Posted on July 22, 2021
On July 13, 2021, the Centers for Medicare and Medicaid Services (CMS) issued the Proposed Rule for the 2022 Medicare Physician Fee Schedule (PFS) which includes several proposals to implement changes to the Quality Payment Program (QPP). CMS is accepting public comments on the Proposed Rule until September 13, 2021, and is expected to release a Final Rule later this year. The proposal includes significant revisions to the existing MIPS program and outlines a timeframe for transitioning to the new MIPS Value Pathways (MVPs). Here are the key takeaways that will have a major impact on the future of clinician reporting.
Proposed Changes to Traditional MIPS
The Quality Payment Program was originally established in 2017 with two payment tracks that clinicians could choose from which included MIPS and Advanced Alternative Payment Models (APMs). “Traditional MIPS” refers to this original framework available to MIPS eligible clinicians for collecting and reporting data.
CMS has proposed substantial policy changes to traditional MIPS reporting in 2022 and is considering sunsetting the program after 2027 and replacing it with MVPs.
MIPS Eligible Clinicians
Two new clinician types would be added to the existing list of MIPS eligible clinicians beginning with the 2022 performance year:
- Clinical social workers
- Certified nurse midwives
MIPS Performance Category Weight Changes
By law, the Quality and Cost performance categories must be equally weighted at 30% beginning with the 2022 performance period. The weights for the Promoting Interoperability (25%) and Improvement Activities (15%) categories will remain the same as 2021.
Minimum Performance Threshold and Payment Adjustments
CMS is required to establish a performance threshold that is either the mean or medium of the final MIPS scores for all MIPS eligible clinicians for a prior performance period beginning with the 2022 performance year. The agency proposes a minimum performance threshold of 75 MIPS points in 2022 (up from 60 MIPS points in 2021) which is the mean final score from the 2017 performance year. Next year clinicians would need to achieve a final MIPS score of at least 75 points to avoid any MIPS penalty.
An additional performance threshold of 89 points would be established for exceptional performance. The 2022 performance year is the last year for an additional MIPS adjustment for exceptional performance.
The maximum payment adjustments for 2022 remain the same at +/- 9% and would be applied towards a clinician’s 2024 Medicare Part B payments for covered professional services. This means a MIPS eligible clinician who does not participate in MIPS in 2022 will receive a negative payment adjustment of -9% in 2024.
CMS is proposing several changes to the MIPS Quality category.
- Data Completeness - MIPS eligible clinicians would continue to meet the current data completeness threshold of 70% (e.g., must report at least 70% of eligible cases for each Quality measure) for the 2022 performance period. However, this threshold would increase to 80% for the 2023 performance period.
- Quality Measure Scoring - Scoring updates would be applied to measures that do not meet case minimum and data completeness requirements, and measures that do not have a benchmark.
- Measures with a benchmark - The 3-point floor would be removed for measures that can be scored against a benchmark. These measures would receive 1-10 points.
- Measures without a benchmark - The 3-point floor would be removed for measures without a benchmark (except small practices). These measures would receive 0 points (small practices would continue to earn 3 points).
- Measures that don’t meet case minimum requirements (20 cases) - The 3-point floor would be removed (except small practices). These measures would earn 0 points (small practices would continue to earn 3 points).
- New Quality Measures - A 5-point floor would be established for the first 2 performance periods for new Quality measures.
- Bonus Points - Bonus points would no longer be awarded in 2022 for end-to-end (ETE) electronic reporting and reporting additional Outcome/High-priority measures beyond the required measures.
- Benchmarks - Performance period benchmarks would be used to score Quality measures for the 2022 performance period, or a different baseline period (such as CY 2019), pending
CMS analysis of the 2020 performance period data..
- Scoring for Groups Reporting Claims Measures - CMS would only calculate a group-level Quality category score from Medicare Part B Claims measures if the practice submitted data for another performance category as a group (signaling their intent to participate as a group).
- CMS Web Interface - The CMS Web Interface would be extended as a collection type and submission type in traditional MIPS for registered groups, virtual groups, and APM Entities with 25 or more clinicians for the 2022 performance period.
- Quality Measures - Substantive changes are proposed for 84 existing Quality measures. CMS has proposed one new specialty measure set for Certified Nurse Midwives, five new Quality measures (including 2 new administrative claims measures), and would remove 19 existing Quality measures. CMS is also seeking comments on one quality measure for potential future inclusion within MIPS that pertains to SARS-CoV-2 Vaccination by Clinicians.
The Proposed Rule would add five newly developed episode-based Cost measures for the 2022 performance period.
