2018 MIPS Rules

On November 2, CMS released the 2018 Updates to the Quality Payment Program final rule, under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law. You can find the Fact Sheet here.

Here are some of the highlights:

  • Performance Period:
    • Quality: 12-month calendar year performance period (instead of 90 days minimum).
    • Cost: 12-month calendar year performance period.
    • Advancing Care Information: 90 days minimum performance period.
    • Improvement Activities: 90 days minimum performance period.
  • Performance Threshold / Payment Adjustment: 
    • Performance threshold set at 15 points (instead of 3).
      • How to achieve 15 points:
        • Report all required Improvement Activities or
        • Meet the Advancing Care Information base score and submit 1 Quality measure that meets data completeness or
        • Meet the Advancing Care Information base score, by reporting the 5 base measures, and submit one medium-weighted Improvement Activity or
        • Submit 6 Quality measures that meet data completeness criteria.
    • Additional performance threshold stays at 70 points for exceptional performance.
    • Payment adjustment for the 2020 payment year ranges from - 5% to + (5% x scaling factor) as required by law. (The scaling factor is determined in a way so that budget neutrality is achieved.)
    • The MIPS payment adjustment factor applies to payments for both items and services under Medicare Part B – this includes Part B drugs.
  • Quality:
    • Weight to final score: 50% (instead of 60% in 2017).
    • Data completeness: CMS proposes increased the data completeness threshold to 60% instead of 50%. Measures that do not meet data completeness criteria will get 1 point instead of 3 points, except that small practices will continue to get 3 points.
    • Scoring: Keep 3-point floor for measures scored against a benchmark. Keep 3 points for measures that don’t have a benchmark or don’t meet case minimum requirement. Measures that do not meet data completeness requirements will get 1 point instead of 3 points, except that small practices will continue to get 3 points. No change to bonuses. Starting with the 2018 MIPS performance year, CMS proposes to use a cap of 6 points for a select set of 6 topped out measures. 
    • Improvement Scoring for Quality: Improvement scoring will be based on the rate of improvement so that higher improvement results in more points, particularly for those improving from lower performance in the transition year. Improvement is measured at the Quality performance category level. Up to 10 percentage points available in the Quality performance category.
    • Topped out measures: For 2018, there are 6 topped out measures that be will scored with a maximum of 7-points instead of the standard 10-points:
      • #21. Perioperative Care: Selection of Prophylactic Antibiotic-First or Second Generation Cephalosporin
      • #23. Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
      • #52. Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy
      • #224. Melanoma: Overutilization of Imaging Studies in Melanoma
      • #262. Image Confirmation of Successful Excision of Image Localized Breast Lesion
      • #359. Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description
  • Improvement Activities: 
    • Weight to final score: 15%
    • No change in the number of activities that MIPS eligible clinicians have to report to reach a total of 40 points. CMS is proposing more activities to choose from and changes to existing activities for the Inventory. MIPS eligible clinicians in small practices and practices in a rural areas will keep reporting on no more than 2 medium or 1 high-weighted activity to reach the highest score.
    • For group participation, only 1 MIPS eligible clinician in a TIN has to perform the Improvement Activity for the TIN to get credit.
  • Advancing Care Information: 
    • Weight to final score: 25%
    • Allow MIPS eligible clinicians to use either the 2014 or 2015 Edition CEHRT in 2018; grants a bonus for using only 2015 Edition CEHRT.
    • Add exclusions for the EPrescribing and Health Information Exchange Measures.
    • Adds more Improvement Activities that show the use of CEHRT to the list eligible for an Advancing Care Information bonus.
    • For the performance score, one may earn 10% in the performance score for reporting to any single public health agency or clinical data registry.
    • A 5% bonus score is available for submitting to an additional public health agency or clinical data registry not reported under the performance score.
    • Add a decertification exception for eligible clinicians whose EHR was decertified, retroactively effective to performance periods in 2017.
    • Change the deadline for the exception application submission for 2017 and future years to be December 31 of the performance year.
    • For small practices (15 or fewer clinicians), add a new category of hardship exceptions to re-weight Advancing Care Information performance category to 0 and reallocate the Advancing Care Information performance category weight of 25% to the Quality performance category.
    • CMS will reweight the Advancing Care Information performance category to 0 and reallocate the performance category weight of 25% to the Quality performance category for the following reasons:
      • Automatic reweighting:
        • Hospital-based MIPS eligible clinicians;
        • Non-Patient Facing clinicians;
        • Ambulatory Surgical Center (ASC)— based MIPS eligible clinicians, finalized retroactive to the transition year;
        • Nurse practitioners, physician assistants, clinical nurse specialist, certified registered nurse anesthetists
      • Reweighting through an approved application:
