Quality Payment Program Final Rule: Six important changes

Quality Payment Program Final Rule

The Quality Payment Program final rule is out. Based on updated requirements from the proposed rule, the Centers for Medicare and Medicaid Services (CMS) estimates that between 592,000 and 642,000 eligible clinicians will be required to participate in the Merit-Based Incentive Payment System (MIPS) in 2017, and between 70,000 and 120,000 clinicians will participate in Advanced Alternative Payment Models (APMs). Here are six important aspects of the Quality Payment Program that are different in the final rule from what was previously proposed. You may be glad to learn about some of these changes, since they are likely to ease participation for clinicians next year.

  1. 2017 is now a transition year, so participants will have time to ramp up
  2. The MIPS Cost category will not count toward the MIPS Composite Performance Score in 2017
  3. The reporting requirements for full MIPS participation have been reduced
  4. There will be new opportunities to participate in Advanced Alternative Payment Models
  5. Qualifying Participants in Advanced APMs will be notified about QP status during the performance period
  6. In support of small practices, the Medicare low-volume threshold for MIPS exclusion has been raised

1. 2017 is now a transition year, so participants will have time to ramp up

CMS has designated 2017 as a transition year for providers to ease into the requirements of the Quality Payment Program. The first performance year still begins on January 1, 2017, with performance impacting 2019 Medicare Part B payments, but the changes enable clinicians to more easily avoid negative payment adjustments by creating more options for satisfactory participation. Healthcare providers who are eligible for MIPS in 2017 now have four participation options so that providers and groups can pick the pace that is most appropriate:

Participation Option Payment Adjustment Impact
(1) Full MIPS Participation. Report all measures required under the MIPS program, in all performance categories that require reporting, for a full 90-day period or, ideally, the full calendar year. Eligible for maximum positive adjustment. Clinicians who meet these requirements are maximizing their chance to qualify for a positive adjustment. Exceptional performers who achieve a MIPS Composite Performance Score of at least 70 out of 100 will be eligible for an additional positive adjustment from a bonus pool of $500 million.
(2) Partial MIPS Participation. Report more than one measure in the Quality category, more than one activity in the Improvement Activities category, or more than one of the required measures in the Advancing Care Information category for at least a full 90-day period. Avoid a negative payment adjustment and be eligible for a positive payment adjustment. Clinicians who meet these requirements will avoid a negative payment adjustment and potentially earn a positive payment adjustment in 2019.
(3) Minimum MIPS Participation. Report one measure in the Quality performance category, report one activity in the Improvement Activities performance category, or report the required measures in the Advancing Care Information performance category. Avoid a negative payment adjustment only. Clinicians who meet these requirements will meet the 2017 MIPS performance threshold (3 points) and avoid a negative 4% payment adjustment in 2019. With this level of participation, there will be no opportunity to earn additional incentive payments.
(4) Participate in an Advanced APM. Participate in an Advanced APM in 2017 and meet the minimum Qualifying Participant payment or patient requirements. Potentially earn the Advanced APM positive payment incentive. MIPS eligible clinicians participating in one or more Advanced APMs who receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM(s) will qualify for a 5% bonus incentive payment in 2019.

Medicare providers who are eligible for the MIPS payment adjustment who do not meet Advanced APM requirements and choose to not report even one measure or activity under the MIPS program will receive the full negative 4% payment adjustment in 2019.

2. The MIPS Cost category will not count toward the MIPS Composite Performance Score in 2017

For the transition year, the Cost performance category (referred to as the Resource Use performance category in the proposed rule) will be weighted at 0% in the MIPS Composite Performance Score. The primary purpose for this change is to give clinicians the opportunity to become more familiar with the measures in the context of MIPS before the measures impact payment adjustment amounts.

The 2017 MIPS Composite Score will be calculated entirely based on the other three integrated MIPS performance categories: Quality, Improvement Activities (previously Clinical Practice Improvement Activities), and Advancing Care Information. Although cost and utilization measures will not be used to determine the MIPS Composite Performance Score in 2017, CMS will calculate a performance score based on certain cost measures based on claims and give performance feedback to clinicians for whom they were able to reliably calculate a score. As was described in the proposed rule, there is no reporting requirement for cost measures, so no action is required on the part of clinicians.

The Cost performance category contribution to the MIPS composite score will begin in performance year 2018, with an initial weighting of 10%. The weight of this category will gradually increase to the 30% by the third MIPS performance year (2019).

3. The reporting requirements for full MIPS participation have been reduced

In response to concerns about the reporting burden placed on providers participating in MIPS, the Quality performance category, the Improvement Activities category (formerly Clinical Practice Improvement Activities) and the Advancing Care Information (ACI) category will have reduced reporting requirements for full participation in 2017.

