Top Five Issues to Watch in the 2019 QPP Proposed Rule

1. Will CMS change the low-volume threshold in 2019?
2. How will the agency simplify and streamline the Quality Performance Category in 2019?
3. How will CMS implement the MACRA-related provisions in the 2018 BBA?
4. Will MIPS APMs preserve their advantage?
5. Will year three bring expanded participation in Advanced APMs?

1. Will CMS change the low-volume threshold in 2019?
2. How will the agency simplify and streamline the Quality Performance Category in 2019?
3. How will CMS implement the MACRA-related provisions in the 2018 BBA?
4. Will MIPS APMs preserve their advantage?
5. Will year three bring expanded participation in Advanced APMs?

The Centers for Medicare and Medicaid Services (CMS) is scheduled to release the 2019 Quality Payment Program (QPP) proposed rule shortly. The rule will lay out proposals for the third year of implementation of the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs) tracks. The QPP was established by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

While the QPP was released independently in previous years, it is anticipated that the 2019 QPP proposed rule will be combined with the 2019 Medicare Physician Fee Schedule proposed rule, which generally is released on or around July 1.

Many of the changes CMS made in the 2018 QPP final rule were aimed at reducing burdens and enhancing flexibilities for clinicians. On that theme, CMS implemented the Patients Over Paperwork Initiative, a cross-cutting, collaborative process that evaluates and streamlines regulations with a goal to reduce unnecessary burdens, increase efficiencies and improve the beneficiary experience. CMS also launched the Meaningful Measures Initiative to identify high-priority areas for quality measurement and reduce the quality reporting burden. We anticipate that CMS will continue to articulate goals and priorities around these themes in the 2019 proposed rule.

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1. Will CMS change the low-volume threshold in 2019?

The MIPS low-volume threshold exemption is a MACRA provision that exempts certain health care providers from participating in MIPS based on their Medicare billing volume.

CMS increased the low-volume threshold exception from ≤ $30,000 in Part B allowed charges/OR ≤ 100 Part B beneficiaries in 2017 to ≤ $90,000 in Part B allowed charges/OR ≤ 200 Part B beneficiaries for 2018.

After the implementation of the QPP in 2017, there was significant anxiety regarding the complexity of the program. CMS received feedback from the provider community that MIPS was overwhelming and unduly burdensome for solo and small practitioners. In the 2018 QPP final rule, CMS acknowledged that small practices and practices in designated rural areas face unique challenges to successful participation in MIPS, and that increasing the low-volume participation threshold would reduce the burden on these practices. It is unclear if CMS will maintain the same low-volume threshold in 2019.

A related policy that could also be addressed in the 2019 QPP proposed rule is a MIPS opt-in option for low-volume threshold clinicians. This policy was considered but not implemented in 2018, and CMS indicated that it would revisit the policy in future rulemaking. In the 2018 QPP final rule, CMS was particularly concerned with how this policy would affect the overall MIPS makeup if only high performers were to opt-in.

2. How will the agency simplify and streamline the Quality Performance Category in 2019?

As noted, CMS launched the Meaningful Measures Initiative to identify high-priority areas for quality measurement and improvement. CMS is conducting a thorough review of measures across the various Medicare and Medicaid quality programs and removing those that do not meet designated criteria.

How will the Meaningful Measures Initiative affect MIPS? For 2018, clinicians can meet their MIPS Quality Performance Category requirement by selecting from approximately 275 MIPS quality measures that can be reported via registry, electronic health records or on their claims. Clinicians can also report Quality Clinical Data Registry (QCDR) measures that are submitted through a QCDR. While CMS proposed to remove a number of measures from the inpatient quality programs for 2019, it may be more challenging for CMS to reduce measures for a physician quality program, because CMS must ensure the inclusion of an adequate number of measures that accurately reflect the work of specialists.

A proposal to implement a facility-based scoring option for the Quality and Cost Performance Categories of MIPS is also anticipated to be included in the 2019 QPP proposed rule. Under a facility-based scoring mechanism, clinicians who practice in the inpatient environment could use their facility’s score from the Hospital Value Based Purchasing Program as a proxy for their MIPS Quality and Cost scores. There are high expectations that such a policy could significantly reduce the reporting burden for certain clinicians and provide more meaningful data to CMS.

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3. How will CMS implement the MACRA-related provisions in the 2018 BBA?

On February 9, 2018, after a brief shutdown, Congress passed, and President Trump signed, the Bipartisan Budget Act (BBA) of 2018. The law includes several provisions that will affect the 2019 QPP proposed rule.

MACRA established a fee schedule update of 0.5 percent beginning July 1, 2015, and continuing each year through 2019. Section 53106 of the BBA reduces the 2019 update from 0.50 percent to 0.25 percent.

While CMS took an incremental approach to implementation in the first two years of the QPP, by statute various elements were required to be implemented in year three (2019), but the BBA pushed back some of these timelines. As a result, CMS may continue a phased-in approach to implementation in 2019. There are two provisions in particular that allow CMS, if it chooses, to continue incremental implementation of the program.

  • MACRA originally required CMS to fully implement the Cost Performance Category to a weight of 30 percent of the total MIPS score by the third year of the program (2019). In 2018, the Cost Performance Category was weighted at 10 percent. Many stakeholders expressed concerns that the jump from 10 percent to 30 percent represented a cliff in MACRA implementation. The BBA extends the timeline so that CMS has until the fifth year of the program to bring the Cost Performance Category weight to 30 percent.
  • In the first two years of the MIPS program, CMS set the threshold that determines if a clinician will receive a neutral, positive or negative payment adjustment relatively low, resulting in a gradual transition to MIPS for clinicians. MACRA requires that in the third year of the program, CMS set this threshold at the historical mean or median of MIPS scores nationally. The new law continues this policy by allowing CMS to continue to gradually increase the performance threshold from the third through the fifth years of MIPS.