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What You Need to Know Now: Analyzing the 2018 MACRA Quality Payment Program Final Rule

Yesterday the Centers for Medicare & Medicaid Services (CMS) issued the final rule with comment for the second year of the Quality Payment Program (calendar year 2018) as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The changes reflect the commitment CMS has made to minimizing the burden of participation in the Quality Payment Programs while still focusing on meaningful measurement and improved healthcare delivery.

As published in the Federal Register, CMS’s senior officials wrote, in the introduction to the 1,653-page published final rule, “Clinicians have told us that they do not separate their patient care into domains, and that the Quality Payment Program needs to reflect typical clinical workflows in order to achieve its goal of better patient care."

CMS listened to feedback from the health care community and used it to inform policy making. As a result, the Year 2 final rule continues many of the flexibilities included in the transition year, while also preparing clinicians for a more robust program in Year 3.

“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,” said Seema Verma, Administrator of CMS. “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.”

Also: 5 MIPS Myths Debunked!

Among the key points of the 2018 MACRA Quality Payment Program Final Rule is an exemption for those practices in areas hit by a hurricane. States CMS: “We are issuing an interim final rule for automatic extreme and uncontrollable circumstances where clinicians can be exempt from these categories in the transition year without submitting a hardship exception application. Clinicians in affected areas that do not submit data will not have a negative adjustment. We know that the circumstances have created a significant hardship that has affected the availability and applicability of measures.”

CMS did state that clinicians that choose to submit data for 2017 will be scored on their submitted data, however, as noted above, clinicians in areas affected by hurricanes do not need to worry about participating in the program in 2017 or submitting a hardship exception application.

Overview of MIPS Participation in 2018

Year 2 will hold the same basic two-track format of either joining an advanced alternative payment model or participate in the Merit-based Incentive Payment System (MIPS).

MIPS will continue to be made up of the existing four categories:

  • Advancing Care Information
  • Improvement Activities
  • Cost
  • Quality

However, some changes will take place within these four categories. Here is an overview of those changes as well as what to expect 

Advancing Care Information 

  • The reporting period in 2018 for ACI remains at 90 days.
  •  For 2018, ACI will be weighted at 25%
  • If a physician writes less than 100 permissible prescriptions they are relieved of the e-Prescribing category*
  • Those physicians who transfer a patient to another setting or refer a patient fewer than 100 times during the performance period are exempt from the health information exchange/summary of care measures*

*These exemptions apply to 2017 as well as future years.

  • Ambulatory surgical center (ASC)-based physicians are exempt from ACI, and this exception is retroactive to the current (2017) reporting year. Physicians practicing in off-campus-outpatient hospital (place of service 19) sites are also exempt, as they are now incorporated in the “hospital-based physician” definition.

Improvement Activities

  • 21 new improvement activities (some with modification) have been added, and CMS made changes to 27 previously adopted improvement activities for 2018.
  • The reporting period in 2018 for IA remains at 90 days.
  • In 2018, Improvement Activities will be weighted at 15%


  • The reporting period for the quality and cost measures is 12 months in 2018
  • Cost will be weighted at 10%. It is being calculated based on the Medicare Spending per Beneficiary (MSPB) and total per capita cost measure, and the announcement also confirmed CMS’ commitment to a 30% weighting of the cost component for 2019 and beyond.


  • Practices can use only one mechanism for reporting the quality measures in 2018, a surprising departure from the proposed rule. Indeed, CMS acknowledges the need for this flexibility, but won’t implement it until 2019.
  • The reporting period for the quality and cost measures is 12 months in 2018. It is important to note that some quality measures won't score at the highest level in 2018. Be sure to review the quality measures carefully each year to ensure your are on track for success with MIPS.
  • For 2018, Quality will be weighted at 50%.


Opportunity for Bonus Points

  • Five bonus points are available for the “treatment of complex patients,” a judgment driven by CMS using the dual eligibility ratio and average HCC risk score.
  • Small practices – those with 15 or fewer clinicians – get an automatic bonus 5 points. Neither do they have to worry about data completeness for the quality measures, as they receive an automatic 3 points per measure. Perhaps the biggest surprise comes in the fact that a small practice size exempts one from the ACI category, with an end-of-year due date for the application for this exception.


MIPS & Advanced APM Participation Updates for 2018 

  • Practices can continue to use their 2014-certified electronic health record (EHR) systems although there are bonus points for reporting exclusively on the 2015 edition. 15 points are required to avoid the penalty in 2018, up from three points needed during the 2017 transition year. 

  • Virtual groups can be formed by joining with other practices, in order to participate in MIPS.

  • If a practice joins an advanced alternative payment model in the middle (or near the end) of the reporting year, the practice can be officially incorporated in the entity based on an alteration in CMS’ look-back periods, as long as they were able to participate for at least 60 continuous days during the performance period.

  • The bar for participation was raised to $90,000 in Medicare Part B total allowed charges (or 200 Medicare patient encounters) removing an additional 123,000 clinicians from the program, estimates CMS. If you fall below those thresholds, you do not need to be concerned with the Quality Payment Program in 2018 and beyond. If you'd like to check whether you qualify for MIPS participation, visit https://qpp.cms.gov/ and enter your NPI number for complete information on your eligibility and participation options.

Also: How Advanced APMs Differ from APMs

For More Information

For more information about the Quality Payment Program, please visit: qpp.cms.gov

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