Yesterday afternoon, CMS released the 2018 Final Rule for the MACRA Quality Payment Program. The rule finalized some changes we were expecting, and others that came as a surprise. The second year of the Quality Payment Program will be more advanced than the first, aiming to get clinicians ready for the even more intense requirements mandated by the MACRA legislation to be enacted in 2019.

Back to Basics: What is the QPP?

As was the case in 2017, the MACRA Quality Payment Program (QPP) consists of two tracks that aim at transitioning payment models from fee-for-service to value-based reimbursement. The Advanced APM track (A-APM) aims at allowing clinicians to deliver high-value care in a way that is cost-effective and streamlined to their clinical practice workflow. The Merit-based Incentive Payment System (MIPS) uses "four statutory pillars" that CMS believes are able to be connected to existing clinical workflows: quality measures, meaningful use of EHR technology, clinical quality improvement activities, and appropriate resource use. MIPS is viewed as a means for eligible clinicians and groups to prepare for future A-APM participation.

The QPP aims to improve beneficiary outcomes and engage patients in their care plans, while providing clinicians with the tools they need to not be overly burdened by reporting. The anticipated burden brought by reporting to small practices and practices located in rural areas or Health Professional Shortage Areas is specifically addressed through the allocation of $100 million for practice assistance and education, along with other exemptions and bonuses. Additionally, the wider adoption of CEHRT is incentivized to increase interoperability and access to medical records.

MIPS in 2018 (and Beyond)

The Merit-based Incentive Payment uses Clinical Quality Measures as the primary method of determining quality of care. CMS intends to shift the focus of MIPS measures over time away from process (or "check the box") measures to measures that drive outcomes.

For MIPS participants, quality of care is determined using four performance categories: Quality, Advancing Care Information, Improvement Activities, and Cost. Each category accounts for a percentage of a MIPS eligible clinician or group's final MIPS score. For 2017 reporting, a transition year provision allowed participating clinicians with a MIPS score of 3 or higher in order to avoid a penalty. For the second transition year (2018), a minimum of 15 points will be required to avoid the -5% adjustment. The exceptional performance threshold that allows providers to be eligible for an incentive beyond +5% is still set at 70 points.

MIPS eligibility and options for participation have some significant changes. The types of clinicians that eligible to report has not changed; physicians, physician assistants, nurse practitioners, clinical nurse specialists, a certified registered nurse anesthetists are all considered eligible clinicians for the 2018 performance year. Clinicians new to Medicare, falling below the low-volume threshold or participating an Advanced Alternative Payment Model are also still exempt.

    MIPS Eligible Clinicians                         

The biggest change to eligibility is the raising of the low-volume threshold. Otherwise MIPS eligible clinicians who bill less than or equal to $90,000 in Medicare Part B charges OR see less than or equal to 200 Medicare Part B beneficiaries will be exempt from MIPS participation. CMS estimates that 540,000 clinicians will fall below this threshold. Individual clinicians who fall below the low-volume threshold are not eligible to participate in virtual groups. Additionally, in response to the catastrophic hurricanes in 2017 (Harvey, Irma, and Maria) CMS implemented a provision for automatic hardship exemption for eligible clinicians in affected areas.

Virtual Groups are a new way to participate in MIPS this upcoming year. Solo providers and groups of less than 10 who are eligible MIPS clinicians can participate in Virtual Groups, which allow for these smaller practices to reap potential benefits of MIPS group reporting. Benefits of group reporting include better measure eligibility and a lower threshold for success for the Improvement Activities performance category. Just like with group reporting, the benefits of reporting as a Virtual Group will vary from practice to practice.

Advanced Alternative Payment Models in 2018

There are eight types of Advanced APM models for the 2018 performance year:

1. Next Generation ACO Model
2. Comprehensive Primary Care Plus (CPC+) Model
3. Comprehensive ESRD Care (CEC) Model (Two-Sided Risk Arrangement)
4. Vermont All-Payer ACO Model
5. Comprehensive Care for Joint Replacement Payment Model (CEHRT track)
6. Oncology Care Model (Two-Sided Risk Arrangement)
7. Medicare ACO Track 1+ Model
8. MSSP ACO Track 2 & 3

Clinicians who receive 25% of their Medicare Part B payments through an Advanced APM or see 20% of Medicare patients through an Advanced APM are considered Qualified APM Participants (QPs) and are exempt from the MIPS payment adjustment. They will instead receive the 5% APM incentive payment.

Final Thoughts

In a recent Medpac report, MACRA was described as "a complex system that will not identify or appropriately reward high and low-value clinicians, requires a massive reporting effort, and sends conflicting signals as to which models clinicians should move to." Although the report was savagely critical of MACRA, Medpac identified strategies to improve the MACRA Quality Payment Program over repeal. Some of the changes made reflect reform suggestions Medpac included in their report; including initiatives designed to increase meaningfulness and data comparability like virtual groups, facility-based measurement, and continuing to shift towards outcome-based measures. Other challenges, such as the perceived financial upside to MIPS dissuading providers from joining A-APMs, have yet to be addressed. Overall it seems like MACRA is headed in a more meaningful direction, but has several years to go before meeting its strategic objectives.