On November 2, 2017, the Centers for Medicare & Medicaid Services (CMS) issued the final rule with comment period for the second year of the Quality Payment Program (calendar year 2018), along with an interim final rule to establish an automatic extreme and uncontrollable circumstance policy for the 2017 performance period for MIPS eligible clinicians in regions or locales impacted by Hurricanes Harvey, Irma and Maria. Clinicians in the impacted areas are automatically exempt from MIPS reporting without having to submit a hardship exception application. The Quality, Improvement Activity and Advancing Care Information performance categories will automatically be weighted at zero percent for the 2017 performance period. Provisions of the final and interim rules are effective on January 1, 2018.
Year 2 Final Rule Highlights for the Merit-based Incentive Payment System (MIPS)
Small Groups, Virtual Groups and Complex Patients
- For Year 2 of the Quality Payment Program, CMS will increase the low-volume threshold to exempt clinicians that receive < $90,000 in Medicare Part B allowed charges or treat < 200 Medicare Part B beneficiaries.
- Individual and small group practices of 15 or less will receive an additional 5 bonus points to their final MIPS score.
- Small group practices of 10 or less have the option to form or join a Virtual Group to participate with other practices.
- CMS will continue to award small practices 3 points for quality measures if they do not meet the data completeness requirements.
- Clinicians can earn up to 5 bonus points for treatment of complex patients.
- CMS will measure improvement from one year to the next for the Quality and Cost performance categories, as proposed.
- If statistically significant changes are measured in the Quality performance category, CMS will allow up to 10 percentage points.
- Only 1 percentage point is available for the Cost performance category.
Performance Threshold, Payment Adjustment and Reporting Cycle
- CMS is raising the MIPS minimum performance threshold from 3 points to 15 points in Year 2 of the Quality Payment Program. The “Pick Your Pace” transition policy that currently allows clinicians to choose how they want to participate in MIPS will not apply in 2018. The threshold for exceptional performance will remain at 70 points.
- The payment adjustment for the 2018 performance period (2020 payment year) will increase to a positive or negative 5 percent, as required by statue.
- Data for the Quality and Cost performance categories will be measured for a full calendar year, whereas data for the Improvement Activities and Advancing Care Information performance categories will be measured for any consecutive 90-day reporting cycle during the performance period.
Data Completeness Requirements
- CMS will implement the previously finalized requirement for individual and group practices participating in MIPS to submit 60 percent of quality measure data for Medicare Part B and non-Medicare patients if using a QCDR, EHR or qualified registry for submission.
- If using claims to submit quality measure data, only data for 60 percent of Medicare Part B patients is required. The same requirements apply for 2019 performance period (Table 5)
Topped Out Quality Measures
- CMS finalized the proposed timeline and methodology for identifying topped out measures, which specifies that after a measure has been identified as topped out for three consecutive years, CMS may propose to remove it during the fourth year.
- Qualified Clinical Data Registry (QCDR) measures that are consistently identified as topped out during the four-year period would not be approved for use in the fourth year during the QCDR self-nomination review process.
- Benchmarked measures identified as topped out for two consecutive years will receive a 7 point cap instead of 6 points, as proposed.
- The topped out measure policy does not apply to CMS Web Interface measures.
Quality Performance Category
- For Year 2 of the Quality Payment Program, CMS did not finalize the alternative proposal to weight the Quality performance category at 60 percent, and instead, will maintain the previously established policy that sets the Quality performance category at 50 percent of the MIPS final score for the 2018 performance period.
- As proposed, clinicians will be required to report at least six quality measures (listed in Table A), including at least one outcome measure if applicable. If an outcome measure is not applicable, clinicians are required to report one other high priority measure (appropriate use, patient safety, efficiency, patient experience, and care coordination measures) in lieu of an outcome measure.
- Alternatively, urologists can report six measures listed in the Urology Measure Set (Table Group B). The Urology Measure Set was expanded from 11 to 22 quality measures for 2018.