- 2 procedural measures: Melanoma Resection, Colon and Rectal Resection
- 1 acute inpatient measure: Sepsis
- 2 chronic condition measures: Diabetes, Asthma/Chronic Obstructive Pulmonary Disease [COPD]
Improvement Activities (IA) Category
CMS proposes to update the Improvement Activities inventory for the 2022 performance year, including adding seven new activities and modifying 15 current activities. Many of the changes pertain to health equity and standardizing language related to equity across the activities. There are six activities proposed for removal.
The Proposal Rule would also allow CMS to suspend an Improvement Activity if there is a reason to believe that the continued collection raises possible patient safety concerns or is obsolete. In these cases, CMS would immediately notify clinicians and the public through the usual communication channels and would then propose to remove or modify the activity as appropriate in the next rulemaking cycle.
|Proposed Improvement Activities to be Removed||Proposed New Improvement Activities|
|IA_ BE_13 Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms||IA_AHE_XX - Create and Implement an Anti-Racism Plan (High)|
|IA_PSPA_11 - Participation in CAHPS or other supplemental questionnaire||IA_AHE_XX Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols (Medium)|
|IA_BE_17 - Use of tools to assist patient self-management||IA_BMH_XX - Implementation of a Trauma-Informed Care (TIC) Approach to Clinical Practice (Medium)|
|IA_BE_18 - Provide peer-led support for self-management.||IA_BMH_XX - Promoting Clinician Well-Being (High)|
|IA_BE_20 - Implementation of condition-specific chronic disease self-management support programs||IA_ERP_XX - Implementation of a Personal Protective Equipment (PPE) Plan (Medium)|
|IA_BE_21 - Improved practices that disseminate appropriate self-management materials||IA_ERP_XX - Implementation of a Laboratory Preparedness Plan (Medium)|
| ||IA_PSPA_XX - Application of CDC’s Training for Healthcare Providers on Lyme Disease (Medium)|
Promoting Interoperability (PI) Category
CMS is proposing to apply automatic reweighting to the following, beginning with the 2022 performance period:
- Clinical social workers
- Small practices
Changes are also proposed to the following PI reporting requirements:
- Revises reporting requirements for the Public Health and Clinical Data Exchange objective to support public health agencies (PHAs) in future health threats and a long term COVID-19 recovery. CMS would require reporting of the Immunization Registry Reporting and Electronic Case Reporting (unless an exclusion can be claimed). The Public Health Registry Reporting, Clinical Data Registry Reporting, and Syndromic Surveillance Reporting measures would be optional and MIPS eligible clinicians could earn 5 bonus points if they report a “yes” response for either of them. CMS would remove the exclusions for these measures.
- Modifies the Provide Patients Electronic Access to Their Health Information measure to require that patients have access to their health information indefinitely, for encounters on or after January 1, 2016.
- Requires MIPS eligible clinicians to attest to conducting an annual assessment of the High-Priority Guide of the Safety Assurance Factors for EHR Resilience Guides (SAFER Guides) beginning with the 2022 performance period.
- Modifies the Prevention of Information Blocking attestation statements.
Complex Patient Bonus
CMS is proposing to continue doubling the complex patient bonus for the 2021 MIPS performance year. These bonus points (capped at 10-points) would be added to the final score. The agency is also proposing to revise the complex patient bonus beginning with the 2022 MIPS performance year by:
- Limiting the bonus to clinicians who have a median or higher value for at least one of the two risk indicators (HCC and dual proportion).
- Updating the formula to standardize the distribution of 2 two risk indicators so that the policy can target clinicians who have a higher share of socially and/or medically complex patients.
- Increasing the bonus to a maximum of 10.0 points.
Some clinicians and practices are designated as facility-based and eligible for special scoring. CMS is proposing to adopt the following changes to facility-based measurement for the 2022 performance year:
- The MIPS quality and cost performance category scores will be based on the facility-based measurement scoring methodology unless a clinician or group receives a higher MIPS final score through another MIPS submission.
Redistributing Performance Category Weights for Small Practices
The Proposed Rule would update the redistribution policies for small practices. When the Promoting Interoperability performance category is reweighted the following category weights would apply:
- Quality would be weighted at 40%.
- Cost would be weighted at 30%.
- Improvement activities would be weighted at 30%.
In cases where both the Cost and the Promoting Interoperability performance categories are reweighted the Quality and Improvement Activities categories would be equally weighted at 50%.
The Future of the Quality Payment Program
While MIPS has gone through incremental changes since its inception in 2017, CMS intends to transform the program in future years through the adoption of the proposed MIPS Value Pathways (MVPs) and the APM Performance Pathway (APP).
