Key Takeaways: 2018 Quality Payment Program Proposed Rule

On Tuesday, June 20, 2017, the Centers for Medicare & Medicaid Services (CMS) released the 2018 Updates to the Quality Payment Program (QPP) Proposed Rule.  According to CMS, the QPP rule supports eligible clinicians in improving the health of their patients and increasing care efficiency. It emphasizes high-value care and patient outcomes while minimizing burden on eligible clinicians.  The Program is also designed to be flexible, transparent, and structured to improve over time with input from clinicians, patients, and other stakeholders.

Moreover, CMS stated that given the diversity among clinician practices in their experience with quality-based payments, the agency expects QPP to evolve over multiple years in order to achieve national goals. CMS underscored that QPP has laid the groundwork for expansion toward an innovative, outcome-focused, patient-centered, resource-effective health system that leverages health IT to support clinicians and patients and builds collaboration across care settings. The 2018 QPP proposed rule is the next part of the agency’s staged approach in implementing this vision.  

The Key Takeaways from the Proposed Rule include the following:

The QPP Implementation Strategy and Areas of Focus is Largely Consistent Across the Transitions in Administrations

CMS under the Trump Administration is highlighting many of the same points as the agency emphasized in Year 1 of the program from the Obama Administration.  In this proposed rule, CMS continues the slow ramp-up of QPP by establishing special policies for Program Year 2 aimed at encouraging successful participation in the program while reducing burden, reducing the number of clinicians required to participate, and preparing clinicians for the calendar year (CY) 2019 performance year (which corresponds to the CY 2021 payment year).

Support for Small Practices Remains Paramount 

In 2017, CMS excluded many practices from QPP requirements through the low-volume threshold, which was set at less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare Part B patients.  Since CMS is listening to feedback from the community, it knows that challenges still remain for participation from small practices, so the agency is proposing additional flexibilities, including: increasing the low-volume threshold to less than or equal to $90,000 in Medicare Part B allowed charges or less than or equal to 200 Medicare Part B patients; adding a significant hardship exception from the advancing care information performance category for MIPS eligible clinicians in small practices; and providing bonus points that are added to the final scores of MIPS eligible clinicians who are in small practices.

CMS believes that these additional flexibilities and reduction in barriers will further enhance the ability of small practices to participate successfully in QPP. 

CMS is Proposing that Clinicians Can Still Use EHR Technology Certified to the 2014 Edition in 2018, but Bonus Points are Available for Those that Fully Adopt and Report Using the 2015 Edition

Although CMS continues to recommend that clinicians migrate to the implementation and use of EHR technology certified to the 2015 Edition so they may take advantage of improved functionalities, it recognizes that some practices have challenges in adopting new certified health IT. Therefore, the agency proposes that MIPS eligible clinicians may continue to use EHR technology certified to the 2014 Edition for the 2018 performance year.  However, CMS is proposing to offer a bonus of 10 percentage points under the advancing care information performance category for MIPS eligible clinicians who report the Advancing Care Information Objectives and Measures for the performance year in CY 2018 using only 2015 Edition certified EHR technology.

In an April 2017 Letter to Department of Health and Human Services Secretary Tom Price, MD, HIMSS expressed concern with current level of available certified vendor products, as well as the implementation timeline for the 2015 Edition Health IT Certification Criteria and recommended moving the start date for the 2015 Edition requirement to July 1, 2018, rather than January 1, 2018.  HIMSS contended that this extension would increase the likelihood that providers, vendors, and consultants have the necessary time to ensure products complete the certification process, are fully tested and implemented, and staff training and workflow adjustments are achieved to ensure safe, effective and efficient implementation and use of 2015 Edition Certified EHR Technology (CEHRT).

Clinician Participation in the Advanced APM Track is Expected to Jump for 2018/2020

CMS estimated that for the CY 2017 performance year/2019 payment year, 70,000 to 120,000 eligible clinicians would be qualifying APM participants (QPs).  With new Advanced APMs expected to be available for participation in 2018, including the Medicare ACO Track 1 Plus (1+) Model, and the reopening of the application process to new participants for some current Advanced APMs, such as the Next Generation ACO Model and Comprehensive Primary Care Plus Model, CMS anticipates higher numbers of QPs in subsequent years of the program.  The agency currently estimates that approximately 180,000 to 245,000 eligible clinicians may become QPs for the 2018 performance year/2020 payment year. 

The Cost Performance Category under the Merit-based Incentive Payment System (MIPS) is Proposed at a 0% Weight for 2018

With CMS proposing to continue to weight cost at 0% for the 2018 performance year, the agency is recommending the same final weight payment structure for the other three MIPS performance categories: Quality at 60%; Advancing Care Information at 25%; and, Improvement Activities at 15%.  Much like for 2017, CMS included a 0% weight for the cost performance category to allow clinicians an opportunity to ease into QPP. 

The agency also emphasized that the cost performance category will require no separate submissions for participation which will minimize the burden on clinicians.  Moreover, CMS did stress that the assessment of cost is a vital part of ensuring that clinicians are providing Medicare beneficiaries with high-value care and given the primary QPP focus on value, it intends to align cost measures with quality measures over time in the scoring system.

Look to HIMSS for additional resources and detailed information on the QPP Proposed Rule in the coming days. 

CMS; 2018 Quality Payment Program Proposed Rule