2018 Quality Payment Program proposed rule

Medicare's Quality Payment Program (QPP) consists of the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). The vast majority of AAD members will continue to be in MIPS for the foreseeable future. In a proposed rule released on June 20, 2017, the Centers for Medicare and Medicaid Services (CMS) addressed elements that were not included in the first year of the program, including virtual groups, facility-based measurement, and improvement scoring. Details on the changes CMS proposes appear below.

Read the AADA's comment letter to CMS.

MIPS performance period

CMS proposes:

  • A 12-month calendar year performance period for quality and cost reporting (Jan. 1 – Dec. 31) for 2018 and all future years.
  • A continuous 90-day minimum performance period for Advancing Care Information (ACI) and Improvement Activities (IA) for both 2018 and 2019.
  • Requiring claims to be submitted within 60 days of the end of the performance period for purposes of assessing performance and computing the payment adjustment.

Exclusions

Eligible clinicians are excluded during their first year in Medicare. The low volume threshold was increased to $90,000 in Part B charges or 200 Medicare patients; clinicians who do not exceed one of these thresholds are automatically exempt from MIPS reporting requirements. 

Beginning in 2019, CMS proposes that eligible clinicians who do not exceed the low volume threshold on one of the measures but not the other will be allowed to opt-in if they want to. For example, if they have less than $90,000 in charges but more than 200 patients, they could choose to participate in MIPS.

Reporting mechanisms

Important change: Eligible clinicians and groups will be able to submit measures and activities via as many mechanisms as possible to meet the requirements. In 2017, only one mechanism per category is allowed.

For clinicians reporting individually


Quality
  • Claims
  • Qualified clinical data registry (QCDR)
  • Qualified registry
  • EHR

Cost
  • Administrative claims1

Advancing Care Information
  • Attestation
  • QCDR
  • Qualified registry
  • EHR

Improvement Activities Attestation
  • QCDR
  • Qualified registry
  • EHR

For clinicians reporting as groups


Quality
  • QCDR
  • Qualified registry
  • EHR
  • CMS Web Interface (groups of 25 or more)
  • CMS-approved survey vendor for CAHPS for MIPS (must be reported in conjunction with another data submission mechanism)
  • Administrative claims (for all-cause hospital readmission measure; no submission required)

Cost
  • Administrative claims1

Advancing Care Information
  • Attestation
  • QCDR
  • Qualified registry
  • EHR
  • CMS Web Interface (groups of 25 or more)

Improvement Activities
  • Attestation
  • QCDR
  • Qualified registry
  • EHR
  • CMS Web Interface (groups of 25 or more)

1Requires no separate data submission to CMS: measures are calculated based on data available from MIPS eligible clinicians’ billings on Medicare Part B claims. Note: Claims differ from administrative claims as they require MIPS eligible clinicians to append certain billing codes to denominator eligible claims to indicate the required quality action or exclusion occurred.

MIPS score

Each eligible professional in the MIPS program will receive a composite performance score of 0‐100. The composite is based on three categories. Weighting: Quality 60%, Cost 0%, Improvement Activities 15%, and Advancing Care Information 25%.

Quality

60% of composite score unless the practice gets an ACI exemption (then increases to 85% of score).

  • Maintains the data completeness threshold at 50% in 2018.
  • Measures that do not meet data completeness criteria will get 1 point instead of 3 points, except that small practices will continue to get 3 points.
  • The specialty-specific measure set for dermatology includes all 7 current dermatology-specific measures.
  • Proposes to include all-payer data for the QCDR, qualified registry, and EHR submission mechanisms.
  • No change in submission criteria except for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. This includes keeping the number of measures that must be reported for maximum scoring at 6, including at least one cross-cutting measure.
  • The CAHPS for MIPS survey is an optional quality measure that groups participating in MIPS can elect to administer. CMS is considering expanding the patient experience data available for this survey.

Improvement Activities (IA)

15% of composite performance score (or a maximum of 60 points)

  • Generally, IA requirements remains same as 2017 for small practices with 15 of fewer eligible clinicians (90 days reporting; 1 high-weighted / 2 medium-weighted choices; submitted via either data registry, EHR, or the CMS portal; & same 15% weight for scoring)
  • Proposes changes: adding new IAs (table F, pg. 1037) and revising existing IAs (table G, pg. 1044) for 2018.
  • All the 2017 IAs continue as they were, except those listed in Table G.
  • Continue to promote and incentivize IA related to using HIT, telehealth, and connecting patients to community services, and open new HIT capabilities as part of IA list.
  • In future, CMS to set up a formal nomination process for new IAs for -2019 QPP to increase IA list.

