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Tuesday Aug 14, 2018

Proposed Changes to QPP: What You Need to Know

"Get your facts first, then you can distort them as you please."
-- Mark Twain

[notebook labeled regulations and calculator]

In my previous post, I outlined the key Medicare Physician Fee Schedule (MPFS) provisions included in the 2019 Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Medicare Part B(s3.amazonaws.com) proposed rule. The proposed rule also includes several changes to the MACRA Quality Payment Program (QPP) for the 2019 participation period. In this post, I will outline those changes and analyze their impact on family medicine.

In previous years, CMS published separate proposed rules for the fee schedule and QPP. We anticipated that as QPP matured, CMS would incorporate QPP provisions into the MPFS rule rather than continuing to publish a stand-alone rule. Apparently 2019 is the year that transition will happen.

Although the proposed revisions to QPP are impactful, by historical standards, CMS has proposed a modest set of changes to the program for the 2019 performance period that will determine payment rates for 2021.

Performance Thresholds, Payment, Bonuses

Among the proposals,

  • payment adjustments for the 2019 performance period (2021 payment period) increase to +5 percent;
  • the performance threshold for the 2019 performance period increases to 30 points;
  • the exceptional performance threshold increases to 80 points; and
  • bonus points are maintained for small practices, care for complex patients, and end-to-end reporting.

Eligible Clinicians

CMS defines Merit-Based Incentive Payment System (MIPS)-eligible clinicians as physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. For the 2019 performance period, CMS proposes adding clinical psychologists, physical therapists, occupational therapists and clinical social workers to the list of eligible clinicians.

Performance Scoring

CMS continues to tweak the weighting of the MIPS programs' four quadrants of quality, cost, promoting interoperability and improvement activities. In the proposed rule, these are weighted as follows:

[resized itt table]

Promoting Interoperability

CMS proposes to change the name of the advancing care information category of the program to the promoting interoperability category. The agency also proposes that all eligible clinicians must use 2015 edition certified electronic health record technology (CEHRT) during the 2019 performance period. Currently, physicians can use either the 2014 or 2015 edition. CMS would maintain a 90-day reporting period and the all-or-nothing scoring criteria for the category.

The proposal emphasizes e-prescribing and the opioid epidemic with two new measures related to opioid and substance-use disorder. Physicians who demonstrate that they routinely query their state's prescription drug monitoring program will receive five bonus points in the category, as will those who verify that they have an opioid treatment agreement with their Medicare patients who use opioids in their treatment protocol.

Low-volume Threshold

CMS proposes maintaining the low-volume threshold (LVT) that exempts from participation in the MIPS program physicians and group practices that

  • have less than $90,000 in Part B allowed charges for covered professional services,
  • provide care to fewer than 200 Medicare fee-for-service beneficiaries, or
  • provide fewer than 200 covered services to Part B patients.

As mandated by the Bipartisan Budget Act of 2018, LVT determinations will be made on covered professional services only, not on all Part B-allowed charges.

Despite continuing the program, CMS is proposing to allow physicians who qualify for the LVT to opt into the MIPS program. Physicians who qualify for exemption under the LVT but choose to participate will be eligible for payment increases, but are also exposed to potential reductions in payments based on performance. There is one exception: Physicians who meet all three qualifying criteria for exemption are not allowed to opt in.

Advanced Alternative Payment Models

CMS does not clarify how it plans to make available a greater number of Advanced Alternative Payment Models (AAPMs) in the proposed rule. The agency does, however, propose a handful of tweaks to the criteria for current and future AAPMs, including:

  • increasing the CEHRT threshold to require that at least 75 percent of eligible clinicians use CEHRT products;
  • maintaining a nominal risk standard of 8 percent of revenue through 2024;
  • allowing certain Medicare Advantage plans to qualify as an alternative payment model through a demonstration program called the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI), which would waive MIPS reporting requirements for clinicians in Medicare Advantage networks that resemble advanced alternative payment models.

Key Concerns for Family Physicians

There are several points in the proposal that would especially affect family physicians, notably,

  • the mandated transition to 2015 CEHRT,
  • a 365-day quality reporting period,
  • unreliable cost measures for primary care,
  • all-or-nothing scoring in the promoting interoperability category, and
  • a lack of primary care AAPMs.

The AAFP has high-quality resources to position you and your practice for success under the MIPS program. The suite of MACRA resources contains information and resources to help you with the four categories of the MIPS program. I encourage you to start with the MIPS Playbook.  

Wonk Hard

The AAFP has placed a high priority on ensuring that independent physician practices are positioned to be leaders in the health care system. Although the big hospitals and health systems like to suggest that the road to higher quality and more efficient care runs through consolidation, we know this isn't always the case. There are many roads to quality and efficiency, and some of them are two-lane highways, not interstates.

Case in point, on Aug. 2, the Commonwealth Fund published findings(www.commonwealthfund.org) from a recent study on high-cost patients. There are many interesting points in the study, but I would direct your attention to this short, quippy sentence: "Though larger practices are often thought to provide better care, the results of this study do not support this assumption."

And this key finding: "Large practices -- with 100 or more physicians -- spent $1,870 more annually per high-need Medicare beneficiary than practices with one to two physicians."

Earlier this year, the AAFP joined several key partners to launch the Partnership to Empower Physician-Led Care (PEPC).(physiciansforvalue.org) This coalition is focused on positioning independent physician practices at the center of health care policy debates, ensuring that the value of community-based, patient-centered, independent physician practices is not lost in the noise of "BIGGER IS BETTER." You can follow this effort by becoming a PEPC supporter (free for individual physicians). If you are interested in following along at home, email your name with credentials, the name of your practice/clinic, and your city and state to info@physiciansforvalue.org.

Posted at 09:00AM Aug 14, 2018 by Shawn Martin

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Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.