On Nov. 2, the Centers for Medicare and Medicaid Services (CMS) released the 2018 Medicare Quality Payment Program (QPP) final rule, addressing participation requirements for 2018 and future years under the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (Advanced APM) pathways created by the Medicare Access and CHIP Reauthorization Act (MACRA). Policies under the final rule go into effect Jan. 1, 2018, the start date for year two of QPP. Through the policies finalized in this rule, CMS is recognizing year two as another year for clinicians to prepare for a "robust program" in the third year.

Based on 2018 performance, clinicians and groups will be eligible to receive a bonus of up to +5 percent or higher based on budget neutrality or a -5 percent penalty on Medicare Part B services provided in 2020 under MIPS. Qualifying participants in an Advanced APM will continue to be eligible to receive a five percent lump sum bonus.

"Much work remains to be done to ensure these programs are implemented in a way that encourages high-quality patient care without needlessly burdening clinicians. It is encouraging to see CMS recognize 2018 as another learning year for clinicians. However, the College is disappointed to see CMS incorporate cost into the 2018 performance year MIPS score while so much is still being done to develop reliable measures in this area. We anticipate working further with CMS to ensure that the addition of this category does not negatively impact clinicians or patient care," said ACC President Mary Norine Walsh, MD, FACC.

Additional highlights of the final rule include –

MIPS

• Cost will begin to count toward the MIPS composite score in the 2018 Performance Year/2020 Payment Year. The MIPS category weights for most clinicians is finalized as:
  • 50 percent weight for Quality, a decrease from 60 percent in 2017.
  • Maintained 25 percent weight for Advancing Care Information; clinicians can use 2014 or 2015 certified electronic health record technology (CEHRT), with a bonus for using only 2015 CEHRT.
  • Maintained 15 percent weight for Improvement Activities.
  • 10 percent weight for Cost based on total per capita costs for all attributed beneficiaries and the Medicare Spending per Beneficiary (MSPB) measure. CMS will not use episode-based cost measures in 2018.
• MIPS composite score performance threshold for avoiding a penalty set at 15 points, an increase from the three-point threshold for the 2017 performance year.
• Implementation of bonus points to recognize improvement in the Quality and Cost performance categories.
• Up to five bonus points available to recognize clinicians who treat complex patient populations, based on a combination of Hierarchical Condition Categories (HCCs) and the dual eligible population treated.
• Continued flexible participation requirements for MIPS/APM participants.
• Finalized increase in 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 Part B patients.
• Additional assistance for small practices (equal to or less than 15 MIPS-eligible clinicians) including bonus points to the final MIPS composite score and credit for quality measures submitted below data completeness standards.
• Implementation of virtual groups starting in 2018, allowing small groups and solo practitioners under two or more taxpayer identification numbers to participate in MIPS as a single group. Registration for virtual group participation is open through Dec. 1, 2017.
• Continued recognition of qualified clinical data registries such as the NCDR PINNACLE Registry and Diabetes Collaborative Registry MIPS data reporting options.

Advanced APMs

• Maintained nominal risk and qualifying participant thresholds for the Advanced APM pathway.
• Implementation of the 'All-Payer Combination Option' for the Advanced APM pathway starting in the 2019 performance year. CMS confirmed that Medicare Advantage models will apply to the All-Payer option and will not be counted toward Medicare A-APM qualifying status.
• CMS maintains the current definition of Physician-Focused Payment Models to only include payment arrangements where Medicare is a payer.

Other key points can be found in the CMS QPP Fact Sheet.

The ACC will continue to review the final ruling and develop educational resources on the reflected changes for the 2018 performance year. QPP updates will be in focus at ACC's Cardiovascular Summit, Feb. 22 – 24, in Las Vegas, NV. Continue to watch ACC's MACRA Hub for instruction on 2017 participation and forthcoming information on the 2018 requirements.

Keywords: Medicare Part C, Medicare Part B, Centers for Medicare and Medicaid Services, U.S., Medicaid, Health Expenditures, Electronic Health Records, Registries, Patient Care, Medicare Access and CHIP Reauthorization Act of 2015

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