        • New hardship exception for clinicians in small practices (15 or fewer clinicians);
        • New decertification exception for eligible clinicians whose EHR was decertified, retroactively effective to performance periods in 2017.
        • Significant hardship exceptions—CMS will not apply a 5-year limit to these exceptions; 
  • Cost:
    • Weight to final score: 10% (instead of 0% in 2017)
    • CMS is including the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures to calculate your Cost performance category score for the 2018 MIPS performance period. These two measures carried over from the Value Modifier program and are currently being used to provide feedback for the MIPS transition year.
    • CMS will calculate cost measure performance; no action is required from clinicians.
  • Offering the Virtual Groups participation option. The Year 2 rule offers Virtual Group participation, which is another way clinicians can elect to participate in MIPS. Virtual Groups would be composed of solo practitioners and groups of 10 or fewer eligible clinicians, eligible to participate in MIPS, who come together “virtually” with at least 1 other such solo practitioner or group to participate in MIPS for a performance period of a year. Generally, clinicians in a Virtual Group will report as a Virtual Group across all 4 performance categories and will need to meet the same measure and performance category requirements as non-virtual MIPS groups.
    • Solo practitioners and groups who want to form a virtual group must go through the election process.
    • Virtual groups election must occur prior to the beginning of the performance period and cannot be changed once the performance period starts.
    • Election period is October 11 to December 31, 2017, for the 2018 MIPS performance period.
    • To learn more, see the 2018 Virtual Groups Toolkit
  • Low-Volume Threshold: Increase  the threshold to exclude individual MIPS eligible clinicians or groups with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries during a low volume threshold determination period that occurs during the performance period or a prior period
  • Non-Patient Facing: There is no change in how CMS is defining non-patient facing clinicians  (Individual’s ≤100 patient facing encounters. Groups: > 75% NPIs billing under the group’s TIN during a performance period are labeled as non-patient facing.) however; CMS is using the same definition for Virtual Groups. Virtual Groups: > 75% NPIs within a Virtual Group during a performance period are labeled as non-patient facing.
  • Complex Patients Bonus: Apply an adjustment of up to 5 bonus points by adding the average Hierarchical Conditions Category (HCC) risk score to the final score. Generally, this will award between 1 to 5 points to clinicians based on the medical complexity of the patients they see. 
  • Small Practice Bonus: Adjust the final score of any eligible clinician or group who’s in a small practice (defined in the regulations as 15 or fewer clinicians) by adding 5 points to the final score, as long as the eligible clinician or group submits data on at least 1 performance category in an applicable performance period. 
  • Extreme and Uncontrollable Circumstances Payment adjustments: CMS estimates that approximately 572,000 eligible clinicians would be required to participate in MIPS in the 2018 MIPS performance period.  Under the proposed rule, the payment adjustment for the 2020 payment year would range from - 5% to +5X% where X is an adjustment factor to allow the MIPS program to stay budget neutral. MIPS payment adjustment factors based on final scores
    • For the transition year, if a MIPS eligible clinician’s CEHRT is unavailable as a result of extreme and uncontrollable circumstances (e.g., a hurricane, natural disaster, or public health emergency), the clinician may submit a hardship exception application to be considered for reweighting of the Advancing Care Information performance category. This application is due by December 31, 2017.
    • This final rule with comment period extends this reweighting policy for the three other performance categories (Quality, Cost, and Improvement Activities) starting with the 2018 MIPS performance period. This hardship exception application deadline is December 31, 2018.
  • According to CMS, MIPS eligible clinicians would receive approximately $173 million in positive MIPS payment adjustments, including up to an additional $500 million for those with exceptional performance (eligible clinicians whose final score is 70 points or higher). CMS estimates that roughly 77% of eligible clinicians in all practice sizes will have exceptional performance and receive a positive payment adjustment. CMS also estimates that 3.9% of the providers eligible for MIPS in 2018 will get a penalty. The average MIPS payment amount would be 0.9%.
  • CMS estimates these numbers based on projecting past PQRS participation, past PQRS performance scores and past EHR Meaningful Use participation into the 2018 MIPS rules.
  • Based on the CMS numbers, the penalty for a clinician not reporting MIPS with an average of $130,000.00 in Medicare Part B income, will be $6,500 (5% negative payment adjustment). 
  • We estimate that the average payment for a clinician with a MIPS score between 15 and 69 will be $324.00 (0.25% positive payment adjustment).
  • We estimate that the average payment for a clinician with a MIPS score between 70 and 100 will be $1173.00 (0.91% positive payment adjustment). 
  • Because CMS is proposing to make it easy to avoid the penalty (performance threshold at 15 points) the reward for MIPS eligible clinicians with a final score of 100 points could be around 3% percent (<$3,900 for a clinician with an average $130,000 of Medicare income).

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