On June 30, the Centers for Medicare & Medicaid Services (CMS) issued a much anticipated rule outlining proposed payment and policy changes to the new Medicare Part B Quality Payment Program (QPP) that was created by the Medicare Access and Chip Reauthorization Act of 2015 (MACRA). The proposed rule seeks to offer additional flexibility and programmatic support to eligible clinicians, particularly those in small practices, and continues to phase in QPP reporting obligations and payment adjustments.

The proposed rule reiterates MACRA’s goals and continues the core principles of the QPP, including its two pathways for eligible clinicians: (1) the default Merit-based Incentive Payment System (MIPS) path, which includes upward or downward payment adjustments based on scores in four performance categories, and (2) the Advanced Alternative Payment Model (Advanced APM) path for clinicians who meet the criteria of a Qualifying APM Participant (QP) in an Advanced APM. The proposed rule includes key changes impacting both pathways and provides detail on new policies that become effective in and after Year 2 of the QPP.

Key Changes to the MIPS Pathway

The proposed rule emphasizes CMS’s desire to design a flexible and transparent QPP that reduces the burden on clinicians. CMS anticipates that “at least 80 percent of clinicians in small practices with 1-15 clinicians will receive a positive or neutral MIPS payment adjustment” based on changes intended to assist clinicians that practice in rural areas or small groups, which include:

  • Increasing the low-volume threshold to exclude from MIPS clinicians who bill ≤ $90,000 in Part B allowed charges OR provide care for ≤ 200 Part B enrolled beneficiaries, which is a big increase from the transition year (i.e., 2017-Year 1) thresholds of $30,000 in charges and 100 beneficiaries. CMS estimates this change would exclude an additional 134,000 clinicians from MIPS. In a departure from current policy, CMS would allow excluded clinicians to opt-in to MIPS starting in the 2019 performance year.
  • Implementing the virtual group provision of MACRA to allow solo practitioners and groups of 10 or fewer clinicians to combine resources and participate in MIPS as a group, by submitting a written election by December 1 of the calendar year preceding the performance period and entering into a formal written agreement with each member.
  • Implementing a significant hardship exception to certified electronic health records technology (CEHRT) requirements of the Advancing Care Information (ACI) performance category.
  • Providing five bonus points to the final MIPS score of any clinician in a practice of 15 or fewer clinicians.

Other provisions of the rule highlight CMS’s efforts to add flexibility to MIPS. In a significant policy change, CMS proposes implementing an option for facility-based clinicians to use their institutions’ performance in value-based programs to assess performance in the quality and cost performance categories of MIPS. CMS also deviates from its strict transition year policy of requiring clinicians to use one reporting submission mechanism per performance category by allowing multiple submission mechanisms.

The proposed rule would allow clinicians to continue using 2014 Edition CEHRT in 2018, but provide bonus points for reporting ACI objectives and measures using only the 2015 Edition. CMS also proposes numerous other modifications to MIPS scoring including the bonus points for small practices and offering three bonus points for treating complex patients. While CMS proposes continuing to weight the Cost performance category at zero for the 2020 MIPS payment year to allow improved clinician understanding of the measures and continued development of episode-based measures to be used in the category, it seeks comments on staying on track with the planned 10 percent weight and still proposes to increase the Cost performance category weight to 30 percent for the 2021 MIPS payment year.

Advanced APM Pathway Policies Update

The proposed rule affirms CMS’s position that alternative payment models represent an important step in its efforts to move the healthcare system from volume-based to value-based care. CMS estimates the number of QPs in the Advanced APM pathway potentially could more than double for the 2018 performance year as a result of the reopening of applications for current Advanced APMs and roll out of new models.

The proposed rule updates and invites comments on policies that apply in the Advanced APM pathway. To qualify as an Advanced APM, a payment model must (1) require participants to use CEHRT; (2) provide payment for professional services based on quality measures comparable to those in the MIPS Quality performance category; and (3) either require participants to bear more than a nominal amount of financial risk or be a qualifying medical home model expanded under authority of the Centers for Medicare and Medicaid Innovation. CMS proposes to extend, through performance year 2020, the revenue-based nominal risk standard for an alternative payment model to qualify as an Advanced APM, which is ≥8 percent of the average estimated Parts A and B revenue. The rule exempts participants in the Comprehensive Primary Care Plus Model from the requirements that the standards for medical homes only apply to Advanced APMs with fewer than 50 clinicians in their parent organization. It also increases more gradually the total potential risk standard for medical homes.

In the proposed rule, CMS also updates policies that will apply to the All-Payer Combination Option, which will allow QP status to be determined based on participation both in the current Medicare Part B Advanced APMs and in other alternative payment models that meet the three criteria applicable to Advanced APMs. This option would be available for Medicaid, Medicare Advantage, and CMS multi-payer models for performance year 2019. In outlining proposals to determine whether private payment models will qualify as Other Payer APMs, CMS recognizes and invites comments on the challenges. The proposed rule additionally sets forth proposed policies on how it will determine whether a clinician has participated sufficiently in a combination of Advanced APMs and Other Payer APMs to qualify as a QP.

CMS is accepting comments on its proposal through August 21, 2017.

Editor’s Note: Reprinted with permission from the American Health Lawyers Association. Any further reproduction of this article requires the advance written permission of the American Health Lawyers Association.