MACRA in the Year Ahead: Changes to the Quality Payment Program (QPP) in 2018

Authors: Leslie Kociemba, M.P.H.; Matthew T. Popovich, Ph.D.

ASA Monitor 01 2018, Vol.82, 52-53.

On November 2, The Centers for Medicare & Medicaid Services (CMS) published its “CY 2018 Updates to the Quality Payment Program Final Rule with Comment” as well as an Interim Final Rule for “Extreme and Uncontrollable Circumstance Policy for the Transition Year”. Updates to the Quality Payment Program (QPP) for 2018 will impact physician anesthesiologist participation in the Merit-based Incentive Payment System (MIPS) components as well as the Advanced Alternative Payment Models (APMs). Although the administration has emphasized burden reduction, changes to the rule may offer short-term relief in lieu of addressing some of the larger concerns ASA and physician anesthesiologists have experienced with the Medicare Access and CHIP Reauthorization Act (MACRA) in 2017.

Of note, CMS recognized the impact that natural disasters have had for eligible clinicians (ECs) in 2017. The Interim Final Rule, as noted above, applies to clinicians practicing in areas where natural disasters occurred, including Hurricanes Harvey, Irma and Maria as well as the devastating fires in Northern California. Clinicians in these areas do not have to submit a hardship application for transition year 2017, but instead will receive a neutral adjustment based on location within affected areas. Anesthesiologists unable to report in performance year 2018 due to a natural disaster will need to submit a hardship application by December 31, 2018, for a neutral payment adjustment in 2020. If clinicians within affected areas choose to submit data, they will be scored based on standard performance thresholds and requirements.

Regardless of natural disasters, practices should continue to monitor and act locally upon the changes that CMS has finalized for MIPS in 2018. Anesthesiologists can expect continued ramping up of requirements in year two of MIPS, the pathway that most eligible anesthesiologists will find themselves assessed within. Several changes have been made across the program, including specific changes to requirements in the four MIPS components of Quality, Cost, Improvement Activities (IA) and Advancing Care Information (ACI).

Practices will find that the “Pick Your Pace” options offered in transition year 2017 are not available this year. Instead, CMS finalized the performance period for the MIPS Quality and Cost components as the full calendar year. For these categories, ECs are responsible for submitting MIPS Quality Component data while CMS will automatically calculate an individual or practice’s MIPS Cost Component. The required performance period for IA and ACI components is for a period of 90 continuous days.

In 2018, the low-volume threshold to report MIPS is set at clinicians who bill $90,000 in Medicare Part B allowed charges and provide care for 200 Medicare patients in a year. This is a significant change since the 2017 low-volume threshold was defined as clinicians billing $30,000 in Medicare Part B allowed charges and providing care for 100 Medicare patients in a year. With this change, ASA expects fewer anesthesiologists will be eligible to report MIPS.

The minimum threshold change could be considered by some practices as a burden reduction while other practices that have invested significant time, energy and money might find the direction of CMS confusing. CMS indicated in the rule that the increase in the QPP low-volume threshold would reduce reporting burdens for many small practices. On the flip side, practices that are not considered eligible for the QPP because of the threshold will miss out on opportunities to receive up to a 5 percent payment adjustment or even more by exceeding the exceptional performance threshold. ASA has expressed to CMS our concern with the dramatic change in eligibility criteria, especially how it sends a confused message to practices that participated in 2017 and in previous quality reporting programs.

For individual ECs and their practices, the payment adjustment factor increases to 5 percent this year from 4 percent in 2017. To receive a neutral payment adjustment in 2020 based upon your performance in 2018 MIPS, ECs and groups must meet the performance threshold of 15 points, a change from three points in transition year 2017. Practices may use any combination of MIPS category performance scores to meet 15 points – for example, attesting to and documenting all improvement activities. Another opportunity may be reporting at least five quality measures with the required minimum amount of data submitted. Either way, earning 15 points is quite feasible, and practices may also strive for reaching the exceptional performance threshold that remains at 70 points.

Beginning in 2018, a range of bonuses are available to certain MIPS ECs and groups. Practices meeting the small practice definition of 15 or fewer ECs will have five bonus points added to their total MIPS score. Five bonus points will also be awarded to ECs treating complex patients based on the Hierarchical Condition Category (HCC) risk score. ECs and groups showing improvement from one year to the next can receive bonuses in their overall Quality and Cost component scores, up to 10 percentage points and one percentage point, respectively.

In 2018, the Quality component accounts for 50 percent of an EC or group’s total MIPS score, compared to 60 percent last year. Anesthesiologists and other clinicians are still required to report six measures, including one outcome or another high-priority measure. The data completeness requirement was increased to 60 percent, meaning that ECs and groups must report 60 percent of all denominator-eligible cases for each measure during the reporting year. Additionally, ASA successfully advocated for the inclusion of MIPS #463: Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics) in MIPS and the Anesthesiology Specialty Measure Set.

The MIPS Cost component will account for 10 percent of the total MIPS score in 2018. ECs and groups will be evaluated on two measures: Medicare Spending Per Beneficiary (MSPB) and Total Per Capita Cost, when attribution is possible. Anesthesiologists have traditionally been excluded from these measures because of problems related to how the measure is attributed to the individual clinician or practice. No reporting is required by the EC or group for this component. Instead, CMS will calculate the Cost component score automatically. When CMS is unable to calculate a Cost component score because of the inability for the clinician or practice to meet data minimums, this component will be reweighted to the MIPS Quality component.

The MIPS IA component remains at 15 percent of an EC or group’s total MIPS score. The same attestation and activity weighting applies in the 2018 performance year. ASA successfully advocated for the inclusion of a new improvement activity for participation in a Perioperative Surgical Home (PSH) and will release a list of IAs most applicable to anesthesia.

In the Final Rule, CMS finalized that ECs can use either 2014 or 2015 certified electronic health records technology (CEHRT) for the 2018 performance year. CMS also finalized two additional ACI exemptions. One exemption will cover ambulatory surgical center-based MIPS ECs who are defined as those who furnish 75 percent or more of their covered professional services in sites of service identified by POS code 24. The second exemption is for small practices with 15 or fewer ECs. Additional hardship exemptions are available but must be requested via CMS application.