On Halloween, as I was waiting for MACRA's Quality Payment Program (QPP) Year 2 ruling to be finalized, I was pondering tricks and treats. Would practices find a full sized candy bar when the door opened or a toothbrush? As trick-or-treaters often find, the ruling was a little of both. For me, the trick is a ruling that came in at a hefty 1,653 pages: the treat, the 20+ page fact sheet and executive summary.
For practices and healthcare organizations, the treat is that the 2018 reporting year will be another transitional year so there are many accommodations: the trick, CMS held the line in some places to prepare increased participation in future years. In general, there were few surprises. In the instances that CMS deviated from the proposed ruling, they had solicited comments on components that were incorporated in the finalized one.
In its Final Rule Overview, CMS says that they have been leveraging feedback to make sure that:
- The program’s measures and activities are meaningful
- Clinician burden is minimized
- Care coordination is better
- Clinicians have a clear way to participate in Advanced APM’s
1. The low volume threshold for MIPS eligible individual clinicians or groups is raised to greater than or equal to $90,000 in billed charges or greater than or equal to 200 beneficiaries
This was finalized as proposed. While it does not decrease the burden or complexity of the program, it’s estimated that it could eliminate up to 123,000 clinicians from participation.
2. Weight Cost at 10%
While CMS originally proposed weighting cost at 0% for the 2018 reporting year, they did solicit comments on a 10% weighting so this is not a complete surprise. By law, cost must be weighted at 30% for the 2019 reporting year, so 10% is in preparation for that. Cost will be calculated on Medicare Spending Per Beneficiary (MSPB) and total per capita cost measures. CMS will continue to develop episode based measures to be adopted for the 2019 reporting year.
3. Facility Based Measurement for hospital based clinicians deferred to the 2019 reporting year
It was proposed that hospital based clinicians could elect to use their attributed hospital’s Value Based Purchasing (VPB) score to calculate the cost and quality components via a conversion algorithm. CMS wants to proceed, but felt that 2018 was needed to “ensure providers better understand the opportunity and ensure operational readiness to offer Facility Based Measurement”. In other words, it is a great idea but there is not enough time to implement it between the finalized ruling and January 1, 2018. As a result, this will come into effect for the 2019 reporting year.
4. Allow the continued use of 2014 CEHRT technology in 2018 for Advancing Care Information
This was finalized as expected. A 10% bonus is available in this category for practices and healthcare organizations that only use 2015 edition CEHRT in 2018.
5. Virtual Groups
Finalized as proposed. Individual and small practices can band together to create a virtual group for reporting. Participation numbers for 2018 are expected to be very small, so we will see how this program fares in its first year.
With cost weighted at 10%, quality will be changed to 50% to offset it. Advancing Care Information and Improvement Activities remain unchanged at 25% and 15% respectively. The minimum threshold to avoid penalty was set at 15 points as proposed. While the bar has been raised, it was felt to be an easily obtainable goal. QPP Year 2 also introduced a number of opportunities for additional points:
- Small practices are granted a bonus of 5 points
- A Complex Patient bonus of up to 5 points is available based on the average Hierarchical Condition Code (HCC) score and dual eligibility ratios
- Improvement bonuses for the Quality and Cost Categories
7. Performance Period
There were no changes from the proposed rule. Advancing Care Information and Improvement Activities have a minimum 90 day reporting period; cost and quality have a minimum 12 month performance period. What did change is that cost is now weighted at 10%, rather than 0%. There were a multitude of requests that quality be set at 90 days. In the full ruling, CMS outlines that they felt this would give practices and healthcare organizations a larger sample size and denominator for reporting, as well as the fact that many of the measures are geared towards 12 months of reporting.
Trick or Treat?
Just prior to the finalized rule being dropped, CMS announced two initiatives to support their first two goals. The goal of Patients Over Paperwork is to address regulatory burden. Meaningful Measures specifically focus on reexamining Quality Measures, which generates the most work. While both of these initiatives hold great promise for future years, they have little impact on QPP Year 2 requirements. Patients Over Paperwork this year largely generates relief via exclusions by raising the low volume threshold and excluding healthcare organizations impacted by this fall’s natural disasters or by attempting to distribute the burden via Virtual Groups. Also, while CMS admits that the current Quality Measures need an overhaul and that the “burden associated with reporting measures will run the risk of outweighing its intended purpose”, the performance period for that category is set at a full 12 months. Hopefully, when we knock on their doors next year, QPP Year 3 will have a basket full of all of our favorite full sized candy bars.
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