July 17, 2019 Read Advisory Board's take: What to remember about these data

The number of clinicians who participated in MACRA's Advanced Alternative Payment Model (Advanced APM) track increased from 2017 to 2018, while the number of clinicians who participated in MACRA's Merit-based Incentive Payment System (MIPS) decreased, according to preliminary data CMS released Thursday.


Under MACRA's Quality Payment Program (QPP), which took effect in 2017, eligible clinicians can choose from two payment tracks:

  • The Advanced APM track, for clinicians who take on a significant portfolio of Advanced APMs, which include risk-based accountable care organization (ACO) models; or
  • MIPS, for providers who are reimbursed largely through fee-for-service.

Clinicians' pay in the MIPS track largely follows a traditional fee-for-service structure, but CMS adjusts eligible clinicians' pay based on how they "score" in four categories of metrics:

  • Cost;
  • Improvement activities;
  • Promoting interoperability, formerly called Advancing care information (ACI); and
  • Quality.

CMS deemed 2017 a "transition year" and required eligible clinicians to submit only 90 days' worth of data. Participating clinicians had the option of submitting data on one quality measure or improvement activity, or four or five advancing care information measures, to meet MIPS requirements. As long as providers scored at least 3 points across those categories, they avoided penalties of up to 4% applied to payments in 2019. Those who scored a 3 or higher received what CMS called a modest payment adjustment of up to 1.88% for the 2019 payment year.

But for the 2020 payment year, which is based on 2018 data, CMS raised the threshold for positive payment adjustments. In 2018, eligible clinicians needed to report on a full year's worth of quality data, and CMS increased the performance threshold to 15 points for providers to avoid the 5% penalty, applied to payments in 2020. The potential penalty will rise incrementally until it reaches 9% in payment year 2022.

Clinician participation rises in 2018, Verma says

According to CMS data, the number of clinicians who participated in:

  • Advanced APMs increased from 99,076 in 2017 to 183,306 in 2018;
  • MIPS via APMs increased from 341,220 participants in 2017 to 356,828 in 2018; and
  • MIPS without an APM decreased from 1,057,824 participants in 2017 to 916,058 participants in 2018.

CMS Administrator Seema Verma in a blog post wrote that the percentage of eligible clinicians who participated in MIPS overall increased from 95% in 2017 to 98% in 2018, and the percentage of eligible clinicians from small practices who participated in MIPS rose from 81% in 2017 to about 90% in 2018.

Verma wrote that the "increase in APM participation supports the evolution of [QPP] and incentives toward a system of value that puts patients first." She continued, "These participation improvements may be related to the increasing number of participation opportunities in 2018, particularly through [ACOs] … in the [Medicare] Shared Savings Program."

More clinicians receive positive payment adjustments, Verma says

Verma also noted that more clinicians are expected to receive a positive payment adjustment in 2020 based on their performance in 2018.

According to Verma, 97% of clinicians participating in MIPS exceeded the performance threshold of 15 points in 2018 to receive a positive payment adjustment on their Medicare Part B claims in 2020, up from 93.1% of clinicians participating in MIPS who exceeded the required performance threshold in 2017. In addition, Verma wrote that 85% of clinicians in small practices are expected to receive a positive payment adjustment in 2020 based on their performance in 2018, up from 74% in 2017.

However, Verma did not specify how much of a bonus payment eligible clinicians could expect to see in 2020.

Verma wrote that the increase in the number of clinicians who will receive positive payment adjustments is "a strong sign that our incremental approach and flexible options lead to clinician success in MIPS." She added, "Scores improved across performance categories, with the biggest gain in the quality performance category, which highlights the program's effectiveness in measuring outcomes for beneficiaries."

Though clinicians' scores have increased under QPP, Verma wrote CMS "recognize[s] that [the program needs] additional long-term improvements." Verma wrote that CMS has "heard from clinicians and stakeholders that the program, specifically MIPS, remains overly complex due to the use of broad clinician flexibility," and that "some clinicians in small practices are still receiving negative payment adjustments." As such, Verma wrote that CMS "will continue to leverage initiatives like Patients Over Paperwork and Meaningful Measures to address concerns and look for possible solutions."