Clinicians will be able to report MVPs beginning with the 2023 performance year as a new reporting framework to eventually replace the traditional MIPS program. MVPs will be voluntary for the 2023 performance year. CMS also plans for MVPs to be voluntary for the 2024-2027 performance years, but is considering sunsetting the traditional MIPS program in 2027 and mandating the reporting of MVPs beginning with the 2028 performance year.
The purpose of MVPs is to align and connect measures and activities across the MIPS Quality, Cost, Promoting Interoperability, and Improvement Activities performance categories for different specialties or conditions. CMS has proposed seven MVPs for the 2023 performance year:
- Stroke Care and Prevention
- Heart Disease
- Chronic Disease Management
- Emergency Medicine
- Lower Extremity Joint Repair
More information about MVP reporting and the future of the MIPS program can be found here.
In the 2021 Final Rule for the Quality Payment Program (QPP), CMS introduced a new reporting framework for MIPS Alternative Payment Models (APMs) and Accountable Care Organizations (ACOs) called the APM Performance Pathway (APP). The APP is a single, pre-determined measure set that MIPS APM participants may choose to report on beginning in the 2021 performance year. While Medicare Shared Savings Program (MSSP) ACOs were originally required to begin reporting all-payer Quality data (eCQMs/MIPS CQMs) through the APP beginning in 2022, CMS is now proposing a longer transition period for these organizations.
The 2022 Proposed Rule would extend the CMS Web Interface as an option for two years for MSSP ACOs (during the 2022 and 2023 performance years). However, in 2023, they would have to report at least one eCQM/CQM.
- 2021-2022 - ACOs would either report the 10 CMS Web Interface measures or the three all-payer eCQMs/MIPS CQMs. Under the APP, all ACOs would administer the CAHPS for MIPS Survey and be scored on two administrative claims-based measures (calculated by CMS).
- 2023 - ACOs would either report the 10 CMS Web Interface measures and at least one all-payer eCQM/MIPS CQM or the three3 all-payer eCQMs/MIPS CQMs. Under the APP, all ACOs would continue to administer the CAHPS for MIPS Survey and be scored on two administrative claims-based measures (calculated by CMS).
- 2024 - ACOs would have to report on all three eCQMs/MIPS CQMs.
FHIR and Digital Quality Measures (dQMs)
CMS aims to move fully to digital quality measures (dQMs) for quality reporting using Fast Healthcare Interoperability Resources (FHIR) by 2025. FHIR is a free and open-source standards framework (in both commercial and government settings) created by Health Level Seven International (HL7®) that establishes a common language and process for all health IT. It allows systems to communicate and information to be shared seamlessly with a lower burden on stakeholders.
CMS plans to align eCQMs with the FHIR standard and support quality measurement via application programming interfaces (APIs). One key goal of the plan is to improve the efficiency of quality reporting by moving to digital measures and using advanced data analytics. CMS believes FHIR standards enable collaboration and information sharing, which is essential for delivering high-quality care and better outcomes at a lower cost. By aligning technology requirements for payers, health care providers, and health IT developers CMS can advance an interoperable health IT infrastructure that ensures providers and patients have access to health data when and where it is needed.
The ONC 21st Century Cures Act created a Standardized API for Patient and Population Services certification criterion for health IT that requires the use of FHIR Release 4 and several implementation specifications. Health IT certified to this criterion will offer single patient and multiple patient services that can be accessed by third-party applications like MDinteractive registry. The rule also requires health IT developers to update their certified health IT to support the United States Core Data for Interoperability (USCDI) standard by December 31, 2022.
The use of APIs will reduce longstanding barriers to quality measurement. Currently, integrating between different health IT systems is burdensome and costly, and it is difficult to reliably obtain high quality data across EHRs. As health IT developers map their health IT data to the FHIR standard, APIs can enable structured data to be easily accessible for quality measurement or other use cases, such as care coordination, clinical decision support, and supporting patient access.
The proposed rule describes 4 future actions that would enable the transformation to a fully digital quality measurement enterprise by 2025:
- Leveraging and Advancing Standards for Digital Data and Obtaining all EHR Data Required for Quality Measures via Provider FHIR-based APIs.
- Redesigning Quality Measures to be Self-Contained Tools.
- Building a Pathway to Data Aggregation in Support of Quality Measurement.
- Potential Future Alignment of Measures Across Reporting Programs, Federal and State Agencies, and the Private Sector
The 2022 Proposed Rule would make significant changes to the traditional MIPS program next year and lays out a plan to introduce MVP reporting. CMS is accepting public comments until September 13, 2021. A final regulation will be issued later this year, but MIPS eligible clinicians should begin considering the proposed changes now so they understand the potential impact on their reporting practices.
MIPS 2022 Proposed Rule MVPs APP MACRA