The day after the federal Centers for Medicare and Medicaid Services (CMS) released the final rule making changes in the second year of the Quality Payment Program (QPP) under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, healthcare industry leaders are voicing mixed reactions, but do seem satisfied with some of the increased flexibilities that were maintained from the proposed rule, and intended to provide clinicians with a smoother transition to the Quality Payment Program.
Late in the afternoon on Thursday, Nov. 2, CMS published the 1,653-page calendar-year 2018 QPP final rule, under the MACRA law, affecting Medicare-participating physicians covered either under the MIPS (Merit-based Incentive Payment System) program, or participating in APMs (advanced payment models). It’s clear that easing provider burden in complying with MACRA was a priority for CMS officials in keeping with many of the proposals in the proposed rule.
In a press release announcing the final rule, CMS officials stated, “While part of CMS’s broader strategy to relieve regulatory burdens for providers, these rules also reflect the agency’s efforts to promote innovation in healthcare delivery aimed at lowering prices, increasing competition and strengthening the relationship between patients and their doctors.”
“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,” Seema Verma, CMS Administrator said in a statement. “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.”
Some of the key changes in the final rule include raising the MIPS performance threshold to 15 points in year 2, from 3 points in the transition year, and 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. For the 2018 MIPS performance year final score, the performance category weights will be: quality, 50 percent; cost, 10 percent; improvement activities, 15 percent; and Advancing Care Information, 25 percent. A 26-page fact sheet summarizing the final rule can be found here.
Some healthcare industry leaders have expressed concerns about CMS’s decision to require a full-year reporting period for the cost and quality performance category, rather than a 90-day reporting period.
Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association (MGMA), said in a statement, “MGMA is very disappointed that CMS quadrupled the length of the quality reporting period under MIPS from the current 90 days to 365 days in 2018. This fourfold increase to the quality reporting requirements is in stark contrast to the Agency’s statements today that the final rule reduces regulatory burdens. CMS is in effect prioritizing quantity over quality and giving physicians less than 60 days to prepare for the 2018 MIPS requirements.”
It should be noted that the final rule sets a 90-day reporting period in both 2018 and 2019 for Advancing Care Information and Improvement Activities performance categories.
According to CMS, the final rule includes a number of policies designed to provide clinicians with a smoother transition to the Quality Payment Program. “The QPP final rule includes policies that reduce burden and support clinicians in small and rural practices to successfully participate in this program. CMS is decreasing the number of clinicians required to participate,” CMS stated in the press release.
“There weren’t a whole lot of surprises” with the final rule,” notes Jeff Smith, vice president of public policy at the American Medical Informatics Association (AMIA). “When you focus on the quality payment program in MIPS, I think CMS telegraphed that they want to provide much more flexibility and are looking for ways to make the program more feasible for docs, and I think the final rule really does follow through with that intention.”
Adaeze Enekwechi, Ph.D., vice president of McDermott + Consulting, a Washington, D.C.-based healthcare consulting firm, who previously worked at the White House Office of Management and Budget (OMB) under the Obama Administration as the associate director for health programs, contends that CMS designed year 2 of the MACRA QPP as a gradual ramp up to full implementation in 2020.
Sharing her initial takeaways on the 2018 MACRA QPP final rule, Enekwechi, who also previously served as a senior analyst with the Medicare Payment Advisory Commission, and at the Congressional Budget Office, says, “What the Administration is doing is really making an effort to continue to ease the burden of implementation of MACRA this second year, but, at the same time, they recognize that full implementation will begin in the third year, so they don’t want to leave clinicians completely unprepared. You see evidence of a little bit of a ramp up, when you look at the MIPS scoring, whereas before you needed a minimum of 3 points and now it’s 15. And, cost is now weighted at 10 percent in the second year as opposed to zero in the first year,” she says, adding, “To me, it read very much like a real effort to get folks ready for 2020.”
In the proposed rule, plans from CMS signaled that many more clinicians will be exempt from MIPS once again, like they were in year one of the QPP, which began in January. In keeping with the proposed rule, the final rule will increase 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.