Performance data might appear skewed, expert says

Darryl Drevna, senior director of regulatory affairs at American Medical Group Association, said more clinicians receiving a positive payment adjustment in 2020 does not necessarily mean more clinicians performed better in 2018.

Drevna noted that the number of clinicians who participated in MIPS decreased after CMS raised MIPS' exemption threshold from clinicians who reported up to $30,000 in Medicare revenue or saw fewer than 100 Medicare patients to clinicians who reported up to $90,000 in Medicare revenue and saw fewer than 200 Medicare patients. CMS estimated the adjustment would exclude about 134,000 clinicians from participating in the program.

Because of the adjustment, Drevna said CMS has "excluded too many providers and the only ones left are the high-performing groups."

Further, Drevna said it is unlikely clinicians will see a substantial increase in their bonuses for the 2020 payment year because QPP is budget neutral, which means CMS relies on funds from the pool of penalties to award bonuses, and only 1.95% of clinicians received a penalty in 2018. Drevna recommended that CMS adjust QPP's thresholds to make it more difficult for participating clinicians to receive bonus payments (Ellison, Becker's Hospital CFO Report, 7/15; Slabodkin, Health Data Management, 7/15; Castellucci, "Transformation Hub," Modern Healthcare, 7/12; Morse, Healthcare Finance News, 7/15).

Advisory Board's take

What to remember about these data

Overall, the 2018 MIPS data are what we would have expected given CMS policies. In particular, we saw that:

  • Low thresholds led to fewer penalties: A higher eligibility threshold means more low-volume practices (mostly small and rural groups) have been exempted from participation, and a relatively low MIPS performance threshold resulted in few providers receiving penalties.
  • Payment bonuses remained low: The highest scoring providers will continue to receive nominal positive adjustments for exceptional performance. In conversations with our members, their QPP feedback reports indicate that providers who achieved the maximum MIPS score in 2018 will receive a 1.68% positive adjustment in 2020.

The 2018 findings are interesting to observe, but must be taken in the context of an evolving program. It's important to remember that:

  • It's only the second year of the program. The 2018 data reflect CMS policies that intentionally gave MIPS-eligible providers the opportunity to slowly dial-up their performance based on overwhelming feedback the agency received to let providers adjust slowly and to be mindful of the challenges faced by rural providers, small practices, and solo practitioners.
  • Incentivizing APM participation remains a primary goal. QPP policies aim to reduce MIPS reporting burden for APM participants, and reward providers who take on downside-risk in Advanced APMs (which allow them to potentially qualify for the APM track bonuses). In other words, 2018 data echo overall trends in the move toward value-based care.

Based on these results, here's how we recommend providers maintain focus on avoiding penalties and earning potential incentives in 2019 (and beyond):

  • Maximize 2019 MIPS performance. CMS added more provider types to MIPS for 2019 and established opt-in policies for groups that would have otherwise been exempted based on low volumes. With more providers included, more revenue is at stake, meaning practices must be prepared to meet more stringent requirements in 2019. Specifically, the threshold to avoid the penalty has been raised to 30 points, and the maximum penalty is increased to up to 7%. We provide more details and recommendations for success in our webconference on the 2019 QPP requirements.
  • Move toward risk-based contracts. Practices should carefully consider their Medicare risk strategy and readiness to take on risk-based contracts, which could potentially qualify providers for the 5% APM track bonus. CMS continues to create additional opportunities for providers to enter into Advanced APMs, with models that are applicable to primary care and specialty care providers.
  • Monitor future changes and make your voice heard. Any day now, we expect CMS to publish the 2020 Physician Fee Schedule proposed rule, which will include a peek into the QPP policies for next year. Providers are encouraged to submit public comment in response to the proposed rule in order to help shape the policies that will be finalized in November. As always, you can rely on us for forthcoming resources on how the proposed policies will impact providers and for guidance on your QPP initiative.
To learn more about how your organization can succeed with MIPS, make sure to download our infographic outlining 'How to Navigate the Land of MIPS.'

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