9 notes on the 2018 proposed rule for MACRA's Quality Payment Program

CMS issued the proposed rule Tuesday for the 2018 performance year of the Quality Payment Program under the Medicare Access and CHIP Reauthorization Act.

In the second year of the QPP, the agency hopes to further streamline reporting requirements, while maintaining Medicare quality and continuing to push providers toward value-based care.

Here are nine things to know about the changes in the proposed rule for the 2018 performance period.

1. CMS proposed raising the low-volume threshold for the Merit-based Incentive Payment System. In 2017, clinicians or groups were exempt from MIPS reporting requirements if they billed $30,000 or less in Medicare Part B charges annually or had 100 or fewer Medicare Part B beneficiaries. This left just one-third of Medicare clinicians eligible for MIPS. However, to ease the burden on small and rural practices, CMS proposes raising this threshold in 2018 to 200 Medicare Part B beneficiaries and $90,000 in Medicare Part B allowed charges per year.

2. The rule includes the option for providers to band together in Virtual Groups. This option was not available in 2017. Virtual Groups allow solo physicians or physicians in groups of 10 or fewer to virtually combine for MIPS participation. To become a Virtual Group, a solo physician or group must combine with at least one other solo physician or group, regardless of location or specialty, and register before the 2018 performance year. Solo physicians must be eligible for MIPS on their own.

3. CMS proposed adding bonus points to the MIPS scoring methodology. Clinicians have the opportunity to earn bonus points if they care for complex patients (up to three points), are part of practice with 15 or fewer clinicians (up to five points), or exclusively use the 2015 Edition Certified EHR Technology. The program allows the use of 2014 Edition CEHRT, but CMS wants to push providers to use the 2015 Edition through the use of bonus points.

 4. The weights of the measures that contribute to the MIPS composite score were adjusted. For the 2018 performance year, the composite score will be weighted as follows:

  • Quality: 60 percent
  • Cost: 0 percent
  • Advancing Care Information: 25 percent
  • Improvement Activities: 15 percent

The proposed rule the amount of time the cost category is weighted at 0 percent to 2020. Beginning in 2021, CMS would still ramp up the weight of the cost category to 30 percent as originally planned.

5. The amount of Medicare Part A and B revenue that must be at risk to qualify as an advanced Alternative Payment Model — set at 8 percent in 2017 —was extended for two years. Clinicians must bear more than "nominal" financial risk for financial losses to qualify as an advanced APM. The proposed rule extends the revenue-based nominal amount standard of 8 percent to the 2020 performance year.

6. The required risk for medical home models will increase more slowly. Clinicians can also qualify as an advanced APM if they participate in a medical home model created under the Center for Medicare and Medicaid Innovation. The 2018 proposed rule increases the risk required for medical home models more slowly. In 2017, medical home models were required to have at least 2.5 percent of estimate average Parts A and B revenue at risk, and this was expected to increase to 3 percent in 2018, 4 percent in 2019 and 5 percent in 2020. However, CMS proposes decreasing the amount of risk for medical homes to 2 percent of Medicare Parts A and B revenue in 2018 and increasing this by one percentage point per year going forward.

7. The proposed rule also offers more detail on the All-Payer Combination Option for APMs that would begin in 2019. This option would allow physicians to qualify as advanced APMs through a combination of Medicare and commercial payer APM participation.

8. MIPS APM reporting would be more streamlined. Physicians who have some APM participation, but do not qualify for advanced participation, are subject to MIPS reporting requirements and known as MIPS APMs. The 2018 proposed rule updates the scoring policy for these providers to increase flexibility and identify policies for MIPS APMs in virtual groups.

9. The proposed changes have been met with mixed responses from the industry so far. The American Medical Association praised the changes and the slowed pace offered in the 2018 proposed rule. "Not all physicians and their practices were ready to make the leap, and many faced daunting challenges," the AMA said in an emailed statement. "This flexible approach will give physicians more options to participate in MACRA and takes into consideration the diversity of medical practices throughout the country."

However, the American Medical Group Association felt the draft rule slowed the transition to value too much. "If CMS wants to transition to value-based payment for care, the program needs to be fully implemented," Chester Speed, AMGA's vice president of public policy, said in an emailed statement. "We recommend that CMS revise its proposal to fully incentivize high performers in the Medicare program."


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