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CMS Proposes Quality Payment Program Rule for 2018: Here's What You Need to Know

On Tuesday, CMS issued a proposed rule that would make changes in the second year of the Quality Payment Program. The proposed rule includes changes that would not only simplify the program, but also ensure high-quality care within Medicare is at the forefront of the Quality Payment Programs. Here's what you need to know about the proposed rule for the 2018 performance period.

The proposed rule for 2018 makes some changes to existing requirements and also contains new policies such as virtual groups and participation awards. These changes seem to largely support the ongoing initiative to improve the participation in the Quality Payment Programs and remove some existing barriers that exist for smaller, independent, and rural practices.

“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient. That’s why we’re taking a hard look at reducing burdens.” -Seema Verma, CMS Administrator

Here are a few of the main takeaways from the proposed rule that are expected to improve flexibility and reduce barriers to participating in Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). 

1. Clinicians can continue to use legacy systems.

The proposed rule for 2018 would allow clinicians to use 2014 certified EHR technology for next year's reporting period.

Practices that use 2015 certified EHR technology in 2018 would receive a 10 percent payment bonus from CMS but again, it is not required.

Note that Advancing Care Information and Improvement Activities will both require 90-days minimum for a performance period which will benefit those practices that want to upgrade to a 2015 certified EHR technology or need more time to adopt a new EHR.

2. More hardship exemption options available for Advancing Care Information.

As you probably recall, the Advancing Care Information (ACI) category replaces the Meaningful Use program. The proposed rule will offer more hardship exemption options for small practices (if they qualify) to skip this category. CMS is also allowing clinicians to skip immunization registry reporting and they can receive bonus points for additional registry reporting.

Another important change to note under ACI is the proposal to change the deadline for the exception application submission for 2017 and future years to be December 31 of the performance year.

3. An extra 5 points to small practices just for participating.

Yes, you read that correctly. Practices with 15 or fewer eligible clinicians will get an extra 5 points to their final score just for submitting data on at least one performance category in an applicable performance period.

4. Bonus points for caring for complex patients.

This is new for 2018 and would apply an adjustment of up to 3 bonus points by adding the average Hierarchical Conditions Category (HCC) risk score to the final score. This will award 1 to 3 points to clinicians based on the medical complexity of the patients they see. 

5. MIPS Categories will be weighted the same.

As you'll notice in the table below, every category will be weighted the exact same in 2018 as it is in the 2017 performance period.

   Performance Year  Performance Year
MIPS Category 2017 2018 (proposed)
Quality 60% 60%
Improvement Activities 15% 15%
ACI 25% 25%
Cost 0% 0%

*Note that if practices meet the exclusions for ACI they will have their score reweighted based on the Quality category. CMS requires 70 out of 100 points across the 4 performance categories. 

Related: [Webinar] Preparing Your Practice for MACRA and MIPS

6. Changes to the Quality category.

CMS previously required 50% for the 2018 performance period which would have been a 10% drop from the 2017 performance year. CMS is proposing to keep the weight to final score of the Quality category at 60% (same as it is for 2017 performance/transition year).

 7. Improvement Activities will Increase.

CMS is proposing that more Improvement Activities be made available for clinicians to choose from. Small practices will only have to choose two medium or one high-weighted activity to achieve the highest score of 40 in this category.

[Click here to visit the CMS QPP website and explore available Improvement Activities]

Practices with more than 15 eligible clinicians will need to submit either four medium or two high-weight activities to achieve the highest score for Improvement Activities.

8. Improvement Scoring Methodology.

The proposed rule would reward improvement in both Quality and Cost categories for an individual MIPS clinician or group for a current performance period compared to the prior performance period.

  • For Quality, higher improvement will result in more points and up to 10 percentage points are available.
  • For Cost, improvement scoring will be based on statistically significant changes at the measure level.

Now you might recall that we just mentioned how CMS is proposing that the Cost performance category weight be finalized at 0% for the 2018 performance year. If Cost is not finalized at 0% for the 2018 performance year, CMS proposes an improvement scoring methodology which would affect the 2020 MIPS payment year.

9. Virtual Groups as an additional participation option.

Virtual Groups are not currently available and would be new for the 2018 proposed rule. Virtual Groups are an additional participation options which would be composed of solo practitioners and groups of 10 or fewer eligible clinicians. These clinicians would come together "virtually" with at least 1 other such solo practitioner or group to participate in MIPS for a performance period of a year.

There are considerations with Virtual Groups and we suggest you take a look at pages 5-6 of the Proposed Rule Fact Sheet to better understand the concept of Virtual Groups.

10. Exemption Threshold will increase.

CMS is proposing a higher exemption threshold in 2018 which will increase the threshold to exclude individual MIPS eligible clinicians or groups with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries during a low volume threshold determination period that occurs during the performance period or a prior period.

There are also proposed changes for the 2019 performance period which would allow those clinicians that exceed one or two low-volume exemption thresholds to opt in to MIPS.

Related: Are You Exempt from the Merit-based Incentive Payment System?

Resources to Help You Succeed with MACRA

Keep in mind that these are proposed changes and have not been finalized by CMS. We will be publishing more updates from CMS on the proposed rule for 2018 and the final rule upon its release. Subscribe to instant updates to our blog to receive this information right to your inbox.

The Quality Payment Program brings significant changes to how clinicians are paid within Medicare. It's crucial that healthcare providers understand how the Quality Payment Programs affect their practice and reimbursement. Below are some resources to assist you in understanding the MACRA legislation and both Quality Payment Programs, APMs and MIPS.

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