2018 final rule for MACRA's Quality Payment Program is here: 10 things to know

CMS issued the 2018 final rule for the Quality Payment Program created under the Medicare Access and CHIP Reauthorization Act.

In the second year of the program, CMS continues to adjust the program to be more comprehensive, more flexible and offer more incentives to providers. The agency still plans to ramp up to full implementation of the law in the third year of the program, which begins in 2019.

Here are 10 things to know about the rule, how it will change the Merit-based Incentive Payment System and the Advanced Alternative Payment Models, and how it has been received so far.

MIPS changes

1. Clinicians in the MIPS track will begin to be held accountable for the cost of care. The final rule reweights the quality and cost performance categories from their original respective weights of 60 percent and 0 percent. The final score will be based 50 percent on quality, 10 percent on cost, 15 percent on improvement activities and 25 percent on advancing care information. The performance period for the quality category will be extended from a 90 day minimum to a full 12 months. Performance periods for the other categories will remain the same: advancing care information (minimum of 90 days), improvement activities (minimum of 90 days), and cost (12 months).

2. CMS provided more bonus opportunities in the final rule for clinicians. Physicians in small practices of 15 physicians or fewer can earn five additional points if they submit data on at least one performance category. Physicians can also earn up to five more bonus points for treating especially complex patients, as defined by CMS' Hierarchical Condition Categories and the number of patients treated who are eligible for both Medicare and Medicaid.

3. The low-volume threshold was raised. Previously, physicians were exempt from MIPS if they billed less than $30,000 to Medicare Part B or treated fewer than 100 Part B beneficiaries annually. The 2018 final rule raises this bar to $90,000 in Medicare Part B charges and 200 patients annually. This means even fewer physicians will be subject to MIPS. The previous benchmark left about one-third of Medicare Part B physicians subject to MIPS.

4. Physicians will be able to band together in virtual groups to report for MIPS for the first time next year. Individual physicians and physicians in groups of 10 or fewer can band together virtually, no matter their geographic location or clinical specialty, to report on MIPS measures. All physicians and groups must exceed the low-volume threshold.

5. CMS added leniency for physicians and practices affected by hurricanes Harvey, Irma and Maria. The 2018 rule includes a provision for extreme and uncontrollable circumstances. It allows MIPS physicians affected by hurricanes, natural disasters and public health emergencies to submit hardship exception applications by Dec. 31 for the following: reweighting of the advancing care information category for the 2017 transition year; and reweighting the quality, cost and improvement activities categories for the 2018 performance year. Because the final rule will not go into effect until 2018, CMS also issued an interim final rule to exempt clinicians automatically — without submitting an application — from the quality, cost and improvement activity categories in 2017 if they were impacted by extreme weather or public health emergencies.

APM changes

6. The final rule offers additional information on MIPS APMs. This applies to physicians who are participating in APMs but do not meet the standards to qualify as Advanced APMs. The final rule adds another determination period for MIPS APMs, which will allow more Medicare Shared Savings Program physicians to qualify as MIPS APMs. It also provides more details on scoring for MIPS APMs, available here.

7. The final rule extends the risk minimum for Advanced APMs by two years. This means at least 8 percent of physician revenue has to be at risk to qualify, and this standard will be extended through the 2020 performance year. The rule also applies this standard to Other Payer Advanced APMs, so physicians who are in APMs with non-Medicare payers can also qualify as an Advanced APM if at least 8 percent of revenue from that payer is at risk.

8. The rule also provides additional details on the All-Payer Combination Model, which will be available in 2019. This includes information on the performance period, determination and data submission for this model, which will allow physicians to qualify as Advanced APMs through a combination of Medicare and Other Payer Advanced APMs.


9. The final rule already has mixed reception. Some groups have lauded the rule for its flexibility. For example, Nelly Ganesan, senior director of Avalere Health, said in an emailed statement: "Today's final rule reflects the administration's continued commitment to providing flexible participation options for clinicians." Others, however, feel the rule "shies away" from value-based care. "The transition to value is challenging and CMS understandably wants to ease providers into value," AMGA President and CEO Jerry Penso, MD, said in a press release. "But excluding providers isn't the same as learning how to deliver care in a value-based world. Taking accountability for the quality and cost of care requires years of experience. Despite CMS' intentions to ensure a smooth transition, AMGA is concerned that this rule actually hinders the prospects for value-based care."

10. CMS is soliciting comments until Jan. 2, 2018. Comments may be submitted electronically, by mail or by courier. Comments will be made public. Find more information on how to submit a comment here.


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