July 13, 2018

How CMS wants to change MACRA's QPP in 2019

Daily Briefing

    Read Advisory Board's take on this story: Three highlights from the proposed changes

    CMS on Thursday released a proposed rule with policy updates for year three of MACRA's Quality Payment Program.

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    Thursday, August 2

    Decode the 2018 MIPS Cost category

    Thursday, August 16

    Unpack the 2019 QPP proposal

    CMS is accepting public comments on the proposed rules until Sept. 10.

    Background

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

    • The Advanced Alternate Payment Model (Advanced APM) track, for clinicians who have a sufficient amount of Medicare business in Advanced APMs, like risk-based accountable care organization (ACO) models; or
    • MIPS, for providers who are reimbursed largely through fee-for-service.

    Physicians' pay in the MIPS track follows a traditional fee-for-service structure—but CMS adjusts eligible professionals' pay based on how they "score" in four categories of metrics: promoting interoperability (formerly called advancing care information), cost, improvement activities, and quality.

    Clinicians who are eligible for the Advanced APM track qualify for a 5% incentive payment and are exempt from MIPS.

    Quality Payment Program proposed rule details

    CMS in the rule proposed changes to reduce clinician burden, emphasize patient outcome measures, and promote electronic health record interoperability.

    For example, CMS proposed removing MIPS process-based quality measures that physicians have said are low-value. CMS also proposed overhauling MIPS' promoting interoperability category to support greater EHR interoperability and to improve patient access to their health information.

    Expanding QPP eligibility

    In addition, CMS proposed expanding the number of providers who are eligible to participate in QPP. To be eligible for MIPS in 2018, physicians and practitioners must treat at least 200 Medicare beneficiaries and submit at least $90,000 in Medicare Part B claims. For 2019, CMS is proposing an additional eligibility threshold for providers who do not submit at least 200 claims for the covered professional services under the Physician Fee Schedule. CMS also said it would permit clinicians or groups who meet some but not all of these eligibility thresholds to opt into MIPS.

    The agency also proposed expanding the types of clinicians eligible to participate in MIPS. Currently, five types of clinicians are eligible to participate in MIPS: certified registered nurse anesthetists, clinical nurse specialists, nurse practitioners, physicians, and physician assistants. Those clinicians could also qualify as part of a group. For 2019, CMS proposed expanding the eligibility pool to include clinical psychologists, clinical social workers, physical therapists, and occupational therapists.

    Changes to the MIPS categories

    In addition, CMS proposed increasing the weight of MIPS' cost category in 2019 by 5 percentage points to 15%. The agency would offset that change by reducing the weight of the quality category from 50% to 45%. Weights for the remaining two categories—promoting interoperability and improvement activities—would remain at their 2018 levels, i.e., 15% each.

    Streamlining quality measures

    CMS also proposed removing 34 quality reporting measures that it deemed ineffective. CMS Administrator Seema Verma said that change would save doctors $2.3 million in 2019. According to Modern Healthcare, the proposed rule also would add 10 quality measures, including four based on patient-reported outcomes.

    New Medicare Advantage demonstration program

    In addition, CMS included a proposal teased about earlier this month to test a Medicare Advantage demonstration program called Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI). Under the proposed MAQI model, eligible clinicians would not be subject to MIPS requirements.

    Changes to EHR requirements

    In addition, CMS proposed changes intended to align MIPS' promoting interoperability performance category with those proposed for hospitals. As part of that effort, it would overhaul the scoring methodology and measures. Verma said the overhaul would place a greater emphasis on EHR interoperability.

    CMS also proposed requiring MIP-eligible clinicians to use 2015 edition certified EHRs. Currently, clinicians can use 2014-certified systems to be eligible for the program. However, that proposal has been met with pushback by some provider groups. Anders Gilberg, senior vice president for governmental affairs at Medical Group Management Association, said, "Today's rule proposes to require physicians to deploy costly EHR upgrades for 2019 and takes further steps toward implementing burdensome appropriate use criteria."

    Overall, CMS estimated that changes in the QPP proposed rule, if finalized, would save clinicians a total of 29,305 hours and reduce administrative costs by about $2.6 million in 2019 (Clason, CQ News, 7/12 [subscription required]; AHA News, 7/12; Baker, "Vitals," Axios, 7/13; CMS release, 7/12; Diamond, "Pulse," Politico, 7/13; CMS PFS factsheet, 7/12; CMS QPP factsheet, 7/12; Dickson, Modern Healthcare, 7/12).

    Advisory Board's take

    Naomi Levinthal, Practice Manager, Quality Reporting Roundtable

    In our daily work with providers on the Quality Payment Program (QPP), we've been on the lookout for the 2019 proposal since the spring. We anticipated that the proposal would have a new home in the MPFS, which came to fruition. Now that this new home is established, providers can better plan for when QPP updates will happen (usually in July and November each year). This is good news!

    Our initial take of the QPP-related proposals is that CMS intends to reduce provider burden, and shows that they can be responsive to provider and industry feedback. These efforts should make it easier for some providers to succeed in the QPP. For example, providers who primarily practice in hospital settings will no longer need to report separate quality measures and can instead rely on their facility's Value-Based Purchasing performance.

    As we digest this proposal, here are a few highlights from what we've read so far:

    1. CMS plans to expand the definition of eligible clinicians to include new provider types, i.e.: Physical Therapists, Occupational Therapists, Clinical Social Workers, and Clinical Psychologists. This means more types of providers can earn incentives (or face penalties).
    2. The same overhaul we saw earlier in the spring to meaningful use (MU) measures for hospitals were also proposed for QPP participants. There is a new name for the MU-related category, now "Promoting Interoperability" instead of "Advancing Care Information." CMS slashed and re-aligned the scoring methodology and measures to match those proposed for Medicare hospitals.
    3. There is a new way proposed for providers to qualify for the APM track (through their TIN volume). Additionally, APM track notification should happen faster now that CMS has experience making these types of determinations and are able to take advantage of efficiencies they have learned along the way.

    Want to learn more about this year’s requirements and those proposed for 2019 in the QPP? Join us for two upcoming webconferences on QPP.

    On August 2nd, we'll cover the 2018 MIPS Cost category requirements and explore how data on cost performance will be incorporated into the final MIPS scores.

    Register Here

    On August 16th, we'll take a deeper dive into the 2019 QPP proposal and relay the implications of the most important changes.

    Register Here

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