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Wednesday Jul 05, 2017

What You Need to Know About the 2018 QPP Proposed Rule

"Summertime is finally here. That old ballpark, man, is back in gear."
-- Kenny Chesney

A belated happy 241st birthday, America! I hope our members were able to spend the holiday with family and friends doing anything other than thinking about MACRA, ICD-10, health care reform or anything else work related.

Here is a little history to get this post started. July Fourth is the day that the Second Continental Congress approved the Declaration of Independence. Adoption of the Declaration came two days after the Congress approved a Resolution of Independence from Great Britain. It is unclear if all the founding fathers signed the Declaration of Independence on July 4, 1776, but it is well-established that some did, including Thomas Jefferson.

July Fourth has a close connection with the U.S. presidency as well. Three presidents died on July Fourth: John Adams (1826), Thomas Jefferson (1826) and James Monroe (1831). In addition, one president was born on the Fourth of July -- Calvin Coolidge in 1872.

Now, back to health policy.

On June 20, CMS released the 2018 Medicare Quality Payment Program (QPP) Proposed Rule(s3.amazonaws.com). The proposed rule recommends several changes to the QPP Merit-Based Incentive Payment System (MIPS) and advanced alternative payment model (AAPM) payment pathways. The most notable and significant change is CMS would not continue the Pick Your Pace program for the 2018 performance period. However, it takes several steps to shield solo and small practices from negative payments and enhance the evaluation of quality and performance for these practices to include special scoring provisions for practices with 15 or fewer eligible clinicians (EC). Many of the proposed modifications are consistent with recommendations the AAFP has provided CMS, and we are pleased that the agency followed our advice and recommendations.  

There are other areas that still need work, and we will be communicating with CMS on these issues.

I have summarized 10 issues below, but you can read the AAFP's full executive summary of the proposed rule if you want a more deeper understanding of it. I also would encourage you to review the summary provided by CMS(qpp.cms.gov), which did a nice job of comparing the proposed changes for the 2018 performance period to current requirements.

The 2018 QPP proposed rule would:

  • Modify the low-volume threshold (LVT) to exclude a greater number of individual MIPS-eligible clinicians (EC) from participation in the 2018 performance period. For the 2017 performance period, the LVT threshold is less than $30,000 in Part B allowed charges OR less than 100 Part B beneficiaries. The CMS proposal, if implemented, would increase the LVT thresholds to less than $90,000 in Part B allowed charges OR less than 200 Part B beneficiaries for the 2018 performance period. 
  • Add a hardship exemption for small practices (15 or fewer clinicians) for the advancing care information (ACI) performance category.
  • Establish incentives for small practices. Qualifying small practices will receive five bonus points added to their final MIPS composite score if the eligible clinician or group submits data on at least one performance category in the 2018 performance period. CMS will continue providing small practices three points in the quality category for measures submitted that do not meet data completeness requirements.
  • Allow the continued use of 2014 Edition Certified Electronic Health Record Technology (CEHRT) for the 2018 performance period, while encouraging the use of 2015 edition CEHRT by providing bonus points for physicians using such technology during the performance period.
  • Establish virtual groups as an available option for solo and small group practices participation in the MIPS program for the 2018 performance period. CMS did not promulgate regulations for virtual groups during the 2017 performance period to the disappointment of the AAFP. Practices wishing to form and participate as a virtual group will be required to notify CMS of their intentions in advance of the 2018 performance period.
  • Continue the current MIPS performance category weighting (scoring) percentages for the 2018 performance period. The 2018 weighting for the cost category will be 0 percent -- just as it was in 2017, the quality category will be 60 percent, improvement activities will be 15 percent, and the ACI category will account for 25 percent. The reporting period will be a full year for the quality and cost categories and a minimum of 90 days for the ACI and improvement activity categories.
  • Expand participation in AAPMs. CMS continues to expand the number of qualifying alternative payment models available for physicians. For family physicians, there are two primary APMs available -- Comprehensive Primary Care Plus(innovation.cms.gov) (CPC+)  program and the Medicare Shared Savings Program(www.cms.gov) (ACOs). CMS estimates that between 180,000 and 245,000 eligible clinicians will become qualifying APM participants during the 2018 performance period -- a significant increase from the 2017 performance period. CMS estimates that between 70,000 to 120,000 eligible clinicians will earn incentive payments in 2019 due to their successful participation in an AAPM during the 2017 performance period.
  • Modify the definition of certified patient-centered medical homes (PCMH) to include the CPC+ APM model. The proposal also makes clear that the term "recognized" is the same as the term "certified" with respect to PCMH or the comparable specialty practices. Finally, the proposal clarifies the percentage of practices that must be a recognized PCMH for the purposes of securing the maximum points in the MIPS Improvement Activities (IA) category. Under the  proposal, CMS suggests that for the 2018 performance period, 50 percent of the practices within any group must be recognized as a PCMH for the full practice to secure the maximum IA score.
  • Modify the nominal risk standard for medical home models, so the minimum required amount of total risk increases more slowly. To accomplish this, CMS would exempt the round one participants in the CPC+ from the requirement that the medical home standard applies only to APM entities with fewer than 50 clinicians in their parent organization. This prevents CPC+ round one participants from falling back to the MIPS APM track.
  • Expand the types of activities eligible for recognition under the MIPS Improvement Activities to include accredited CME activities. This was a high priority for the AAFP, and we are pleased that CMS has taken affirmative steps to recognize practice improvement CME as an improvement activity in the MIPS program.

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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.