WASHINGTON -- The Trump administration unveiled a final rule detailing how physicians' performance will be measured under a new system of Medicare payment known as the Quality Payment Program (QPP).
The new payment system reflects an evolution of the Medicare Access and CHIP Reauthorization Act (MACRA), enacted in 2015 to repeal SGR, which was the highly unpopular sustainable growth rate formula.
This plan includes two payment models: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs).
A significant difference for physicians in the MIPS programs is the requirement to submit full year data rather than 90 days of data as was required in the current year.
MIPS participants will also be held accountable for costs using metrics that some argue need more testing. AAPMs, on the other hand, requires far fewer reporting metrics but also a certain amount of down-side risk. (New models must be approved by the agency.)
The Centers for Medicare and Medicaid Services touted the 1,653-page final rule, released late Thursday afternoon, as easing the clinicians burden by requiring only "meaningful measures." The agency said it had reviewed 1,200 comments and worked with 100 stakeholders before the rule's release.
"During my visits with clinicians across the country, I've heard many concerns about the impact burdensome regulations have on their ability to care for patients," said CMS Administrator Seema Verma in a press statement.
"These rules move the agency in a new direction," she said, "and begin to ease that burden by strengthening the patient-doctor relationship, empowering patients to realize the value of their care over volume of tests, and encouraging innovation and competition within the American healthcare system."
On the plus side for MIPS participants, the agency would allow hardship exemptions for certain reporting categories for small practices and for clinicians impacted by natural disasters.
Also, for the first time, clinicians in the MIPS program will be permitted to form "virtual groups" -- solo practices and groups of 10 or fewer clinicians who team up (regardless of specialty or geography) for reporting purposes -- to participate.
Rule Highlights
Most physicians participating in QPP will participate in the MIPS program, with a much smaller fraction expected to enroll in approved APMs.
The MIPS pathway includes four components: Cost, Quality Performance, Improvement Activities, and Advanced Care Information (measures pertaining to electronic health record use).
CMS highlighted the following changes to its 2018 proposed rule in a fact-sheet:
- Increasing the "low-volume threshold" to exclude individual clinicians or groups, otherwise eligible to participate in MIPS, with incomes of $90,000 or less in Part B allowed charges or 200 or fewer Medicare Part B beneficiaries
- Allowing a "hardship exemption" for the Advanced Care Information category for small practices
- Allowing clinicians to form virtual groups, if they exceed the low-volume threshold
- Granting 5 extra points to the final score for clinicians treating patients with complex conditions
- Giving small practices a 5-point boost to their final score
- Weighting the Advanced Care Improvement and Quality Improvement categories at 0% for clinicians hit by Hurricanes Irma, Harvey, and Maria
Weights in the MIPS
Categories in the MIPS program, specifically the 2020 payment period, which relies on 2018 data, will be weighted as follows:
- Quality: 50%
- Cost: 10%
- Advanced Care Information: 25%
- Improvement Activities: 15%
CMS will use the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures to calculate the Cost performance category, which was 0% in the program's first year.
"These two measures carried over from the Value Modifier program and are currently being used to provide feedback for the MIPS transition year," a fact sheet noted, adding that the agency could calculate the measure without any action from clinicians.
Stakeholders Respond
Some stakeholders were frustrated by the extended reporting period.
"[The Medical Group Management Association] is very disappointed that CMS quadrupled the length of the quality reporting period under MIPS from the current 90 days to 365 days in 2018. This fourfold increase to the quality reporting requirements is in stark contrast to the Agency's statements today that the final rule reduces regulatory burdens. CMS is in effect prioritizing quantity over quality and giving physicians less than 60 days to prepare for the 2018 MIPS requirements," said Anders Gilberg, Vice President of MGMA Government Affairs.
Laura Wooster, Associate Executive Director of Public Affairs for the American College of Emergency Physicians, told MedPage Today, in an email she was pleased to see the "new automatic extreme and uncontrollable circumstance policy for MIPS Quality, ACI, and improvement activities categories to account for Hurricanes Harvey, Irma, and Maria and other disasters that have occurred during the 2017 performance year."
ACEP was also glad to see the 5-point boost to the final score for clinicians who see complex patients.
"Emergency physicians care for the sickest patients due to often being the care setting of last resort for those with socioeconomic challenges. We therefore welcome any opportunities for this to be acknowledged when assessing the quality of care they provide, since under the MIPS program they are competing directly against other clinicians in Medicare Part B who might have a vastly different patient population on which they are scored," she wrote.
Yet, Wooster was "very disappointed" that the MIPS Cost category jumped from 0% to 10% "to 'ease transition' to the 30% in 2019."
Other specialty groups agreed.
"It is encouraging to see CMS recognize 2018 as another learning year for clinicians. However, the [American College of Cardiology] is disappointed to see CMS incorporate cost into the 2018 performance year MIPS score while so much is still being done to develop reliable measures in this area," said ACC President Mary Norine Walsh, MD, in a press statement.
"We anticipate working further with CMS to ensure that the addition of this category does not negatively impact clinicians or patient care," she added.
AAPMs
With regard to the AAPMS, CMS said it aims to increase participation in the pathway, for example, by ensuring that the required benchmark for total financial risk increases at a slower rate for medical home models. In addition, it gives current participants in the "Round 1 Comprehensive Primary Care Plus" a pass from the "50 clinician limit" on organizations that are allowed to earn bonus payments in medical home models.
The new rule also allows clinicians to qualify for bonuses in APMs by allowing participation in models that "begin or end in the middle of a year."
Also, CMS highlighted a significant change for the 2019 performance year: Allowing an "All Payer Combination Option."
"This option allows clinicians to become [Qualifying APM Participants] through a combination of Medicare participation in Advanced APMs and participation in Other Payer Advanced APMs."
Lastly, the agency provided more guidance regarding how "MIPS APMS" -- APMs that do not qualify as "advanced" and are not eligible for the related bonuses -- will be scored under the APM rubric.