Advancing Care Information

25% of composite score

  • Allows either 2014 or 2015 HIT certification for 2018
  • CMS is re-weighting the ACI score to 0 for those in practices less than 15 eligible clinicians if they apply for a hardship exemption. In those cased, the weighting of the quality measures will be increased.
  • Allows an exemption for eligible clinicians whose EHR is decertified
  • The exception application submission has been moved to Dec. 31st from July 1st
  • They are changing the scoring for the clinical data registry submission. You can get 5 points in the performance score for participation in a clinical data registry but you get 10 points if you participate with an immunization registry.
  • Clinicians can no longer get 5 bonus points for participating in a clinical data registry if they utilize it for the performance score.
  • 90-day reporting period
  • There are exclusions for e-prescribing and health information exchange measures. A clinician does not have to do those two measures if they prescribe less than 100 times during the reporting period or transfer fewer than than 100 patients during the reporting period.

Cost

0% of composite score

  • No reporting required. Administrative claims are used for scoring.
  • Though it has no weight this year, practices should pay attention to their reports. For 2019 reporting and beyond the score jumps to 30%, a statutory requirement.
  • In the current year (2017) CMS used the two Value Modifier (VM) and ten episode-based sQRUR measures that were used in 2016.
  • CMS plans to continue to use the 2 VM measures, for total per capita cost and Medicare spending per beneficiary (MSPB). No changes in the attribution method are expected.
  • In 2018 they are required to move toward using care episode and patient condition groups. These groups will be posted in December 2017. The 10 sQRUR measures will not be used in 2018.

Small practices (1-15 eligible clinicians) accommodations

  • Low volume threshold: Increase the low volume threshold for exclusion from QPP to clinicians or groups with under $90,000 in Part B allowed charges or under 200 Part B beneficiaries, an increase from the current $35k/100 patients.  This proposed change would allow more physicians to be excluded from the MIPS program.

  • Bonus points: A small practice bonus of 5 points will be added to the final score for MIPS eligible clinicians, and for groups, virtual groups, and APM Entities that consist of 15 or fewer eligible clinicians, that participate in the program by submitting data on at least one performance category in the 2018 MIPS performance period.

  • ACI: Reweight the advancing care information performance category to zero percent of the MIPS final score for MIPS eligible clinicians who qualify for a hardship exception. Clinicians seeking this exception must submit an application in which they identify overwhelming barriers, such as high cost, that prevent them from complying with the requirements for the advancing care information performance category. CMS does not identify other possible barriers besides cost. If a practice has an ACI exemption, the quality portion will be reweighted to 85%.

  • Improvement activities: Receive full credit for improvement activities by selecting one high-weighted improvement activity or two medium-weighted improvement activities. receive half credit for improvement activities by selecting one medium-weighted improvement activity. This is half the requirement for eligible clinicians not in small practices.

  • Quality: Small practices of 15 or fewer who would still receive 3 points for measures that fail data completeness. In other words, eligible clinicians in small partial is get full credit for partial reporting. And if they also get the ACI exemption, the weighting of these measures is increased.

CMS estimates that at least at least 80% of small practices will receive a small positive or neutral adjustment, due to the flexibilities and exceptions they have created.

Group reporting

  • Generally the same as 2017. Group reporting option is available to eligible participants in a bona fide group (single TIN with two or more EPs, including one MIPS eligible individual).

  • Group assessed and score in aggregate as part of single TIN.

  • Small groups must attest when using CMS portal or self-identified as a “small practice”.

  • There is no registration process for groups submitting data using third party entities (such as DataDerm. Groups must work with appropriate third party entities to ensure the data submitted clearly indicates that the data represent a group submission rather than an individual submission.

    • Background: In the 2017, CMS had discussed setting up voluntary registration process, if technically feasible, to better standardize this process. However, CMS is now saying that it is not technically feasible to develop and build a voluntary registration process.  So until further notice, they are shelving a voluntary [standardized] registration process.

  • Must still register if submitting data through CMS Web Interface or Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey for the quality performance category. Must register by June 30, 2018, for 2018 performance period.

