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8 Highlights from the 2018 Proposed Rule and the future of MIPS

On June 30th, The Centers for Medicare and Medicaid Services (CMS) published the Quality Payment Program (QPP) Proposed Rule for Year 2 in the Federal Register. The good news is the 2018 Proposed Rule continues CMS’s flexible approach to rolling out the QPP by lowering the barriers for eligible clinicians (EC) to participate and succeed in the program.

Pick-Your-Pace continues

Many of the provisions currently in the 2017 transition year are continuing with modifications into 2018, including the “Pick-Your-Pace” options introduced in 2017. Pick-Your-Pace allows providers, ECs, to submit limited amounts of data and still avoid a penalty. In addition to continuing many of the transition-year rules, CMS has proposed additional rules to allow for greater flexibility and additional opportunities to receive bonus points towards the Merit-based Incentive Program (MIPS) Final Score. However, the proposed rule pushes practices to a higher level of performance to avoid a penalty by changing the MIPS threshold score from three to fifteen points.

Low-volume threshold even more beneficial to low-volume providers

It is clear that CMS spent a great deal of time listening to the problems facing small practices in getting up to speed with the QPP. CMS defines small practices as those with 15 or fewer practitioners. Many of the proposed changes are designed specifically to help these small practices. Perhaps, the biggest proposed change is to the low-volume threshold exclusion. CMS is proposing to expand the current low-volume threshold from less than or equal to $30,000 Medicare Part B annual allowable charges OR fewer than or equal to 100 Medicare part B patients to less than or equal to $90,000 dollars Medicare Part B allowable charges OR fewer than or equal to 200 Medicare Part B patients. This change to the low-volume threshold means many more practitioners may be exempt in 2018 that were eligible to participate in MIPS in 2017.

Virtual groups are now an option

In addition to the individual and group reporting options, CMS is proposing to implement a virtual group reporting option. Virtual groups would allow two or more practices of MIPS-eligible solo-clinicians or groups with 10 or fewer MIPS-eligible clinicians to combine virtually and report as a group. A practice is defined by a unique tax identification number (TIN). Like group reporting under PQRS, TINs wishing to join in virtual groups would need to register as a virtual group with CMS prior to the reporting year and would be required to report all categories as a group.

Bonus points for small practices

Finally, CMS is proposing to award five bonus points to the MIPS Final Score for all small practices or virtual groups (with 15 or fewer total practitioners) reporting data for at least one of the MIPS categories (quality, advancing care information (ACI) or improvement activities (IA).

Cost still not a factor until 2019

As mentioned, much of the QPP is proposed to remain unchanged from 2017, including items scheduled to change per last year’s final rule. The 2017 final rule indicated the cost category would represent 10% of the MIPS final score in 2018. CMS has decided not to implement this change in Year 2, and thus the cost category will continue to represent 0% of a MIPS Final Score. CMS is planning to implement the cost category in Year 3, 2019, at 30%. The quality category will continue to be worth 60% of the MIPS Final Score in 2018, instead of dropping to 50%. Quality is expected to be worth 30% of the composite score in year 3.

CMS still plans to score the cost category based on administrative claims data and provide TINs feedback on their cost and resource utilization via their QRUR reports, but it will not be used in determining the Final Score for 2018 performance.

2014 CEHRT still acceptable for Advancing Care Information

Another change proposed last year that will not go into effect is the requirement that practices participate in ACI using 2015 Certified Electronic Health Record Technology (CEHRT). Recognizing the challenge this posed for practices and the lack of readiness by many of the vendors supporting EHR systems, CMS is proposing to continue allowing practitioners to participate in ACI using either the 2014 or 2015 CEHRT through the 2018 performance period.

Quality Category scoring

The Proposed Rule makes several changes to scoring in 2018, particularly in the quality category. CMS chose not to implement the increase in the data completeness criteria and thus the data completeness criteria in 2018 remains at 50%. CMS still requires that eligible instances represent patients of all payers, not just Medicare Part B. However, the Proposed Rule does decrease the base score for measures not meeting the data completeness criteria from three points down to one point. Again, in an effort to help small practices, this rule would not apply to small practices where the floor for points on a measure would remain at three.

Moving forward with proposals made in last year’s final rule, CMS will cap the points available on a small number of topped-out measures at six points. In addition to the bonus points practitioners can receive for submitting additional outcome or high priority measures or submitting quality measures using CERHT, CMS will award bonus points to the quality category score based on year-over-year improvement in the category. Practices can earn upwards of 10 points for improvement within the quality category based on the level of improvement in the category.

Finally, CMS is proposing to award one to three bonus points to a submission’s Final score based on the complexity of the patients the practice cared for. The proposed rule indicates CMS will use Risk Adjusted Hierarchical Condition Category (HCC) coding data to make this determination.

Commenting is important

There are lots more changes in the 2018 Proposed Rule, especially related to Alternative Payment Models (APMs) — but we have hit the highlights for those submitting under MIPS.

A reminder that this is just the Proposed Rule. In 2016, we saw significant changes between the 2017 Proposed and Final Rule. The changes were prompted by many comments CMS received that the QPP was overly burdensome on small practices. It is clear that CMS is listening.

We encourage everyone to submit comments on the Proposed Rule—or share your concerns with us here in the Blog comments section, and we’d be happy to submit a comment on your behalf.

The full text of the rule and instructions for commenting can be found here: https://www.federalregister.gov/documents/2017/06/30/2017-13010/medicare-program-cy-2018-updates-to-the-quality-payment-program

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