When the Centers for Medicare & Medicaid Services (CMS) published the calendar-year 2018 Quality Payment Program (QPP) final rule, under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law last week, industry stakeholders had varying takeaways, many of which were dependent on how the rule might affect their particular organization or membership/client base.
One of the key points that was made in the hours following the release of the final rule was how many MIPS (Merit-based Incentive Payment System)-eligible clinicians will again be exempt in 2018. Indeed, according to an important table on page 1,274 of the rule, CMS stated that in 2018, only 40 percent of Medicare Part B clinicians will be left in MIPS after exemptions. This is noteworthy because it signals a shift from previous QPP proposals which estimated such negative consequences for small practice physicians that led some to wonder if the complexity involved would force doctors out of practice.
John Halamka, M.D., CIO at Boston’s Beth Israel Deaconess Medical Center, was one health IT expert who created buzz last year when he wrote in his blog, “No mere human will be able to understand [the MACRA rule]. This may sound cynical, but there are probably only two rational choices for clinicians going forward –become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.”
Dr. Halamka, however, feels differently today about the direction of MACRA. In a recent interview with Healthcare Informatics, Halamka, who industry CIOs often look to for health IT policy feedback, says he is noticing a common theme from CMS in its recent rulemaking: “Getting us to this new reimbursement model while at the same time reducing the prescriptive burden on [clinicians]. The path we were on of having meaningful use-esque regulations getting more stringent would do nothing more than alienate doctors over time,” he says.
As such, Halamka says he read the MACRA 2018 final rule in a more thematic sense rather than line-by-line. “What I have been hearing from my CIO colleagues and [noticing] in my reading of the rule is that we’ll be given more choice and latitude, and more time to get this done. Because there are fewer requirements, and some 90-day reporting, we will be given an opportunity to listen to our customers again rather than have every one of our agendas co-opted by regulation or legislation.”
John Halamka, M.D.
Halamka adds that his comments on previous iterations of the rule were based on its incredible complexity, which he now sees as having been refined significantly. “There are now so many exceptions for who has to participate and what they have to do, and there is so much more choice involved. The [regulation] isn’t quite the nature of how it used to be,” he says. “I believe that most practices can either say that they simply won’t participate; or they will be exempt; or the practices will participate and just focus on two or three things. So that is what has changed,” he says.
For Larger Orgs, CMS Puts Stake in the Ground for 2018
While CMS has clearly stated that it is willing to offer another year of relief for smaller practices, for larger organizations, the picture has been painted quite differently.
Tom Lee, Ph.D., CEO of the Chicago-based SA Ignite consulting and software services firm, makes a couple of key points when asked what CMS’ goals were in the 2018 QPP rulemaking. For one, he notes, by raising the cost category weight in MIPS to 10 percent in 2018—from 0 percent in the proposal—and then to 30 percent in 2019 (which is mandated in the MACRA law), government officials are telling clinicians that “they are very serious about the cost category.” Says Dr. Lee, “If they kept it at 0 percent for next year, it would be a disservice to clinicians since they won’t have the right level of motivation to take a close look at that category.”
Further touching on the cost category, Lee says that CMS has put in eight new episode-based measures that has the specialty community very focused. He explains that for the last two months, the federal agency has been doing field testing with provider organizations around the country on these eight new measures. But, providers have also been calling CMS with questions regarding their cost discrepancies and how the government is defining the boundary of the episode.
Lee offers an example of an ophthalmology practice that has a patient come in for cataract surgery. Usually that patient will get both eyes done at the same time, but the question brought up by the practice was if the patient came in to get the left eye done first and then the right eye a certain number of weeks later, is CMS costing the left eye as episode one and right eye as episode two, or is it costing both eyes together, which would double the total cost?
As such, Lee notes, “There are very fine-grained details in these episode definitions that greatly impact whether a clinician’s workflow will advantage or disadvantage them.” He adds, “So CMS is putting all this work in, and there is a very high likelihood that in 2019 these episode-based measures will be quite important with 2018 being the last chance you have to get familiarized with what is coming. So you have a double whammy—the percentage in the cost category goes up from 10 percent to 30 percent, and there are also these eight new measures that will count toward your score in 2019.” Lee attests, “CMS has put a stake in the ground for 2018 with the cost category.”
Tom Lee, Ph.D.
What’s more, Lee points out other instances in which CMS has “turned up the heat” on MIPS in 2018. In the quality category, the final rule calls for an increase in the required amount of data needed to fill quality reporting obligations—an uptick from reporting on 50 percent of an organization’s eligible patients to 60 percent. And if the organization doesn’t meet that threshold, if it’s not a small practice, it will only get one out if 10 points for the measure, up from 3 out of 10 points in 2017. “So CMS is signaling that it thinks larger organizations are capable of doing this, generally. And they need to do it to avoid getting just one point,” notes Lee.
And, for the Improvement Activities category, under the 2017 rule, if an organization has just one geographic site within a single Tax Identification Number (TIN) that is a patient-centered medical home (PCMH), but 10 other sites under that TIN in total, every site gets an auto-credit for that category regardless if they are a PCMH are not. But that is being changed in 2018; now, 50 percent or more of those sites must be individually PCMH-certified in order for the whole group to get that credit, notes Lee, adding that it is a “much higher bar to cross.”
Additionally, Lee points to another instance that proves CMS is upping the ante in 2018. He notes a table in the rule which predicts that 75 percent of all clinicians will have a MIPS score of greater than 70—a score that hits the exceptional performance threshold. But, says Lee, in 2019, the performance threshold for MIPS separating the incentives from the penalty losers will have to equal the median or mean of some historical period of performance.
What this means is that for organizations scoring in the 70- to 80-point range, they will have to “further up their game,” says Lee, explaining that there will be a scenario in which CMS is predicting that 75 percent of clinicians will have a score of greater than 70. “So if I want to be on the correct side of the mean or median and not get penalized in 2019, I might need to continually improve and strive to get something in high 80s or low 90s. And they didn’t have that statistic in the proposed rule. So you can’t get too comfortable with a score that seems like it looks high right now,” he says.
Finally, when asked about the required full-year reporting periods for the quality and cost categories, Lee, unlike some of his peers, says he doesn’t see it as a big deal for larger organizations that have been reporting a full year on quality already, while cost data is mostly claims-based, meaning nothing additional is required. “For smaller practices, I would say this is moderately disappointing, but for organizations with 25 or more physicians, I think they are prepared for this,” he says.