negative payment adjustment, and 2 percent received a neutral adjustment (no increase or decrease).

Of the total population, just over one million MIPS-eligible clinicians reported data as either an individual, as a part of a group, or through an Alternative Payment Model (APM), and received a neutral payment adjustment or better. Additionally, under the Advanced APM track, just more than 99,000 eligible clinicians earned Qualifying APM Participant (QP) status, according to the CMS data.

CMS Administrator Seema Verma noted on the first pick-your-pace year of the QPP, “This measured approach allowed more clinicians to successfully participate, which led to many clinicians exceeding the performance threshold and a wider distribution of positive payment adjustments. We expect that the gradual increases in the performance thresholds in future program years will create an evolving distribution of payment adjustments for high performing clinicians who continue to invest in improving quality and outcomes for beneficiaries.”

For 2018, the second year of the QPP, CMS raised the stakes for those participating clinicians. And in the third year of the program, set to start in January 2019, a final rule was just published with year three requirements. Undoubtedly, as time passes, eligible clinicians will be asked for greater participation at higher levels. At the same time, CMS continues to exempt certain clinicians who don’t meet a low-volume Medicare threshold.

Earlier this year, CMS said that 91 percent of all MIPS-eligible clinicians participated in the first year of the QPP, exceeding the agency’s internal goal.

What’s more, from a scoring perspective in 2017, the overall national mean score for MIPS-eligible clinicians was 74.01 points, and the national median was 88.97 points, on a 0 to 100 scale. Further breaking down the mean and median:

  • Clinicians participating in MIPS as individuals or groups (and not through an APM) received a mean score of 65.71 points and a median score of 83.04 points
  • Clinicians participating in MIPS through an APM received a mean score of 87.64 points and a median score of 91.67 points

Additionally, clinicians in small and rural practices who were not in APMs and who chose to participate in MIPS also performed well, CMS noted. On average, MIPS eligible clinicians in rural practices earned a mean score of 63.08 points, while clinicians in small practices received a mean score of 43.46 points.

Said Verma, “While we understand that challenges remain for clinicians in small practices, these results suggest that these clinicians and those in rural practices can successfully participate in the program. With these mean scores, clinicians in small and rural practices would still receive a neutral or positive payment adjustment for the 2017, 2018, and 2019 performance years due to the relatively modest performance thresholds that we have established. We will also continue to directly support these clinicians now and in future years of the program.”

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