AAFP Leads Effort to Halt Proposed QPP Changes

Move to Increase Low-volume Threshold for MIPS Draws Ire

August 25, 2017 05:08 pm News Staff

The AAFP recently collaborated with two other physician organizations in an effort to block changes CMS has proposed to the 2018 Quality Payment Program (QPP) that could hurt some practices.

[Change the Rules spray-painted on brick wall]

Specifically, in an Aug. 21 letter(2 page PDF) to CMS Administrator Seema Verma, M.P.H., the AAFP, the American College of Physicians (ACP) and the American Osteopathic Association (AOA) urge the agency to think through the changes to participation requirements it outlined in the proposed rule published in the June 30 Federal Register(www.gpo.gov).

CMS proposes increasing the low-volume threshold to participate in the Merit-based Incentive Payment System (MIPS) to $90,000 or less in Medicare Part B allowed charges, or 200 or fewer Part B beneficiaries. The current threshold is $30,000 or less in allowed charges, or 100 or fewer beneficiaries.

The agency says the proposed increase in the threshold is intended to recognize the unique challenges faced by small and rural practices, which "would be negatively impacted and at a disadvantage if assessment and scoring methodology did not adjust for social risk factors."

The letter notes that CMS expects that the proposal would exclude an additional 134,000 clinicians from participating in MIPS during the 2018 performance period; that's on top of the estimated 700,000 clinicians excluded from MIPS participation for the current performance period. Overall, the agency estimates that "37 percent of individual MIPS-eligible clinicians and groups would be in MIPS based on the low-volume threshold exclusion (and the other exclusions)."

The AAFP, the ACP and the AOA acknowledge that some practices would "greatly appreciate" not having to comply with MIPS requirements or face potential Medicare payment cuts. But on the flip side, a good many physicians already are participating in the MIPS 2017 performance period based on the current low-volume threshold.

And therein lies the problem.

"By significantly raising the low-volume threshold and prohibiting those below the threshold from opting into and having their payments adjusted under MIPS, CMS is preventing practices that are above the threshold in 2017 -- but below the proposed threshold in 2018 -- from continuing to participate in MIPS and potentially receiving positive MIPS payment adjustments in future years," the letter points out.

Therefore, the organizations contend, this proposal "stalls these exempted practices" and hinders them from making progress on the road to value-based payment, an outcome that is "contrary to the congressional intent of MACRA (the Medicare Access and CHIP Reauthorization Act)."

The proposed change also would "thwart impacted practices from participating in virtual groups," says the letter.

Congress deliberately established in MACRA "a plausible mechanism for solo and small group practices to participate and compete in the MIPS pathway" -- that mechanism being the ability to establish virtual groups.

With a combined voice, the organizations urge a remedy from CMS.

"Though the 2018 QPP proposed rule eventually recognizes the need for practices to be able to opt into the MIPS program in the 2019 performance year, we respectfully demand that the agency offer a MIPS opt-in pathway for practices that are otherwise excluded from MIPS based on the low-volume threshold exclusions in the 2018 performance period," says the letter.

The letter asks that practices of any size be allowed to participate fully in MIPS independently or via virtual groups.

"Excluding these practices in the 2018 performance period, then potentially subjecting them to future years, where the MIPS cost component could be included, would put low-volume threshold practices at a significant disadvantage compared to practices that have experience with the 2017 and 2018 MIPS performance periods," says the letter.

Raising the low-volume threshold for the 2018 performance period -- and needlessly ejecting current participants -- runs counter to the concept of "increasing physician participation, understanding and comfort with the MIPS payment pathway," the groups state.

This proposal will only create "further uncertainty and instability with the program," argue the organizations, and may cause some physicians to assume more low-volume threshold changes will come in future years.

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