AUGUST 14, 2019

Welcome to the MACRA MIPS/APM Update eNewsletter
Editor: Philip L. Ronning
This issue is sponsored by the National ACO Summit, the National Bundled Payment Summit,
the National Medical Home Summit, and the National MACRA MIPS/APM Summit

A MIPS Rewrite is Certain: CMS Proposed Rule for the 2020 Quality Payment Program
The CMS Proposed Rule for the 2020 Physician Fee Schedule and changes to the Quality Payment Program picks up where the "Pathways to Success" ACO rule left off. This time, the "Pathways" shake-up is aimed squarely at MIPS, in the form of "MIPS Value Pathways." We've described the growing frustration with MIPS, specifically MedPAC's report to Congress on its concerns that MIPS is overly burdensome and complex, and doesn't translate into better care. That theme repeatedly shines through the 1,704 page proposal. CMS is using this rule as an initial salvo indicating that MIPS as we know it is headed for reform, to be replaced by MIPS Value Pathways (MVPs). The four pillars of MIPS (Quality, Cost, Promoting Interoperability, and Improvement Activities) will continue to be measured, but requirements and methodologies will be new (and, in fact, are up for debate). The aim is to reduce clinician burnout by aligning the four components and reducing reporting burden. CMS states that they will facilitate this transition by providing additional administrative claims data and enhanced performance feedback. What's left unsaid is how practices will need to continually measure and monitor performance, ensuring that their 2021 Feedback Reports promise incentives in 2023, rather than penalties. (Roji Health Intelligence, July 31, 2019)

97% of MIPS Clinicians Earned a Bonus For 2020--But Don't Expect a Big Payout
The number of clinicians who participated in MACRA's Advanced Alternative Payment Model (Advanced APM) track increased from 2017 to 2018, while the number of clinicians who participated in MACRA's Merit-based Incentive Payment System (MIPS) decreased, according to preliminary data CMS released recently. Under MACRA's Quality Payment Program (QPP), which took effect in 2017, eligible clinicians can choose from two payment tracks:

  • The Advanced APM track, for clinicians who take on a significant portfolio of Advanced APMs, which include risk-based accountable care organization (ACO) models; or
  • MIPS, for providers who are reimbursed largely through fee-for-service.

Clinicians' pay in the MIPS track largely follows a traditional fee-for-service structure, but CMS adjusts eligible clinicians' pay based on how they "score" in four categories of metrics:

  • Cost;
  • Improvement activities;
  • Promoting interoperability, formerly called Advancing care information (ACI); and
  • Quality.

CMS deemed 2017 a "transition year" and required eligible clinicians to submit only 90 days' worth of data. Participating clinicians had the option of submitting data on one quality measure or improvement activity, or four or five advancing care information measures, to meet MIPS requirements. As long as providers scored at least 3 points across those categories, they avoided penalties of up to 4% applied to payments in 2019. Those who scored a 3 or higher received what CMS called a modest payment adjustment of up to 1.88% for the 2019 payment year

But for the 2020 payment year, which is based on 2018 data, CMS raised the threshold for positive payment adjustments. In 2018, eligible clinicians needed to report on a full year's worth of quality data, and CMS increased the performance threshold to 15 points for providers to avoid the 5% penalty, applied to payments in 2020. The potential penalty will rise incrementally until it reaches 9% in payment year 2022. (Advisory Board, July 17, 2019)

MIPS Final Feedback Reports Are Here
Last week, CMS released the MIPS final feedback reports for the 2018 performance year. Feedback includes your MIPS final score and detailed information on each category for which you submitted data. We encourage you log in to the QPP Portal and view your performance feedback as soon as possible to ensure it is accurate. Answers to frequently asked questions about final feedback can be found in the 2018 Performance Feedback FAQs document. For help setting up a HARP account to access the QPP Portal, please refer to the QPP Access User Guide. (Telligen, July 2019)

CMS Adds Some 2017 QPP Performance Data to Physician Compare
The Centers for Medicare & Medicaid Services last week added to the Physician Compare website certain 2017 (year one) Quality Payment Program performance data submitted under the Merit-based Incentive Payment System and Alternative Payment Models. Added to profile pages for MIPS-eligible clinicians and groups, the information includes 12 MIPS quality measures reported by groups and displayed as measure-level star ratings; eight Consumer Assessment for Healthcare Provider and Systems for MIPS summary survey measures; six Qualified Clinical Data Registry quality measures reported by groups; and 11 QCDR quality measures reported by individual clinicians. Eligible clinicians may participate in the QPP through MIPS or Advanced APMs. Clinicians participating in MIPS will receive a payment adjustment in 2019 based on their 2017 performance. Clinicians participating in an Advanced APM can qualify for a 5% incentive payment in 2019 based on their 2017 performance and for exclusion from the MIPS reporting requirements and payment adjustment. In 2018, the number of advanced APM qualifying participants nearly doubled to 183,306, CMS Administrator Seema Verma announced in a related blog post. For more on 2018 QPP participation and performance, see the CMS infographic. (American Hospital Association, July 15, 2019)