Cost Performance Category
- CMS will not maintain the current zero weight for the Cost performance category as proposed. Instead, the Cost performance category will account for 10 percent of the final MIPS score for the 2018 performance year, as previously finalized. However, only the total per capita cost measure and the Medicare Spending per Beneficiary (MSPB) measure will be included in the calculation.
- The 10 episode-based measures, including the urology-specific TURP for BPH measure, adopted for 2017 will be excluded from calculation in 2018 while CMS continues to develop episode-based measures.
- The total per capita cost measure will include Medicare Part A and Part B using a two-step beneficiary attribution process based on the number of primary care services received during the performance period. If the beneficiary did not receive any primary care services from a primary care provider, the beneficiary is attributed to the specialists that provided primary care services during the performance period.
- The MSPB measure attributes beneficiaries to the clinician who provides the plurality of Medicare Part B charges during an episode index hospitalization (3 days prior to admission through 30 days post discharge).
- A minimum of 20 cases for the total per capita cost measure and a minimum of 35 cases for the MSPB measure must apply in order for the clinician to receive a Cost performance category score.
Improvement Activities Performance Category
- The Improvement Activity performance category will continue to account for 15 percent of the total MIPS score.
- Clinicians are still required to complete either two high-weighted activities or four medium-weighted activities to earn the full score of 40 points, unless in a small group practice, rural area or area with a health professional shortage, where only one high-weighted activity or two medium-weighted activities are required.
- CMS has expanded the inventory list of activities from 92 to 112 (Tables F and G of the final rule), and modified 27 of the existing activities.
Advancing Care Information Performance Category
- In 2018, the Advancing Care Information performance category will continue to account for 25 percent of the MIPS total score. The base score requirements are the same.
- As proposed, for Year 2 of the Quality Payment Program, CMS will continue to allow clinicians to use either the 2014 or 2015 Edition of Certified Electronic Health Record Technology (CEHRT).
- Clinicians using 2015 Edition CEHRT for end-to-end use may receive a 10 percent bonus.
- Clinicians based in an ambulatory surgical center or hospital, small groups and clinicians with significant hardship exceptions, or clinicians whose EHR systems were decertified, will have the Advancing Care Information performance category automatically reweighted to zero percent for the 2018 performance period, and the 25 percent weight will be applied to the Quality performance category.
- Individuals and groups reporting to a single public health agency or clinical data registry, such as the AUA’s AQUA registry, may earn 10 percent in the performance score and an additional 5 percent bonus if submitting to an additional public health agency or clinical data registry not reported under the performance score.
Year 2 Final Rule Highlights for Advanced and MIPS Alternative Payment Models (APMs)
- CMS will extend the 8 percent revenue-based nominal amount standard for Medicare Advanced APMs for an additional two years until 2020, as proposed.
- The 8 percent revenue-based nominal amount standard will also apply to Other-Payer Advanced APMs starting with the 2019 and 2020 performance periods, as proposed.
- The Medical Home Models nominal risk standard will be phased in over a 5 year period extending through 2021 instead of ending 2020, as previously finalized. The incremental total potential risk percentage amounts will remain the same.
- Qualifying APM Participant (QP) determinations for Advanced APMs will be based on payment and patient data for entities in operation for a minimum of 60 continuous days.
- Starting in 2019, payers can submit payment arrangements to qualify as an Other Payer Advanced APM, including Medicaid and Medicare Advantage plans.
- CMS will align the scoring standards for the Quality, Improvement Activities and Advancing Care Information performance categories across all MIPS APMs.
- Under the MIPS APM scoring standard, CMS will add a fourth snapshot date for the purpose of reporting and scoring, not for determining QP status in an Advanced APM.
The final rule will be published in the Federal Register
on November 16, 2017. CMS will accept comments on the final rule until January 2, 2018. The AUA will continue to analyze the final rule and prepare written comments. If you have any questions regarding the final changes in the rule, please contact Lisa Miller-Jones at firstname.lastname@example.org