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.
> CMS is implementing provisions around allowing for the submission of data by virtual groups, with a number of provisions for how such virtual groups can participate in the MIPS program.
> CMS officials wrote that “We are not finalizing our proposal to provide clinicians the ability to opt-in to MIPS if they meet or exceed one, but not all, of the low-volume threshold determinations, including as defined by dollar amount, beneficiary count or, if established, items and services.” In other words, low-volume physicians will not be eligible to access potential value-based payment increases under Medicare over the next several years.
> CMS officials said that they are responding to concerns that small practice size could lead to problems in terms of accuracy of data involved. As the final rule puts it: “Several commenters supported using historical claims data to make a small practice size determination. One commenter also noted support for the definition of a small practice using the number of NPIs associated with a TIN.” As a result, they said, “We are finalizing that we will utilize a 12-month assessment period, which consists of an analysis of claims data that spans from the last 4 months of a calendar year 2 years prior to the performance period followed by the first 8 months of the next calendar year and includes a 30-day claims run out for the small practice size determination.”
> Further, CMS officials noted that they are “adding a significant hardship exception from the advancing care information performance category for MIPS-eligible clinicians in small practices; providing 3 points even if small practices submit quality measures below data completeness standards; and providing bonus points that are added to the final scores of MIPS eligible clinicians who are in small practices.”
> Also, referencing recent natural disasters, the final rule automatically weights automatically weights the Quality, Advancing Care Information, and Improvement Activities performance categories at 0 percent of the final score for clinicians impacted by hurricanes Irma, Harvey and Maria and other natural disasters.
> The final rule adds 5 bonus points to the final scores of small practices.
CHIME finds aspects around the cost element and the reporting period to be problematic
Healthcare Informatics caught up with Mari Savickis, vice president of federal affairs for CHIME (the Ann Arbor, Mich.-based College of Healthcare Information Management Executives), live at the CHIME Fall CIO Forum in San Antonio, Texas, for some feedback on the final rule. Says Savickis, “The ability to keep using 2014 CEHRT is a big deal for our members. That syncs up with what CMS finalized for hospitals and it gives clinicians more time [to implement 2015 CEHRT]. It also means that when you look at the ACI category, that’s the part that revolves around 2014 CEHRT. So that means that the transition measures under MIPS (modified Stage 2 ‘like’ measures) are still intact for another year. This is what we advocated for and supported.”
However, at quick glance, there are some aspects of the final rule that Savickis says CHIME does not support. For example, it does not like that CMS moved the cost category in MIPS up from a 0 percent weight in the proposal to a 10 percent weight in this final version. “It’s a significant concern; and they are also calling for the cost category to be weighed at 30 percent in 2019. That’s a tough pill to swallow,” she says, wondering if CMS was thinking that this would be a way for clinicians to “rip off the Band-Aid.”
What’s more, Savickis says that CHIME does not support a full-year reporting period for the cost and quality performance categories, as its members were hoping that these reporting periods would be 90 days instead of a whole calendar year. “Yes, there are some clinicians out there who can report for a full year, but making it mandatory is not supported. It should be voluntary,” Savickis attests.
Premier Inc. express concerns over a payment shift for provider-based hospital departments
Meanwhile, in a statement released by the Charlotte-based Premier Inc. on Thursday evening and attributed to Blair Childs, Premier’s senior vice president of public affairs, Childs offered a mixed view of the final rule. “Premier and its members commend the Centers for Medicare & Medicaid Services (CMS) for allowing individual or small group practice clinicians to join virtual groups as a new channel to participate in the Quality Payment Program’s Merit-based Incentive Payment System (MIPS),” Childs began. “We are also encouraged that CMS indicated its intention to develop a demonstration project to examine how Medicare Advantage (MA) alternative payment models qualify for the threshold test and obtain the five percent MACRA bonus prior to 2021. Nearly one-third of Medicare beneficiaries are enrolled in an MA plan. Many MA plans have engaged providers in innovative value-based contracts that are benefiting patients and should count toward qualifying eligible professionals for the bonus in 2019. This policy would level the playing field for clinicians in areas with high MA penetration.”
Those were the positive elements of the final rule, for Premier. “However,” the statement went on to say, “Premier and its members are disappointed with CMS’s decision to slash payment rates for non-excepted, off-campus, provider-based departments of hospitals by an additional 10 percentage points, from 50 to 40 percent. Basing this decision on an evaluation of a single code is unjustified and fails to reflect the higher costs that these sites incur relative to freestanding physician offices or account for outpatient packaging policies.”
As a result, Childs said, “This decision will reverse momentum on providing care across the continuum. At this transitional moment where the industry is moving from fee-for-service to value-based payment, this decision undermines the movement to provide care outside the walls of the hospital potentially leading to increased Medicare spending.”
Healthcare Informatics will update readers as additional developments occur in this story.