The Medicare Quality Payment Program: Year Two Updates
MACRA called for CMS to implement the creation of a new federal value-based payment system. In response, CMS established the Quality Payment Program (QPP), replacing and consolidating a number of previously existing smaller Medicare payment programs. 2017 represented Year One of the QPP, with physicians’ performance in that year impacting their 2019 payments. The 2017 QPP regulations were designed to allow participants to “pick your pace,” with greatly reduced regulatory burden compared with the anticipated full implementation of the program. As of this writing in February 2018, we are now early in Year Two of the QPP. In Year Two, CMS has advanced a number of the program’s requirements while at the same time adding certain new flexibilities and options. This article highlights a number of these key updates to the QPP for 2018.
In 2018, CMS has lowered the thresholds for physicians to be deemed exempt from the QPP altogether. Now, physicians are exempt if having ≤$90,000 in Medicare Part B allowed charges or ≤ 200 unique Medicare Part B beneficiaries within the year (previously ≤$100,000 and ≤100 beneficiaries, respectively). Physicians participating in the Merit-Based Incentive Payment System (MIPS) of the QPP will continue to receive a final score on a 0-100 scale across a number of weighted categories. In 2018, the threshold score required to avoid a payment penalty is 15 points, increased from a threshold of only three points in 2017. In addition, the payment adjustment (applied on a 2-year offset from the performance year) increases to ±5%, compared to ±4% in Year One (with a scaling factor applied to bonuses to maintain budget neutrality). Further, in 2018, CMS newly introduced bonus points to the final score for physicians in small practices as well as for physicians treating more complex patients. Patient complexity is determined using CMS’ Hierarchical Condition Category (HCC) methodology and will likely be relatively high for IRs.
The Quality Performance category continues to represent the dominant percentage of participants’ final score. In 2018, performance data for individual quality measures must now be submitted for the full calendar year; the option to submit quality data for only a 90-day window has been removed. In addition, the data completeness threshold, defining the percentage of eligible patients for whom data must be submitted for an individual measure, has been increased from 50 percent to 60 percent. Moreover, CMS has placed a limit on the number of points that may be obtained for “topped out” measures (measures meeting criteria for extremely high performance across providers nationally), and introduced a formal process for removing such measures from the program.
Numerous new measures have been added in the Improvement Activities (IA) category in 2018. One of these new measures is ordering physicians using Appropriate Use Criteria through a qualified clinical decision support mechanism.
In 2018, the cost category now represents 10 percent of the final score, increased from 0 percent in 2017. This category relates to resource utilization and spending for Medicare patients attributed to QPP participants. While physicians will be effectively exempt from being scored in this category if not meeting the minimum thresholds for the individual cost measures, radiology groups will potentially meet minimum thresholds in the category’s Medicare Spending per Beneficiary (MSPB) measure. This measure relates to Medicare spending from three days before admission to 30 days after admission for the physician billing for the plurality of a patient’s Part B services during the admission. Physicians and groups must be attributed 35 or more patients to meet the threshold to be scored on the MSPB measure. In addition, CMS is in the process of developing episode-based measures to include in this category in future years.
CMS also introduced the virtual group option for MIPS participation in 2018. By this option, any number of individual physicians and small groups of up to 10 members may voluntarily elect to participate in MIPS all as a single virtual group. The virtual group participants can be of different specialties as well as practice in geographically distinct regions across the country. All members of the group receive a single collective final score in MIPS and hence, a uniform subsequent payment adjustment. Election to form a virtual group must occur prior to the start of the performance year. The virtual group option provides participants the opportunity to share resources and responsibilities across the MIPS performance measures and categories to potentially attain a higher final score.
Physicians deemed non-patient-facing receive somewhat relaxed reporting requirements in MIPS, including being exempt from the Advancing Care Information category and needing to report fewer activities in the IA category. In January 2018, CMS revised its list of services deemed to represent patient-facing encounters. Of note, in response to feedback from the ACR, paracentesis, thoracentesis, joint injections, lumbar puncture, and myelography are no longer considered to be patient-facing encounters. With this update, it is now anticipated that the overwhelming majority of diagnostic radiologists will receive the non-patient-facing special status in MIPS along with its associated reporting advantages.
Finally, CMS has introduced hardship exemptions for physicians in regions impacted in 2017 by Hurricanes Harvey, Irma, Maria, and Nate as well as by the California wildfires. Such physicians do not need to submit data to MIPS and will be exempt from receiving any payment penalties. CMS will automatically apply this exemption to physicians in the designated regions, without the need for physicians to apply for the hardship exemption. Nonetheless, physicians in these regions may choose to submit data in two or more categories, in which case they will then be scored and receive subsequent payment adjustments based on the categories for which data is submitted.
Andrew Rosenkrantz, MD, (@rosenkrantzmd) is a radiologist in the abdominal imaging section at NYU Langone Medical Center and an affiliate research fellow of the Harvey L. Neiman Health Policy Institute®. He is chair of the 2017–2018 ACR-YPS Executive Committee.