As Medicare moves to the second year of its Quality Payment Program (QPP), 2018 will largely serve as another transition period. Most physicians and other health professionals who bill Medicare won’t have to participate in 2018 and hardly any are projected to receive a penalty that will affect their payment in 2020.

In the 2018 QPP final rule, the Centers for Medicare & Medicaid Services (CMS) tripled the low-volume  threshold for participation to the point where the agency  estimates that only 37 percent of clinicians who bill Medicare will be required to participate in the QPP’s Medicare Merit-based Incentive Payment System (MIPS). CMS also released its final rule for the 2018 Medicare Physician Fee Schedule. Look soon for more coverage of the fee schedule final rule’s impact in AMA Wire®. In the meantime, see the AMA's highlights summary.

The increase to the low-volume threshold means that physicians would be required to take part in MIPS if they treat 200 or more Medicare beneficiaries in a year or bill Medicare $90,000 or more in allowed charges. Because of this and other measures CMS is taking, the agency estimates that 90 percent of clinicians in practices of one to 15 and 97 percent of clinicians in all practice sizes will receive either a neutral or positive adjustment in 2020.

The initiation of virtual groups, the low-volume threshold, reduced requirements and bonus points for small practices  are among the regulatory wins that would help small practices (AMA summary). Bonus points for treating complex patients and making 2018 another transition year were other regulatory wins, but CMS warned that requirements will get tougher in 2019 due to requirements in law.

“We believe that these additional flexibilities and reduction in barriers will further enhance the ability of small practices to participate successfully in the Quality Payment Program,” CMS states in the final rule. “We believe the second year of the QPP should build upon the foundation that has been established, which provides a trajectory for clinicians to value-based care. A second year to ramp up the program will continue to help build upon the iterative learning and development of year one in preparation for a robust program in year three.”

Some positive actions taken in the final rule include:

  • Postponing a mandate for upgrading to 2015-edition certified electronic health records (EHRs).
  • Not increasing requirements for the number of quality measures reported. (Physicians will have to report six measures. They would have had to report nine had the old Physician Quality Reporting System had remained in place.)
  • Adding a hardship exemption to the Advancing Care Information (formerly Meaningful Use) category for practices of 15 or fewer physicians.
  • Continuing to allow physicians to report on Improvement Activities through simple attestation.
  • Adding a hardship exemption for physicians affected by hurricanes and wildfires.

The AMA, however, is concerned that CMS is moving forward in 2018 with the cost category. Although CMS had proposed to keep this category at the same zero weight it has in 2017, in the final rule CMS changed course and said that the cost category will account for 10 percent of physicians’ score next year.  The AMA is concerned about both the weighting and the cost measures that CMS will use, which are deeply flawed. 

Key “asks” on the AMA’s regulatory-relief dashboard remain. CMS should:

  • Refrain from counting the cost category in 2018.
  • Simplify MIPS scoring methodology.
  • Ensure the measures and data are sound.
  • Develop reliable risk adjustment.
  • Create APMs for specialists.

CMS is committed to promoting APMs, according to a statement in the final rule.

“APMs represent an important step forward in our efforts to move our health care system from volume-based to value-based care,” CMS states. “Our existing APM policies provide opportunities that support state flexibility, local leadership, regulatory relief, and innovative approaches to improve quality, accessibility and affordability.  AMA will continue to work with CMS to secure more advanced APMs are available for physicians. 

Earlier, CMS had proposed a study to examine the challenges and costs of reporting quality measures. In the final rule, the agency said it will go forward with this study to learn “the root causes of clinicians’ performance-measure data-collection and data-submission burdens and challenges that hinders accurate and timely quality-measurement activities.” 

“We believe that understanding clinicians’ challenges and skepticisms, and especially, understanding the factors that undermine the optimal functioning and effectiveness of quality measures are requisites of developing measures that are not only measuring what it purports but also that are user friendly and understandable for frontline clinicians—our main stakeholders in measure development,” CMS states in the final rule. “This will lead to the creation of practice-derived, tested measures that reduces burden and create a culture of continuous improvement in measure development.”

The QPP and its two pathways, MIPS and APMs, were created by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which repealed the flawed Sustainable Growth Rate Medicare payment formula. And it was designed to help end the fragmentation that can accompany fee-for-service payment and move Medicare toward adjusting physician payments based on quality and coordination of care.

Physicians can still avoid a 4 percent payment penalty for the 2017 QPP reporting year by reporting one quality measure for one patient. The AMA will soon release additional resources to help supports physicians with the 2018 reporting year.

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