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The Centers for Medicare and Medicaid Services (CMS) released its 2024 Medicare Physician Fee Schedule (PFS) proposed rule on July 13, 2023, which includes proposed updates to the Quality Payment Program (QPP). This blog summarizes the key proposals impacting the traditional Merit-based Incentive Payment System (MIPS) program, reporting for Alternative Payment Models (APMs) and Accountable Care Organizations (ACOs), and the continued development of MIPS Value Pathways (MVPs). A 60-day comment period will be open until September 11, 2023. These proposals could go through additional changes before a final rule is published later this fall.
Performance Threshold Increases to 82 Points
MIPS reporting continues to become increasingly challenging for clinicians as they will have to meet a higher performance standard to avoid penalties. CMS is proposing to use the mean of final scores from the 2017-2019 MIPS performance periods to set the MIPS performance threshold. This would increase the performance threshold from 75 points in 2023 to 82 points for the 2024 MIPS performance year for all three MIPS reporting options (traditional MIPS, MIPS Value Pathways (MVPs), and the APM Performance Pathway). Once calculated, each MIPS-eligible clinician’s final score is compared to the performance threshold to calculate the MIPS payment adjustment.
The table below breaks down the payment adjustment associated with the final MIPS score based on the proposed higher performance threshold.
| 2024 Performance Period | |
|---|---|
2024 Final MIPS Score | 2026 MIPS Adjustment |
| 0.0-20.5 | Negative 9% |
| 20.51- 81.99 | Negative MIPS payment adjustment greater than negative 9% and less than 0% on a linear sliding scale |
| 82.0 | 0% adjustment |
| 82.01-100 | Positive MIPS payment adjustment greater than 0% on a linear sliding scale. The linear sliding scale ranges from 0 to 9% for scores from 86.00 to 100.00 This sliding scale is multiplied by a scaling factor greater than zero but not exceeding 3.0 to preserve budget neutrality. |
Quality Performance Category Proposed Updates
Higher Data Completeness Criteria for Quality Measures
Clinicians must meet “data completeness” when reporting Quality measures to ensure that the data submitted is sufficient to assess quality performance. CMS previously finalized a 75% data completeness threshold for the 2024 and 2025 performance periods (up from 70% in 2023) for electronic Clinical Quality Measures (eCQMs), MIPS CQMs, Medicare Part B claims measures, and QCDR measures. Under the proposed rule, the threshold will continue to increase for subsequent performance periods:
- 75% for the 2026 performance period
- 80% for the 2027 performance period
CMS is also proposing the following data completeness criteria thresholds for Medicare CQMs (a new reporting option for Accountable Care Organizations):
- 75% for the 2024, 2025, and 2026 performance periods
- 80% for the 2027 performance period
Quality Measure Inventory Changes
CMS is proposing a total of 200 quality measures for the 2024 performance period which reflect:
- 14 new Quality measures
- Removal of 12 Quality measures
- Partial removal of three measures (retained for MVP use only)
- Substantive changes to 59 existing Quality measures
A list of proposed new measures, along with their collection types, are outlined in the table below.
| Proposed New Quality Measures | Collection Type |
|---|---|
| Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level) | eCQM |
| Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood | MIPS CQM |
| Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument | MIPS CQM |
| First Year Standardized Waitlist Ratio (FYSWR) | MIPS CQM |
| Percentage of Prevalent Patients Waitlisted (PPPW) and Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW) | MIPS CQM |
| Preventive Care and Wellness (composite) | MIPS CQM |
| Connection to Community Service Provider | MIPS CQM |
| Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy | MIPS CQM |
| Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up | MIPS CQM |
| Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up | MIPS CQM |
| Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder | MIPS CQM |
| Gains in Patient Activation Measure (PAM®) Scores at 12 Months | MIPS CQM |
| Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk | MIPS CQM |
| Reduction in Suicidal Ideation or Behavior Symptoms | MIPS CQM |
A list of measures proposed for removal or partial removal is outlined in the table below.
