Medicare & Medicaid

2018 Quality Payment Program: 3 things to like, 3 that need fixes

Andis Robeznieks , Senior News Writer

Three key elements physicians are seeking with the Centers for Medicare and Medicaid Services’ (CMS) Medicare Quality Payment Program (QPP) are simplicity, flexibility and stability. And, within the proposed rule for the second year of the program, there are at least three elements physicians should feel positive about and three where the AMA has serious concerns.

The AMA responded to the proposed rule in a letter to CMS Administrator Seema Verma. In the letter, AMA CEO and Executive Vice President James L. Madara, MD, outlined the steps the AMA believes are necessary to ensure a smooth transition to the new value-based payment system. These include giving physicians time to adopt new practices and to make necessary investments.

The QPP was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Physicians’ QPP participation in 2018 will affect their Medicare payment levels in 2020, and the CMS proposal contained some provisions that the AMA viewed quite positively.

More accommodations for small practices. CMS rules for the first QPP year helped physicians in small practices by making that first year a transition year with a great deal of flexibility in how physicians chose to participate, and exempting from the QPP’s Merit-Based Incentive Payment System (MIPS) all clinicians with fewer than $30,000 in Medicare payments or less than 100 Medicare patients. 

The recent proposal expands the low-volume threshold to clinicians with fewer than $90,000 in Medicare payments or less than 200 Medicare patients, exempting from MIPS one-third of clinicians who treat Medicare patients. Now, of clinicians who are not exempt due to the low-volume threshold, CMS estimates that 81 percent of those in practices of one to 15 clinicians will receive either a neutral or positive adjustment in 2020, based on their 2018 MIPS performance.

Replacement of burdensome legacy programs. Although concerns persist, the QPP is considered an improvement over the legacy programs it replaces. These include the Physician Quality Reporting System (PQRS), Meaningful Use requirements for electronic health records (EHRs) and the physician value-based payment modifier (VBM).

Meaningful-use requirements have been replaced with “advancing care information” measures that, according to the proposed rule, focus on the secure exchange of health information and the use of certified EHR technology (CEHRT) to support patient engagement and clinical data reporting.

More flexibility on EHRs. In the letter, Dr. Madara noted the AMA’s support for dropping an existing requirement for next year that said physicians must start using EHRs that had been certified under 2015 functionality criteria. CMS is proposing to not penalize physicians who use 2014-edition certified EHRs, and to provide extra credit to those physicians who use 2015-edition EHRs for all of 2018.

Related Coverage

AMA to CMS: Work to simplify Quality Payment Program regulations

More work needed to develop Alternative Payment Models (APMs). For MIPS APMs, the AMA suggests having MIPS APMs report only six quality measures—as is required of clinicians under general MIPS scoring. The AMA also does not support a proposal to blend quality measures for MIPS APMs and those who are not APM-MIPS participants, as this would skew quality-measure benchmark calculations.

For Advanced APMs, the AMA said there is “significant and unnecessary uncertainty” over the “more-than-nominal” financial-risk standard. For 2019 and 2020, one of the three financial-risk standard options equals 8 percent of an APM entity’s Medicare Part A and Part B revenues. In the AMA letter, Dr. Madara expressed concern about the potential for this standard to be increased above 8 percent after 2020. He wrote that “there is no good reason” the 8 percent standard should not apply to 2021 and beyond.

“We remain concerned that if CMS does not provide long-term stability in the financial-risk standard, it may discourage physicians from working to design and participate in Advanced APMs or place them in financial jeopardy after an initial period of success,” Dr. Madara wrote.

Flexibility needed on APM financial-risk standards. CMS seeks comments on whether there should be lower financial-risk standards for small and rural APMs. The AMA favors this policy, but disagrees with a related CMS proposal that would prohibit small or rural medical home APMs from being assigned a risk standard lower than the 5 percent standard being proposed for other medical home APMs.

“Requiring a physician practice with fewer than 10 physicians in a sparsely populated rural area to repay 5 percent of its revenue to Medicare will likely be a much bigger deterrent to APM participation than for an urban practice with 40 physicians, so lower risk standards are appropriate for smaller practices participating in medical home models,” Dr. Madara wrote.

Confusion on what constitutes a “small practice.” The AMA urges CMS to consider groups with 15 or fewer “MIPS-eligible” professionals as a “small practice,” and so not count other health professionals (physical therapists, for example) who may be part of the practice but are not eligible to participate in MIPS

“Given the significant confusion around the definition of small practices, the AMA also believes that CMS should continue to make the small practice eligibility determination using claims data,” Dr. Madara wrote. “While an attestation option may be easier for physicians, we are concerned that physicians may incorrectly attest that they are a small practice and find out later that they received a penalty based on an incorrect assumption.”

The AMA has launched an education campaign, “One patient, one measure, no penalty,” to help physicians meet the minimal QPP requirement for 2017. The campaign includes a video and a step-by-step guide. To learn more about QPP 2017 options, listen to this recent ReachMD interview with Kate Goodrich, MD, CMS’ chief medical officer and director of its Center for Clinical Standards and Quality.

A new customizable resource, the MIPS Action Plan, helps physicians choose and implement a QPP strategy, fulfill regulatory requirements, avoid federal penalties and have an opportunity for performance-based incentive payments.

Physicians can also learn about “How an EHR can help you participate in MACRA” in this ReachMD podcast.