Quality Payment Program Year 3

Final Rule Overview

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate (SGR) formula for clinician payment, and established a quality payment incentive program -- the Quality Payment Program. This program provides clinicians with two ways to participate: through Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS).

We continue striving to implement the program as Congress intended while focusing on simplification and burden reduction, drawing on the flexibilities included in the Bipartisan Budget Act of 2018, smoothing the transition where possible, and offering targeted educational resources for program participants. We’ve also never lost sight of supporting a pathway to participation in Advanced APMs, and Year 3 is a reflection of that effort.

Similar to the first two transition years, we will continue to support all clinician practices with a focus on those that are small, independent, and/or rural. And, most importantly, the beneficiaries are always at the heart of our policies. We will continue adopting policies that protect the safety of our beneficiaries and strengthen the quality of the health care they receive.

The Year 3 policies are reflective of the feedback we received from many stakeholders including overall burden reduction, improving patient outcomes and reducing burden through meaningful measures and expanding participation options to other clinicians, to name a few updates. We’ve also received feedback from stakeholders regarding the added value of the Quality Payment Program. To that point, we are using your feedback to (1) assess the current value of the program for clinicians and beneficiaries alike and (2) implement the program in a way that is understandable to beneficiaries, as they are the core of the Medicare program. We will continue offering our free, hands-on technical assistance to help individual clinicians and group practices participate in the Quality Payment Program.

This document provides a high-level overview of the final Year 3 policies.

Quality Payment Program Year 3: MIPS Highlights

The first two transition years of the MIPS were implemented gradually to reduce burden and provide flexible participation options, to allow clinicians to spend less time on regulatory requirements and more time with patients. As a result, in the first year of the program, we experienced a remarkably high participation rate. We’ve taken what we’ve learned in Year 1, which you’ll see in the 2019 Final Rule, and used this data as part of our data modeling process that helps us to project future eligibility, rates of performance, payment adjustments, and more.

For Year 3, we are continuing to build on what is working, and we are using your feedback to improve program policies. In terms of quality measures, we will continue to identify low-value or low-priority process measures and focus on meaningful quality outcomes for patients and streamlined reporting for clinicians. Through seven awarded cooperative agreement partnerships, CMS will work closely with external organizations—such as clinical professional organizations and specialty societies, patient advocacy groups, educational institutions, independent research institutions, and health systems—to develop and implement measures that offer the most promise for improving patient care. We believe that the Meaningful Measures Initiative and this MACRA grant funding opportunity to develop measures for the Quality Payment Program will improve our quality measures over time.

Some prominent Year 3 policies adopted in this final rule include expanding the definition of MIPS eligible clinicians to include new clinician types (physical therapists, occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and registered dietitians or nutrition professionals), adding a third element to the low-volume threshold determination, and giving eligible clinicians who meet one or two elements of the low-volume threshold the choice to participate in MIPS (referred to as the opt-in policy). We are also adding new episode-based measures to the Cost performance category, restructuring the Promoting Interoperability (formerly Advancing Care Information) performance category, and creating an option to use facility-based Quality and Cost performance measures for certain facility-based clinicians.

We are continuing to reduce burden and offer flexibilities to help clinicians successfully participate by adopting the following policies:

• Overhauling the MIPS Promoting Interoperability (formerly Advancing Care Information) performance category to support greater electronic health record interoperability and patient access while aligning with the Medicare Promoting Interoperability Program requirements for hospitals.

• Moving clinicians to a single, smaller set of objectives and measures with scoring based on measure performance for the Promoting Interoperability performance category.

• Allowing the use of a combination of collection types for the Quality performance category.

• Retaining and increasing some bonus points

• For the Cost and Quality performance categories, providing the option to use facility-based scoring for facility-based clinicians, who are planning to participate in MIPS as individuals or as a group. Facility-based measurement does not require data submission, but to be recognized as a group for scoring purposes, a facility-based group would need to submit data for the Improvement Activities or the Promoting Interoperability performance categories. We expect to release a facility-based scoring preview in Q1 of 2019.

We’re also committed to continue helping small practices in Year 3 by:

• Increasing the small practice bonus to 6 points, but including it in the Quality performance category score of clinicians in small practices instead of as a standalone bonus;

• Continuing to award small practices 3 points for submitted quality measures that don’t meet the data completeness requirements;

• Allowing small practices to continue submitting quality data for covered professional services through the Medicare Part B claims submission type for the Quality performance category;

• Providing an application-based reweighting option for the Promoting Interoperability performance category for clinicians in small practices;

• Continuing to provide small practices with the option to participate in MIPS as a virtual group; and

• Offering our no-cost, customized support to small and rural practices through the Small, Underserved, and Rural Support (SURS) technical assistance initiative.

