The Centers for Medicare & Medicaid Services (CMS) has released a proposed rule that would make changes in the second year of MACRA’s Quality Payment Program (QPP), with the aim to simplify the program, especially for small, independent and rural practices.
The rule, which dropped late in the afternoon on June 20, is 1,058 pages in length and is the first major update to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) under new federal healthcare leaders in the Trump administration. The MACRA final rule was released in October, just a few months before the first reporting year of the QPP—inclusive of two payment paths that eligible Medicare-participating physicians could partake in—MIPS (the Merit-based Incentive Payment System) and the advanced alternative payment models (APM) track—was set to begin in January 2017. This new proposed rule aims to make changes to year two of the Quality Payment Program in 2018.
“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” CMS Administrator Seema Verma said in a statement that accompanied the proposed rule. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps towards alleviating burdens and improving health outcomes for all Americans that we serve.”
Specifically, there are a few core areas that healthcare stakeholders will be paying most attention to in this rule. For one, there was significant buzz around the second year of the program being a “transition” year for eligible Medicare clinician participants, similar to what CMS officials, under the Obama administration, did for 2017, with the goal of easing doctors into the quality outcomes-based program in 2017 by making the first year a “pick your pace” period. Essentially, as long as Medicare clinicians reported the minimum amount of data to CMS in year one, they would not be dinged with a negative payment adjustment. However, it doesn’t seem like the government will be offering the same flexibilities in 2018.
Editor’s Note: While there was some initial confusion about if 2018 would be another “pick your pace” year, Healthcare Informatics reached out to CMS for official word, to which a spokesperson from the agency said that the second year of the QPP will not be the same as the 2017 transition year, but several flexibilities are being proposed nonetheless as part of a continued effort to ease clinicians in. Indeed, per CMS, “Some prominent proposals for the Quality Payment Program year two include modestly increasing the performance period requirements to include a full year of data for the Quality and Cost performance categories, though we would not use Cost performance scores for your final score determination. We’re also proposing to increase the performance period to 90-days of data for the Improvement Activity and Advancing Care Information performance categories.”
What’s more, according to CMS, “Clinicians that are not ready to participate in the three (of four) categories, with the increase performance period proposals, could still do well in the program overall by focusing on the performance category that is most important to them. We’re proposing to raise the performance threshold (points) for the Quality Payment Program year two to 15 points [up from 3].
Further, stakeholders were wondering how CMS would offer more help for small practices—many of whom fear that they don’t have the resources to be successful under MACRA. In the new rule, proposals from CMS signal that many more clinicians will be exempt from MIPS once again. The rule proposes increasing clinicians’ low-volume threshold from $30,000 or less in Medicare Part B allowed charges or less than 100 Medicare patients to $90,000 in Part B allowed charges or less than 200 Medicare patients. It was estimated in the final rule last fall that some 380,000 clinicians fell into this low-volume threshold bucket; now, many more small practice clinicians who don’t have high volumes of Medicare patients will be exempt from MIPS in 2018 as well.
Given these new developments, CMS is estimating that less than 40 percent of eligible Medicare clinicians will actually be participating in MIPS in 2018. While this might not come as a surprise to many— especially after the government affirmed last month that some 800,000 clinicians will not be participating in MIPS this year— it’s important to note that for various reasons, most Medicare doctors will not have to be involved in MIPS until 2019 at the earliest.
According to a 26-page CMS fact sheet of the proposed rule, “For the second year of the program, CMS wants to keep what’s working and use stakeholder and clinician feedback to improve the policies finalized in the transition year.”
In construction of this rule, CMS said it has engaged more than 100 stakeholder organizations and over 47,000 people since January 1, 2017 to raise awareness, solicit feedback, and help clinicians prepare to participate. For the MIPS track, CMS proposes to continue to reduce burden and offer flexibilities to help clinicians to successfully participate by:
- Offering the virtual groups participation option.
- Increasing the low-volume threshold so that more small practices and eligible clinicians in rural and health professional shortage areas (HPSAs) are exempt from MIPS participation.
- Continuing to allow the use of 2014 Edition CEHRT (Certified Electronic Health Record Technology), while encouraging the use of 2015 edition CEHRT.
- Adding bonus points in the scoring methodology for: caring for complex patients; and using 2015 Edition CEHRT exclusively.
- Incorporating MIPS performance improvement in scoring quality performance.
- Incorporating the option to use facility-based scoring for facility-based clinicians.
CMS is also proposing more flexibilities for clinicians in small practices that would:
- Add a new hardship exception for clinicians in small practices under the Advancing Care Information performance category.
- Add bonus points to the final score of clinicians in small practices.
- Continue to award small practices 3 points for measures in the Quality performance category that don’t meet data completeness requirements.
Not available in year one of the program, as expected, the year two proposed rule indeed offers virtual group participation, which is another way clinicians can elect to participate in MIPS. Virtual groups would be composed of solo practitioners and groups of 10 or fewer eligible clinicians, eligible to participate in MIPS, who come together “virtually” with at least one other such solo practitioner or group to participate in MIPS for a performance period of a year. According to CMS, “Our goal is to make it as easy as possible for virtual groups to form no matter where the group members are located or what their medical specialties are. Generally, clinicians in a virtual group will report as a virtual group across all four performance categories and will need to meet the same measure and performance category requirements as non-virtual MIPS groups.”
Meanwhile, for the APMs track, which far fewer Medicare clinicians will be participating in early on, CMS is proposing 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 percent 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.
Healthcare Informatics will continue to update its readers on the proposed rule and get industry reaction in the coming days.