Physicians are required to do more in 2018 under Medicare’s Quality Payment Program (QPP) than they were in 2017. But the new payment system, created by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, is still in transition, and many options are available for meeting the minimum requirements and many opportunities exist to score a bonus that will affect 2020 payment levels.
AMA President David O. Barbe, MD, MHA, spoke with ReachMD Vice President and Medical Director Matt Birnholz, MD, and answered questions about what physicians need to know about navigating this year’s iteration of the QPP’s Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).
Are there any general changes to MIPS in 2018?
There were several significant changes.
Practices with 200 or fewer Medicare patients or $90,000 or less of allowed charges are exempt from MIPS. (This is an increase from the 2017 thresholds of 100 patients and $30,000.)
Small practices, with 15 or fewer eligible clinicians, will receive five bonus points right out of the gate. If a practice treats complex patients, they can receive up to an additional five bonus points. (Practices of any size are eligible for the complex-patients bonus.)
In 2017, quality was weighted at 60 percent and the cost component was weighted at 0 percent, so there was not a penalty or bonus for cost. The AMA advocated keeping it that way because we believe the existing cost measures are seriously flawed and new episode-based cost measures are not yet available. The Centers for Medicare & Medicaid Services initially agreed with that approach but then decided to raise the cost category weight to 10% in order to get physicians familiar with cost measures before 2019 when this category was statutorily dialed in to go up to 30 percent of the total program. Congress, at the urging of the AMA and other physician organizations, subsequently extended the timeline, so now CMS is not required to raise the cost weight or meet the 30% requirement until 2021.
What are some EHR-requirement changes?
As a result of AMA advocacy, physicians are able to keep using 2014 certified EHR technology this year and are not required to upgrade to 2015 certified EHR technology. That allows physicians to continue to report measures they may already be familiar with as opposed to being required to report on additional new measures. However, if the practice is ready to move up to the 2015 edition and report on those new measures, there’s an opportunity to get an additional 10 bonus points.
What are the changes to the Improvement Activities category?
Improvement Activities are mostly outcomes focused and are really now more relevant to physicians. They include things like the Diabetes Prevention Programs, consulting appropriate-use criteria for advanced diagnostic imaging or employing digital health tools. We were pleased CMS will continue to allow practices to report through attestation and provide accommodations for small and rural practices.
What were some of the key changes in the Quality Performance category?
There was discussion about where physicians should be required to report eight or 10 quality measures. We convinced CMS to stick with six. The reporting threshold does go up a bit. You have to report now on 60 percent of the eligible patients in a given category. That was 50 percent last year. And you have to report on at least 20 patients—unless you are a small practice. The good thing is there are many quality performance metrics that you can choose from.
Did CMS make any changes for physicians participating in APMs?
MIPS covers the vast majority of physicians now. But, going forward, we believe more physicians will transition into APMs or Advanced APMs.
There are more demonstration projects coming down the line. The Comprehensive Primary Care+ APM is being expanded. We hope more primary care practices will be able to take advantage of it.
How can practices avoid a penalty?
For 2018, physicians must hit 15 points in the total program in order to avoid a penalty. And there are a lot of ways to do that.
This new model allows physicians to participate in the areas that are most relevant to them, so they may do more in the Improvement Activity category and just the least amount possible in the Quality category or vice versa. But, if they report on one improvement activity and one quality measure, they will hit 15 points, particularly if they are in a small practice because you’ve got five bonus points coming in. You’ll have to perform higher than 15 points to get a bonus. But we believe that quite a few practices will get bonuses for their 2018 performance year.
Listen to Dr. Barbe’s interview on ReachMD. More QPP resources are available at the AMA Medicare Payment & Delivery Changes website. These include a MIPS scoring sheet on how to avoid a penalty in 2018 and a MIPS action plan to successfully navigate the payment system. Another useful resource is the AMA’s 2018 MIPS Strategic Scoring Guide, which provides details about available bonuses and other flexible scoring options.