Quality Payment Program proposed rule attempts to ease burden, delay the inevitable

CMS has spoken repeatedly of easing the burden for providers this spring, and the agency’s Quality Payment Program (QPP) proposed rule released June 20 attempts to do that for small practices and other clinicians.  

A large focus of the proposed rule, which aims to update the physician payment programs created as a part of the Medicare Access and CHIP Reauthorization Act (MACRA), is on delaying certain requirements of the programs for another year and creating ways to either exempt providers from participation or create more flexibility for eligible providers to meet QPP requirements.

The QPP is part of an initiative created to revise the physician payment system previously updated through the Sustainable Growth Rate (SGR). It allows providers to choose from two pathways of participation in this program: Advanced Alternative Payment Models (APM) or the Merit-based Incentive Payment System (MIPS). This new system will replace three previous Medicare reporting programs (Medicare Meaningful Use [MU], the Physician Quality Reporting System [PQRS], and the Value-Based Payment Modifier).

2017 marked the first performance year of the QPP, so CMS has regarded 2017 as a transition year to see what aspects of the program work and what aspects do not.

One of the ways the agency is looking to ease provider burden is by further limiting the number of clinicians required to participate. The rule proposes excluding eligible clinicians who bill less than $90,000 in Medicare Part B charges or who see fewer than 200 Part B beneficiaries, a drastic change from the 2017 low-volume thresholds of less than $30,000 in Part B charges or fewer than 100 Part B beneficiaries.

The proposed rule also suggests keeping the Cost portion of the total score, one of four categories, at a 0% weight for 2018 reporting instead of increasing it to the previously planned 10% weight. Additionally, practices would still be able to use 2014 Edition Certified Electronic Health Record Technology (CEHRT) for the 2018 performance year. Previous rules dictated that practices would be required to use 2015 Edition CEHRT for the 2018 performance year or receive a score of 0 in the Advancing Care Information performance category, which will be worth 30% of the total MIPS score.

CMS also proposes pushing back the minimum total potential risk for APM entities under the Medical Home Model Standard by a year. In order for APMs to qualify for participation in the APM pathway of MACRA, these APMs must take on a certain amount of risk -- a percentage of withheld payment, reduced payment, or payments entities make should actual expenditures exceed expected expenditures during a specified performance period. Previously, this risk for entities under the Medical Home Model Standard would be 3% of the estimated average total parts A and B revenue in 2018. It would increase by 1% each year until reaching a final risk total of 5% in 2020. But CMS proposes adjusting that risk down to 2% in 2018 and increasing the number by 1% each year through 2021, when it will reach a final risk total of 5%.

While some of these proposals would likely ease the burden of adjusting to the MACRA regulations, they only delay the inevitable in certain cases. The MIPS program works by configuring a total score for eligible clinicians created by adding the weighted scores achieved in each performance category. These scores are then measured against a threshold set by CMS each year, and physicians are paid based on how their score measures against that threshold. Due to statutes set by the MACRA legislation, the MIPS performance categories must be weighted as follows by Performance Year 3 (2019) of the program:

• Quality – 30%
• Cost – 30%
• Improvement Activities – 15%
• Advancing Care Information – 25%

This means that unlike with ICD-10 implementation, when the switch from ICD-9-CM was delayed repeatedly, there is an end date with MACRA. If Cost is reduced to 0% of the total score for the 2018 performance year, it will still have to jump up to 30% of the total score for the 2019 performance year. CMS also cannot change the percentage of payment adjustment for the 2020 year (determined from the 2018 performance year) due to law, so payment adjustments will increase to a positive or negative 5% for 2020 payment.

CMS is specifically soliciting comments on several topics from the proposed rule. One of these topics is the proposed bonus points categories for practices treating complex patients and/or small practices. Bonus points for complex patients would be based off the average hierarchical conditions category (HCC) risk score for a practice. CMS is soliciting comments on whether to include dual eligibility as a method of adjusting scores either as an alternative to HCC risk scores or in addition to HCC risk scores. Eligible clinicians could earn up to 3 additional points from this category, which would be added to their final MIPS score.

Small practice bonuses of 5 points would be added to the final MIPS score as well for any eligible clinician or group (of 15 clinicians or fewer) as long as the group or clinician submits data from at least one performance category during an applicable performance period. CMS is soliciting comments as to whether this bonus should also be applied to rural practices as well.

The performance threshold is another area that is up for debate. CMS set the performance threshold for 2018 at 15 points, which is significantly higher than the 3-point threshold from 2017 but still on the low end of the 1- through 100-point scale. CMS is asking for feedback on whether this should be adjusted.

The comment period on the proposed rule ends August 21. The final rule is expected to be released in the fall.