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Quality Payment Program (QPP) Final Rule Released November 2

According to the Centers for Medicare & Medicaid Services (CMS), flexibility is the purported theme of the QPP Final Rule, which was issued under its official title, the Medicare Program; CY 2018 Updates to the Quality Payment Program; and Quality Payment Program:  Extreme and Uncontrollable Circumstance Policy for the Transition Year, last night, yet a few surprises are featured. Perhaps the most important result of last night’s announcement is the fact that many physicians won’t need to even worry about the program. The bar for participation was raised to $90,000 in Medicare Part B total allowed charges – or 200 Medicare patient encounters, removing an additional 123,000 clinicians from the program, estimates CMS. If you fall below those thresholds, you need not be concerned with the QPP program in 2018 – and beyond.

For those who remain, the basics of the two-track program persist: either join an advanced alternative payment model (aAPM) or be an active participant in the Merit-based Incentive Payment System (MIPS).

MIPS retains its four core components: quality, advancing care information (ACI), improvement activities and cost. Despite the fact that CMS had proposed dropping the score related to “cost” for another year, it is back on the table with a 10% weight. Cost is being calculated based on the Medicare Spending per Beneficiary (MSPB) and total per capita cost measure, and the announcement also confirmed CMS’ commitment to a 30% weighting of the cost component for 2019 and beyond. In 2018, the relative contributions of the scores are: 50% Quality; 25% ACI; and 15% improvement activities, with cost rounding out the score at 10%.

Practices can continue to use their 2014-certified electronic health record (EHR) systems although there are bonus points for reporting exclusively on the 2015 edition. 15 points are required to avoid the penalty in 2018, up from three points needed during the 2017 transition year. Other highlights of last night’s ruling:

  • Practices can use only one mechanism for reporting the quality measures in 2018, a surprising departure from the proposed rule. Indeed, CMS acknowledges the need for this flexibility, but won’t implement it until 2019.
  • The reporting period for the quality and cost measures is 12 months in 2018, but the ACI and IA categories remain at 90 days. Several quality measures have “topped out,” and, thus, won’t score at the highest level even with perfect performance. This underscores the need to review the quality measures carefully each year to ensure success.
  • Small practices – those with 15 or fewer clinicians – get an automatic bonus 5 points. Neither do they have to worry about data completeness for the quality measures, as they receive an automatic 3 points per measure. Perhaps the biggest surprise comes in the fact that a small practice size exempts one from the ACI category, with an end-of-year due date for the application for this exception.
  • Five bonus points are available for the “treatment of complex patients,” a judgement driven by CMS using the dual eligibility ratio and average HCC risk score.
  • Ambulatory surgical center (ASC)-based physicians are exempt from ACI, and this exception is retroactive to the current (2017) reporting year. Physicians practicing in off-campus-outpatient hospital (place of service 19) sites are also exempt, as they are now incorporated in the “hospital-based physician” definition.
  • Another important retroactive exemption falls in the ACI category: physicians who write less than 100 permissible prescriptions are relieved of the e-Prescribing category and those who transfer a patient to another setting or refer a patient fewer than 100 times during the performance period are exempt from the health information exchange/summary of care measures. These exemptions apply to 2017, as well as future years.
  • 21 new improvement activities (some with modification) have been added, and CMS made changes to 27 previously adopted improvement activities for 2018.
  • Virtual groups can be formed by joining with other practices, in order to participate in MIPS.
  • If a practice joins an aAPM in the middle – or near the end – of the reporting year, the practice can be officially incorporated in the entity based on an alteration in CMS’ look-back periods, as long as they were able to participate for at least 60 continuous days during the performance period.

CMS professes an exemption for practices impacted by the 2017 severe weather. For the 2018 reporting year, CMS pledges to: “Automatically weight[ing] the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the final score for clinicians impacted by hurricanes Irma, Harvey and Maria and other natural disasters.” Although this appears to be a “get-out-of-jail” card for practices, this means that the remaining program component – the cost category – will define their entire performance for the year.

In 2017, however, those practices in areas hit by a hurricane don’t have to worry about anything. CMS espouses: “we are issuing an interim final rule for automatic extreme and uncontrollable circumstances where clinicians can be exempt from these categories in the transition year without submitting a hardship exception application.” Furthermore, because cost is weighted at 0%, that means that practices suffering from the impact of the hurricanes don’t have to be concerned about the program at all in 2017. States CMS: “clinicians in affected areas that do not submit data will not have a negative adjustment. We know that the circumstances have created a significant hardship that has affected the availability and applicability of measures.” However, if you’ve already made the effort (and want to benefit from the bonus), CMS goes on to advocate: “Clinicians that do submit data will be scored on their submitted data.”

While the Final Rule’s announcement professes flexibility, CMS most certainly leaves us with complexity – another 1,653-page document to digest.

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Woodcock & Associates: Changing the Way You Work