Lastly, you’ll notice the use of new language that more accurately reflects how clinicians and vendors interact with MIPS (i.e. Collection types, Submitter types, etc.). We’ve solicited and listened to your feedback and are finalizing these new terms in order to implement the program in a way that is understandable to both participants and beneficiaries. We understand that this terminology is different than what was previously used and may cause some initial confusion. We’ve defined the terms here for you.

New MIPS Terms

• Collection Type is a set of quality measures with comparable specifications and data completeness criteria including, as applicable: electronic clinical quality measures (eCQMs); MIPS clinical quality measures (CQMs) (formerly referred to as “Registry measures”); Qualified Clinical Data Registry (QCDR) measures; Medicare Part B claims measures; CMS Web Interface measures; the CAHPS for MIPS survey measure; and administrative claims measures.

• Submitter Type is the MIPS eligible clinician, group, or third party intermediary acting on behalf of a MIPS eligible clinician or group, as applicable, that submits data on measures and activities.

• Submission Type is the mechanism by which the submitter type submits data to CMS, including, as applicable: direct, log in and upload, log in and attest, Medicare Part B claims, and the CMS Web Interface. There is no submission type for cost data because the data is collected and calculated by CMS from administrative claims data submitted for payment.

Bipartisan Budget Act of 2018

Enacted on February 9, 2018, the Bipartisan Budget Act of 2018 provides us with flexibility to continue the gradual transition in MIPS for three more years. Although the Bipartisan Budget Act of 2018 was enacted after the publication of the Calendar Year (CY) 2018 Quality Payment Program final rule, we were able to implement adjustments to the low-volume threshold calculations for Year 2 of the program prior to the release of Year 3 rules. In the CY 2019 Physician Fee Schedule final rule, we will continue using this authority to help further reduce clinician burden.

Key Changes to MIPS in the Bipartisan Budget Act of 2018 include:

• Providing flexibility in the weighting of the Cost performance category in the final score for three additional years. For year 3, we are finalizing the Cost performance category at 15 points.

• Allowing flexibility in establishing the performance threshold for three additional years (program years 3, 4, and 5) to ensure a gradual and incremental transition to the estimated performance threshold for the sixth year of the program based on the mean or median of final scores from a prior period. For the 2019 performance period, we are finalizing a performance threshold of 30 points along with an additional performance threshold of 75 points for exceptional performance.

• Quality Payment Program Year 3: APM Highlights

• We are building on many of the changes we made for Year 2 of the program, and we are finalizing policies, including:

• Updating the Advanced APM Certified Electronic Health Record Technology (CEHRT) threshold so that an Advanced APM must require that at least 75% of eligible clinicians in each APM Entity use CEHRT, and for Other Payer Advanced APM, as of January 1, 2020, the number of eligible clinicians participating in the other payer arrangement who are using CEHRT must be 75%.

• Extending the 8% revenue-based nominal amount standard for Advanced APMs and Other Payer Advanced APMs through performance year 2024.

• Increasing flexibility for the All-Payer Combination Option and Other Payer Advanced APMs for non-Medicare payers to participate in the Quality Payment Program.

  • Establishing a multi-year determination process where payers and eligible clinicians can provide information on the length of the agreement as part of their initial Other Payer Advanced APM submission, and have any resulting determination be effective for the duration of the agreement (or up to 5 years). We are finalizing this streamlined process to reduce the burden on payers and eligible clinicians.

  • Allowing QP determinations at the TIN level, in addition to the current options for determinations at the APM entity level and the individual level, in instances when all eligible clinicians who have reassigned their billing rights to the TIN are included in a single APM Entity. This will provide additional flexibility for eligible clinicians under the All-Payer Combination Option.

  • Moving forward with allowing all payer types to be included in the 2019 Payer Initiated Other Payer Advanced APM determination process for the 2020 QP Performance Period.

• Streamlining the definition of a MIPS comparable measure in both the Advanced APM criteria and Other Payer Advanced APM criteria to reduce confusion and burden among payers and eligible clinicians submitting payment arrangement information to CMS.

• Clarifying the requirement for MIPS APMs to assess performance on quality measures and cost/utilization.

• Updating the MIPS APM measure sets that apply for purposes of the APM scoring standard.