What Is Changing in MIPS 2020?
CMS released the 2020 Proposed Rule for the Quality Payment Program on Monday July 29, 2019. This proposed rule is a part of the Notice of Proposed Rule making (NPRM) for the CY 2020 Medicare Physician Fee Schedule (PFS) Proposed Rule. For MIPS 2020, CMS follows the MACRA statute requirements for a +/-9% payment adjustment. That means the negative payment adjustment (penalty) for MIPS 2020 is up to -9% on your Part-B payments. The corresponding positive payment adjustment (incentive) is up to +9% on your Part-B payments. CMS released the 2020 Proposed Rule for the Quality Payment Program on Monday July 29, 2019. This proposed rule is a part of the Notice of Proposed Rule making (NPRM) for the CY 2020 Medicare Physician Fee Schedule (PFS) Proposed Rule. This blog post identifies the list of potential significant changes for MIPS 2020. For MIPS 2020, CMS follows the MACRA statute requirements for a +/-9% payment adjustment. That means the negative payment adjustment (penalty) for MIPS 2020 is up to -9% on your Part-B payments. The corresponding positive payment adjustment (incentive) is up to +9% on your Part-B payments.

Note: CMS projects MIPS positive payment adjustments to be less than the full +9%. That's consistent with MIPS 2017, 2018 and 2019. To learn more about why this continues to happen, read Able Health's post on cautions when calculating MIPS payment adjustments. CMS proposes four significant scoring changes in MIPS 2020. The Cost and Quality category weights will change, as well as both performance thresholds. CMS proposes that the Quality category be worth 40% of the composite score in MIPS 2020. That's 5% less than its 45% weighting in MIPS 2019. Additionally, CMS proposes to increase the cost category to 20% in MIPS 2020. That's 5% more than its 15% weighting in MIPS 2019.

CMS proposes to increase the performance threshold to 45 points in MIPS 2020, meaning that eligible clinicians and groups need to get at least 45 points to avoid a penalty. That's 15 points more than the 30-point performance threshold in MIPS 2019. Also, CMS proposes to increase the exceptional performance threshold (aka "additional performance threshold") to 80 points in MIPS 2020. That's 5 points more than the 75-point exceptional performance threshold in MIPS 2019.

CMS proposes increasing the data completeness requirements. The increase would move the requirement to 70% in MIPS 2020. That's 10% more than the 60% requirement in MIPS 2019. CMS further clarifies data completeness requirements by stating, "If quality data is submitted selectively such that the data are unrepresentative of a MIPS eligible clinician or group's performance, any such data would not be true, accurate, or complete." This means that if you are able to submit more than 70% of eligible data, you must do so. (Able Health, July 30, 2019)

Getting the Most Reimbursement from MACRA/MIPS
An estimated 798,000 clinicians will be MIPS eligible in the 2019 performance period. CMS predicts 74% will earn an "exceptional performance" bonus for 2018 with a minimum distribution of 0.25%, while those choosing to not participate will be assigned a maximum penalty of 7%[3]. Fortunately, there are five steps you can take now to help streamline the MACRA/MIPS reporting process and achieve the best possible financial outcome.

  • Engagement and education. A commitment for continued performance improvement by all members of the practice is key as well as continued education. Knowing the major requirements under the program will help clinicians align their quality goals.
  • Use CMS's previous feedback to drive future quality-performance efforts. For example, check your Medicare reports from 2016, 2017, and preliminary 2018 reports, plus your 2016 QRUR reports and your 2017 cost analysis. This feedback can be invaluable for identifying organizational gaps and opportunities to help improve performance levels for 2021. Additionally, check your participation status on the CMS QPP site.
  • While it might be tempting, don't rely on the same set of measures year after year. Eventually, those measures will reach a topped-out list. Consider using new measurements that might be better matched to your specialty. MIPS offers more than 270 quality measures from which to choose. Another option is to work with a qualified clinical data registry (QCDR), which can provide additional measurements based on your practice's unique needs. A QCDR also offers a variety of additional pertinent details you may want to capture and report. Find what works best for you.
  • Leverage your revenue cycle management vendor to help ensure you have the analytics necessary to enable baseline measurements and continuous performance improvements. This is essential to your practice's success and to the effectiveness of your MACRA/MIPS efforts. Analytics are necessary to understand where you stand in comparison to previous quality measurements, as well as to those of other similar entities.
  • Finally--and this cannot be over-emphasized--make sure you submit your data. Neglecting to do so will result in a zero score from CMS, along with the maximum negative adjustment of -5% in 2020 and -7% in 2021.

(Tech Peek, July 29, 2019)

2020 Quality Payment Program Proposed Rule Overview Factsheet with Request for Information for 2021

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Getting to Affordability

Ezekiel J. Emanuel, MD
Vice Provost for Global Initiatives, Diane V.S. Levy and Robert M. Levy University Professor and Chair, Department of Medical Ethics and Health Policy, University of Pennsylvania; Senior Fellow, Center for American Progress; Former Special Advisor, Health Policy to the Director, Office of Management and Budget, National Economic Council, Philadelphia, PA