  • In the Improvement Activities category, the number of activities that participants must report to achieve full credit has been reduced from six medium-weighted or three high-weighted activities to four medium-weighted or two high-weighted activities to receive full credit in 2017.
  • In the ACI category, the number of measures required to achieve full credit has been reduced from 11 to five. All other ACI measures will be optional for reporting, and reporting on additional measures will allow a clinician to earn a higher score.
  • Small practices and practices located in rural areas will have a further-reduced number of measures in the Improvement Activities and ACI performance categories.
  • In the Quality performance category, participants are still required to report six individual measures or measures from a specialty-specific measure set, but these measures can be reported for a 90-day period and the provider will still be eligible for full credit.
  • Another Quality performance category change is that CMS has removed the requirement for reporting at least one cross-cutting measure for full MIPS participation in 2017. However, participants are still required to include at least one outcome measure as part of the six measures that are reported.

4. There will be new opportunities to participate in Advanced Alternative Payment Models

Under the Quality Payment Program, Qualifying Participants (QPs) in Advanced Alternative Payment Models (Advanced APMs) will be excluded from participation in MIPS and will receive a 5% incentive payment each year that requirements are met from 2019 through 2024. To achieve Qualifying Participant status, providers must have at least 25% of their Medicare Part B payments or 20% of their Medicare Part B patients in one or more Advanced APMs.

CMS has committed to expanding the opportunities for providers to participate in Advanced APMs. Methods for expansion include creating additional models that meet the definition of an Advanced APM and by exploring the opportunity to open up already existing models to additional participants. Though the final list of Advanced APMs has not yet been announced, CMS is considering the following:

  • Reopening applications for or modifying the Comprehensive Care for Joint Replacement model.
  • Reopening applications for the Comprehensive Primary Care Plus program.
  • Opening up participation for a new Medicare Shared Savings Program ACO model called Track 1+ that is slated to begin in 2018. This model would incorporate less downside risk than Tracks 2 or 3 of the Shared Savings Program but would carry enough financial risk to be considered an Advanced APM.

In the proposed rule, CMS estimated that 30,000 to 90,000 clinicians would meet the Qualifying Participant requirements in 2017. With the new participation opportunities, they are now estimating that between 70,000 and 120,000 clinicians will meet the requirements in 2017. The set of Advanced APM models for 2017 will be released no later than January 1, 2017.

5. Qualifying Participants in Advanced APMs will be notified about QP status during the performance year

MACRA outlines two methods by which an eligible clinician can be designated a Qualifying Participant (QP) of an Advanced APM in 2017, one of which must be achieved in order to reap the benefits of Advanced APM participation. These methods include having either at least 25% of Medicare Part B payments made through one or more Advanced APMs or at least 20% of Medicare Part B patients in one or more Advanced APMs.

Based on timelines included in both MACRA and the proposed rule, eligible clinicians would not have received confirmation about whether they met the QP requirements until after the performance year was over. In the final rule, CMS has committed to an accelerated timeline and will notify eligible clinicians of their QP status in advance of the end of the MIPS performance period, so that Advanced APM participants will know whether they are excluded before having to submit information to CMS for purposes of MIPS.

This accelerated notification is facilitated by a modified QP Performance Period, which will now be from January 1 to August 31 of the performance year, with three determination “snapshots” during which the Advanced APM Entity group will be evaluated against Qualifying Participant requirements. In 2017, eligible clinicians participating in an Advanced APM are expected to be notified of their QP status starting in August and no later than January 1, 2018.

6. In support of small practices, the Medicare low-volume threshold for MIPS exclusion has been raised

CMS continued to affirm its goal to protect small, independent physician practices by modifying the low-volume threshold that would allow certain Medicare providers to be excluded from MIPS. The final rule sets the low-volume threshold at less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Part B-enrolled Medicare beneficiaries for a single eligible clinician. This Part B allowed charges threshold is higher than the previously proposed threshold of $10,000. Medicare providers who are excluded from MIPS participation based on low-volume thresholds will not be allowed to voluntarily opt in to the program in 2017.

Stay tuned for more resources on the Quality Payment Program

CMS has estimated that if 90% of eligible clinicians participate in MIPS in 2017, the MIPS payment adjustments will be approximately $199 million in both directions (both positive and negative adjustments) to ensure budget neutrality. In addition, there will be an additional $500 million available in bonus payments, which will be distributed to clinicians whose MIPS performance meets or exceeds a threshold of 70. Which group do you want to be in in 2017?

Able Health continue to provide clear and concise information on requirements that impact you, including how your composite score will be calculated and what you need to do to earn a positive payment adjustment in 2017. Sign up for our newsletter to be informed of updates.


Further reading:
Help! I can’t find six relevant MIPS measures for my specialty
Need to Know: New Physician Star Ratings

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