There has been some debate about whether excusing more clinicians from MIPS for another year is beneficial in the long-term. Enekwechi notes that one potential impact of increasing the low-volume threshold is a growing chasm between physicians currently participating in MIPS and those who are exempt.
“You have some clinicians who are participating in MIPS and going through the rigorous effort of measuring quality, reporting, and for all intents and purposes, marching toward higher risk payment models, and just getting more involved in advanced APMs (alternative payment models). And then, on the other side, you have a whole set of clinicians who are not going to be exercised in that way and will not adjust to these new payment models that are coming out, not just from Medicare but from the commercial side. I do think, if we continue down this path where the majority are not participating in MIPS or APMs, I think we’re going to start to see differences between those two classes of clinicians,” she says.
To this point, the National Committee for Quality Assurance (NCQA) said in a statement that it is grateful that the rule lets small practices form virtual groups in 2018. It said, “Virtual groups can help small practices join together to have enough patients for robust measurement and prepare for APMs. Unfortunately, the rule prevents the smallest practices from joining virtual groups by defining low-volume practices as ineligible for MIPS. Low-volume practices—those with less than $90,000 in Medicare revenue or 200 Medicare patients—most need virtual groups so they can have reliable measurement and reap rewards for improvement. CMS could remedy this by amending its low-volume definition to say these practices are ineligible for MIPS ‘unless they join a virtual group.’”
Smith notes several positive developments in the final rule, such as giving providers the ability to use either 2014 Edition Certified Electronic Health Record Technology (CEHRT) or 2015 edition CEHRT, which was also in the proposed rule. “It was good to see that CMS is continuing to try to find ways to gently encourage people to adopt 2015 edition CEHRT as they maintained from the proposal to offer a bonus for using it,” Smith says, referring to the policy in the final rule that states providers can earn a 10 percent bonus if they only use 2015 edition CEHRT.
CMS also increased the number of improvement activities that are eligible for bonus credit under the Advancing Care Information category. As one example, CMS plans to give bonus credit to physicians who consult patient-generated health data from consumer wearables. Smith says, “I think that will be an important policy moving forward, for a host of reasons, not least of which is the fact that there are a growing number of consumer technologies that patients are showing up at their doctor’s office and saying, ‘here’s my data, this is keeping track of my weight or blood pressure and how do we make sense of that.’ If you look at the improvement activity piece of MIPS, they are trying to give credit to innovation and experimentation.”
He continues, “And, while it doesn’t account for a huge portion of the overall MIPS score, I think it’s an important policy lever. It will be interesting to see what additional kinds of issues arise out of this new proposal to pay physicians to take patient-generated health data and spend time with that data, but, I think, overall, that’s a positive aspect of the Improvement Activities.”
In the press release about the final rule, CMS noted that to further ease clinician burden, CMS is adding an option to help clinicians and small, rural practices join together and share the responsibility of participating in value-based payments in virutal groups. CMS is also adding a new hardship exception to assist small practices and clinicians impacted by hurricanes Harvey, Irma, and Maria. This change mitigates the absence of Electronic Health Records as a result of the natural disasters.
CMS also reports that it intends to develop a demonstration project testing the effects of counting as credit participation prior to 2019 and through 2024 in Medicare Advantage plans that meet certain criteria. In a statement released on Thursday, Blair Childs, senior vice president of public affairs at Charlotte-based Premier Inc., said he is encouraged that CMS plans to develop a demonstration project to examine how Medicare Advantage alternative payment models qualify for the threshold test and obtain the five percent MACRA bonus prior to 2021. Childs noted that 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,” he said.
Regarding CMS’s efforts to reduce provider burden, Enekwechi says, “I think they’ve leaned as far as they can, while still maintaining implementation. I think that the slow ramp up in terms of scoring, basically they went from 3 points to 15 points, that’s still pretty low. I think 10 percent weight applied to the cost category is better than 0, and not as terrifying as 30 percent for MIPS eligible clinicians. They have also created multiple ways to submit data and information; you can do it through registries, you can do it through their website. This agency is doing as much as it can to try to ease burden with respect to implementation.”