Virtual groups

In 2018, solo and small practices will have the option to participate in MIPS in three ways:

  • as an individual;
  • as part of a group practice; or
  • through a new route: Virtual Group (VG).
    • A VG will be made up of solo practitioners and small group practices that join together to report on MIPS requirements as a collective entity.
    • A VG will be limited to 10 eligible clinicians.
    • VGs can be based on either geographical location or specialty (i.e., rural practices forming a VG or derm practices banding together to form VG).
    • VGs will operate under the “opt-in” rules, meaning participants must choose to participate prior to the performance year and are then locked into the VG without the option to get out for that full performance year. If a small group practice chooses to participate in a VG, then all members of that group must participate in the VG. Participants can only be in one VG per participation period.
    • Participants must join a VG by December 1, 2017.
    • CMS will provide technical assistance (VG reps/coaches) to facilitate and support participants who are interested in participating through VGs. Technical assistant rep to help confirm if the VG is made up of eligible participants as part of the screening and vetting process using TIN, NPI & claims data. 
    • Formal written agreements for all participants are required and will be provided by CMS, binding the participants to the contract for the performance year, comply with MIPS requirements, and subject to all other applicable laws and regulations (i.e., federal criminal law, False Claims Act, anti-kickback statute, civil monetary penalties law, HIPAA, and physician self-referral law, etc).
    • CMS is expected to issue further sub-regulatory guidance on election/formation period as well as resources for VGs by or before mid-September 2017, giving potential participants interested in forming VGs enough lead time to discuss the formation of VGs, submit an application for vetting and approval before executing participating agreement.
    • MIPS group policies apply to VG, meaning VGs are required to meet all reporting requirement for each measure & activity, and be responsible for aggregating across the VG.
    • VGs must re-register, be vetted, and approved for each performance year to ensure they still meet all the requirements.
    • Essentially, VG model is an exercise in burden sharing, division of labor/strength, risk management with the goal of collectively reaping the rewards of the group’s efforts.
    • For eligible derms (along with their PAs/NPs) who are struggling with or unable to meet all the QPP performance category requirements, then the VG option allows them to team up and collaborate with like-minded colleagues to see, if together, they are able to report on all categories in order to achieve the best group score.
    • Derms interested in VG option should start discussion with other interested colleagues to see if there’s a consensus on moving ahead since it can take at least three months to hammer out all the elements and agreements for a VG arrangements.
    • VGs are not expected to be widely adopted in the first year given their novelty, relative complexity, clinician collaboration barriers, unknown risks/benefit prospects.

Projected impact on dermatology

TABLE 86:  MIPS Estimated Payment Year 2020 Impact on Estimated Paid Amount by Specialty, Standard Participation Assumptions *

  • Number of MIPS eligible clinicians: 9,506
  • Estimated Paid Amount (mil) (80% of Allowed Charges) **:  $2,510
  • Percent eligible clinicians engaging with quality reporting:  91.8%
  • Percent Eligible Clinicians with Positive or Neutral Payment Adjustment: 91.8%
  • Percent Eligible Clinicians with Exceptional Payment Adjustment: 69.6%
  • Percent Eligible Clinicians with Negative Payment Adjustment: 8.2%
  • Aggregate Impact Positive Adjustment (mil)**:  27.2
  • Aggregate Impact Negative Payment Adjustment (mil)**: -10.7
  • Combined Impact of Negative and Positive Adjustments and Exceptional Performance Payment as Percent of Estimated Paid Amount: 0.7%

TABLE 87: MIPS Estimated Payment Year 2020 Impact on Estimated Paid Amount
by Specialty, Alternative Participation Assumptions *

  • Number of MIPS eligible clinicians: 9,506
  • Estimated Paid Amount (mil) (80% of Allowed Charges) **:  $2,510
  • Percent eligible clinicians engaging with quality reporting:  85.3%
  • Percent Eligible Clinicians with Positive or Neutral Payment Adjustment: 85.9%
  • Percent Eligible Clinicians with Exceptional Payment Adjustment: 69.9%
  • Percent Eligible Clinicians with Negative Payment Adjustment: 14.1%
  • Aggregate Impact Positive Adjustment (mil)**:  31.0
  • Aggregate Impact Negative Payment Adjustment (mil)**: -17.9
  • Combined Impact of Negative and Positive Adjustments and Exceptional Performance Payment as Percent of Estimated Paid Amount: 0.5%