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BREAKING NEWS: CMS Publishes CY 2018 MACRA QPP Final Rule

November 2, 2017
by Mark Hagland, Rajiv Leventhal, Heather Landi, and David Raths
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On Nov. 2, CMS published its 2018 QPP final rule under MACRA, with important modifications for physicians

Late in the afternoon on Thursday, Nov. 2, the federal Centers for Medicare & Medicaid Services (CMS) published its calendar-year 2018 Quality Payment Program (QPP) final rule, under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law.

As published in the Federal Register, CMS’s senior officials wrote, in the introduction to the 1,653-page published final rule, “Clinicians have told us that they do not separate their patient care into domains, and that the Quality Payment Program needs to reflect typical clinical workflows in order to achieve its goal of better patient care. Advanced APMs [alternative payment models], the focus of one pathway of the Quality Payment Program, contribute to better care and smarter spending by allowing physicians and other clinicians to deliver coordinated, customized, high-value care to their patients in a streamlined and cost-effective manner. Within MIPS [the Merit-based Incentive Payment System], the second pathway of the Quality Payment Program, we believe that integration into typical clinical workflows can best be accomplished by making connections across the four statutory pillars of the MIPS incentive structure. Those four pillars are: (1) quality; (2) clinical practice improvement activities (referred to as “improvement activities”); (3) meaningful use of CEHRT (referred to as “advancing care information”); and (4) resource use (referred to as “cost”). Although there are two separate pathways within the Quality Payment Program, Advanced APMs and MIPS both contribute toward the goal of seamless integration of the Quality Payment Program into clinical practice workflows,” CMS’s senior officials wrote.

And, CMS senior officials added, “This CY 2018 final rule with comment period continues to build and improve upon our transition year policies, as well as, address elements of MACRA that were not included in the first year of the program, including virtual groups, beginning with the CY 2019 performance period facility-based measurement, and improvement scoring. This final rule with comment period implements policies for ‘Quality Payment Program Year 2,’ some of which will continue into subsequent years of the Quality Payment Program.

“During my visits with clinicians across the country, I’ve heard many concerns about the impact burdensome regulations have on their ability to care for patients,” said Seema Verma, Administrator of CMS, said, in releasing the final rule. “These rules move the agency in a new direction and begin to ease that burden by strengthening the patient-doctor relationship, empowering patients to realize the value of their care over volume of tests, and encouraging innovation and competition within the American healthcare system.”

Among the key points, as of a first reading of the final rule by Healthcare Informatics editors:

> CMS has retained a full-year reporting period for cost and quality. As CMS senior officials wrote on Thursday, “We are also finalizing that for purposes of the 2021 MIPS payment year, the performance period for the quality and cost performance categories is CY 2019 (January 1, 2019 through December 31, 2019). We note that we had previously finalized that for the purposes of the 2020 MIPS payment year the performance period for the quality and cost performance categories is CY 2018 (January 1, 2018 through December 31, 2018). We did not make proposals to modify this time frame in the CY 2018 Quality Payment Program proposed rule and are therefore unable to modify this performance period,

> In terms of the 2017 MIPS period final score, the performance category weights are: quality, 60 percent; cost, 0 percent; improvement activities, 15 percent; and Advancing Care Information, 25 percent. For the 2018 MIPS performance year final score, the weights will be: quality, 50 percent; cost, 10 percent; improvement activities, 15 percent; and Advancing Care Information, 25 percent.

>  The final rule raises the MIPS performance threshold to 15 points in year 2 (from 3 points in the transition year).

>  In terms of quality measures, the final rule states that quality, as a component of value-based payment, will be finalized at 50 percent of the total MIPS score in the 2020 payment year, and at 30 percent in 2021 and beyond.

>  Meanwhile, cost will be finalized at 10 percent in the 2020 payment year, and 30 percent in 2021 and beyond.

> “Advancing Care Information,” set at 25 percent of the MIPS final score in the transition year, will remain set at that level in year 2 of participation in the program.

>  “In this final rule with comment period, we are finalizing updates to the Improvement Activities Inventory,” CMS senior officials wrote in the rule. “Specifically, as discussed in the appendices (Tables F and G) of this final rule with comment period, we are finalizing 21 new improvement activities (some with modification) and changes to 27 previously adopted improvement activities(some with modification and including 1 removal) for the Quality Payment Program Year 2 and future years (2018 MIPS performance period and future years)Improvement Activities Inventory.”

>  The final rule allows the use of 2014 edition and/or 2015-certified electronic health record technology (CEHRT) in year 2 for the Advancing Care Information performance category, and gives a bonus for using only 2015 CEHRT.

>  The final rule awards up to five bonus points on a physician’s MIPS final score for the treatment of complex patients.

>  The low-volume threshold for MIPS exemption remains 200 Medicare patients, and the Medicare reimbursement threshold is $90,000 in Part B billings.

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