Top Five Issues to Watch in the 2019 QPP Proposed Rule

June 25, 2018

McDermott+Consulting

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.

Quality Payment Program

Beginning in 2019, eligible clinicians (including most physicians) will be paid for Medicare Part B services under the new Quality Payment Program (QPP) (based on 2017 reporting activities), and they will either be subject to payment adjustments based upon performance under the Merit-based Incentive Payment System (MIPS) or participate in the Advanced Alternative Payment Model track (APM).

Eligible clinicians choosing the MIPS pathway will have payments increased, maintained or decreased based on relative performance in four categories: quality, use of information technology, clinical improvement activities and cost. Eligible clinicians choosing the Advanced APM pathway will automatically receive a bonus payment once they meet the qualifications for that track.
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.

CMS Rebrands ACI: Promoting Interoperability

CMS recently announced it is rebranding the Advancing Care Information (ACI) Performance Category of MIPS to the Promoting Interoperability Performance Category. The agency has indicated that this change reflects a new phase of electronic health record (EHR) measurement, transitioning from meaningful use to an increased focus on interoperability and improving patient access to health information.

As part of this effort, CMS is also changing the name of the hospital EHR Incentive Programs to the Promoting Interoperability (PI) Programs for eligible hospitals, critical access hospitals, and Medicaid providers. The name change does not merge or combine the hospital EHR Incentive Programs and MIPS. The programs remain separate.
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.
4. Will MIPS APMs preserve their advantage?

Under the early iterations of QPP rulemaking, MIPS APMs were afforded special status. The general idea was that there was a category of APMs that were not advanced APMs and therefore not eligible for the 5 percent APM bonus. Congress and CMS wanted to find a way to encourage entities to start along the APM path, even if they were not ready to take downside risk. Thus, the category of the MIPS APM was created for non-risk-bearing APMs (perhaps most notably, Track 1 Medicare Shared Savings Program (MSSP) Accountable Care Organizations).

Under prior rulemakings, CMS had given these MIPS APMs an advantage compared to clinicians and groups in Fee-for-Service MIPS. For example, in most cases, the quality measures for the model satisfied the MIPS quality reporting requirement, and these organizations were deemed to have met both the Cost and Improvement Activities Performance Category requirements as well. This framework created a clear advantage and incentive to get into a MIPS APM.

In recent weeks, various administration officials and stakeholders have criticized the MIPS APMs, including the Track 1 MSSP ACO program for their failure to achieve significant savings. This raises the question of how the next QPP rule will treat MIPS APMs, including Track 1 MSSPs, as well as the related question of whether CMS will create additional incentives to move MIPS APM participants into Advanced APMs. Of course, any changes in the QPP rule will need to be taken together with proposed changes in a separate MSSP proposed rule, currently pending review at the Office of Management and Budget.

5. Will year three bring expanded participation in Advanced APMs?

Prior to MACRA’s passage, the CMS Office of the Actuary estimated that by 2019, payments to clinicians in APMs would constitute 60 percent of Medicare physician spending. Actual uptake of APMs has lagged behind those initial estimates. Heading into 2019, there are three opportunities to increase uptake of advanced APMs.

First, the 2019 performance year is the first year that eligible clinicians are permitted to count their other payer advanced APM contracts toward their thresholds for qualifying for the Advanced APM bonus payment. Using this option, eligible clinicians who are already participating in a Part B Advanced APM may add their other payer risk contracts to meet higher revenue and patient count thresholds.

In 2018, CMS opened portals for Medicaid, Medicare Advantage and multi-payer model reporting. Through the existing portals, health plans and states may submit information about their risk contracts. In their submissions, plans and states must demonstrate that each payment arrangement meets the MACRA Advanced APM criteria:

  • Payment is tied to quality measures comparable to MIPS.
  • Certified Electronic Health Records Technology (CEHRT) is used.
  • The arrangement bears more than nominal financial risk.

The information is submitted to CMS, and the agency will make a determination as to which plans qualify as advanced APMs.

CMS has indicated that it intends to make a provider-reported option available in fall 2018. To the extent plans and states have not submitted the necessary information, providers would have an opportunity to report their other payer relationships to CMS for approval as Advanced APMs.

It remains to be seen what the response to this opportunity will be. For the first time, in many cases, CMS will be taking a closer look at how health plans pay providers. How many plans and providers will report this information and whether the other payer category becomes a meaningful option for clinicians in 2019 is not yet known.

The second opportunity to increase uptake of advanced APMs is the Physician Focused Payment Model Technical Advisory Committee (PTAC). The PTAC was created under MACRA as a way for stakeholders to have their ideas for physician payment models vetted by experts and then recommended to the HHS Secretary for testing. To date, PTAC has received numerous proposals and none have been tested. Will the QPP rule breathe new life into the PTAC, perhaps by improving the process for PTAC review?

Finally, stakeholders have been closely watching the signals from the new Center for Medicare & Medicaid Innovation (CMMI) deputy administrator, Adam Boehler. While PTAC is one avenue for the adoption of new models, CMMI remains free to also proliferate models without PTAC input. One indication of where the CMMI might be going was the release of a request for information on direct provider contracting. While separate from the QPP proposed rule, this area of development could have an impact on the uptake of Advanced APMs, depending on how models are designed and when they become available for participation.

Physician Focused Payment Model Technical Advisory Committee

MACRA created the Physician Focused Payment Model Technical Advisory Committee (PTAC) to review new physician focused alternative payment models (APMs). The PTAC is made up of 11 individual members appointed by the Comptroller General of the United States. PTAC members, consisting of physicians and non-physicians, generally serve three-year terms.

PTAC evaluates stakeholder-submitted models against criteria established by the Secretary of Health and Human Services. PTAC began accepting payment models in December 2016. For more on PTAC’s progress in reviewing and recommending models, please refer to our MACRA Resource Center and PTAC Tracker.
Conclusion

Even with the incremental approach to implementation taken by CMS during the first two years of the QPP, many clinicians continue to struggle to learn about the different aspects of the program and how to integrate it into their practices. The third year of MACRA implementation may bring opportunities to streamline and strengthen the QPP to further ease the transition for many clinicians.

On the MIPS side, there may be opportunities to further streamline measurement and reporting requirements. It will be interesting to watch how quickly—or slowly—CMS plans to increase the performance thresholds and cost category weighting. Answers to these questions will give stakeholders valuable insights into the administration’s plans for moving from volume to value.

On the APM side, the QPP rule provides an opportunity for the administration to continue to provide incentives for organizations to move into high levels of risk in traditional Medicare. Stakeholders will be watching to see how CMS and CMMI plan to encourage this transition, potentially with a combination of carrots and sticks.

 

For more information please contact Sheila Madhani or Mara McDermott.

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