| Quality Measures Proposed for Removal | Collection Type |
|---|---|
| #14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination | MIPS CQM |
| #93 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use | eCQM |
| #107 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment | eCQM |
| #110 Preventive Care and Screening: Influenza Immunization | Medicare Part B Claims, eCQM, MIPS CQM |
| #111 Pneumococcal Vaccination Status for Older Adults | Medicare Part B Claims, eCQM, MIPS CQM |
| #138 Melanoma: Coordination of Care | MIPS CQM |
| #147 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | Medicare Part B Claims, MIPS CQM |
| #283 Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management | MIPS CQM |
| #324 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | MIPS CQM |
| #391 Follow-Up After Hospitalization for Mental Illness (FUH) | MIPS CQM |
| #402 Tobacco Use and Help with Quitting Among Adolescents | MIPS CQM |
| #436 Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | Medicare Part B Claims, MIPS CQM |
| Quality Measures Proposed to be Removed from Traditional MIPS* | Collection Type |
| #112: Breast Cancer Screening | Medicare Part B Claims, eCQM, MIPS CQM |
| #113: Colorectal Cancer Screening | Medicare Part B Claims, eCQM, MIPS CQM |
| #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan | Medicare Part B Claims, eCQM, MIPS CQM |
*These measures would still be available for MVP reporting. Quality measures 112 and 113 would also be maintained for purposes of the CMS Web Interface collection type available to Shared Savings Program ACOs reporting through the APM Performance Pathway (APP).
New Collection Type for Shared Savings Accountable Care Organizations (ACOs)
CMS would establish a new collection type specifically for ACOs, Medicare CQMs, which can only be reported under the APP. Medicare CQMs are intended to address the data aggregation and patient matching issues Shared Savings Program ACOs experienced when reporting eCQMs and MIPS CQMs under the APP. More information about this reporting option can be found here.
Improvement Activities Category Proposed Updates
CMS is proposing 106 Improvement Activities in the MIPS inventory, including five new activities and the removal of three existing activities as outlined in the table below.
| Proposed New Improvement Activities | Improvement Activities Proposed for Removal |
|---|---|
| Improving Practice Capacity for Human Immunodeficiency Virus (HIV) Prevention Services Guidelines (submitted by CDC) | IA_BMH_6 Implementation of co-location PCP and MH services |
| Practice-Wide Quality Improvement in MIPS Value Pathways | IA_BMH_13 Obtain or Renew an Approved Waiver for Provision of Buprenorphine as Medication-Assisted Treatment [MAT] for Opioid Use Disorder |
| Use of Decision Support to Improve Adherence to Cervical Cancer Screening and Management | IA_ PSPA_29 Consulting Appropriate Use Criteria (AUC) Using Clinical Decision Support when Ordering Advanced Diagnostic Imaging |
| Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women | |
| Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults |
Promoting Interoperability (PI) Category Proposed Updates
Performance Period Expanded
CMS plans to lengthen the performance period for the PI Category from a minimum of 90 continuous days to a minimum of 180 continuous days within the calendar year.
CEHRT Definition Update
The definition of Certified Electronic Health Record Technology (CEHRT) would be updated to align with the Office of the National Coordinator for Health IT (ONC's) regulations which move away from the “edition” construct for certification criteria. References to the “2015 Edition health IT certification criteria” would be replaced with “ONC health IT certification criteria”.
PI Reweighting Changes
CMS intends to discontinue automatic reweighting for the following clinician types beginning with the 2024 performance period:
- Physical therapists
- Occupational therapists
- Qualified speech-language pathologists
- Clinical psychologists
- Registered dietitians or nutrition professionals
The agency plans to continue automatic reweighting for the following clinician types in the 2024 performance period:
- Clinical social workers
- ASC-based clinicians and groups
- Hospital-based clinicians and groups
- Non-patient facing clinicians and groups
- Clinicians in a small practice
PI Measure Changes
Query of Prescription Drug Monitoring Program (PDMP) Measure Exclusion - CMS would modify the current exclusion for the Query of Prescription Drug Monitoring Program (PDMP) Measure to accommodate clinicians who don’t electronically prescribe any Schedule II opioids and Schedule III and IV drugs during the performance period.
Safety Assurance Factors for EHR Resilience (SAFER) Guides Measure - A “yes” response would be required to fulfill the SAFER Guide measure beginning with the CY 2024 performance period.
Applicability to Shared Savings Program ACOs
CMS is proposing that, unless otherwise excluded, all MIPS eligible clinicians, Qualifying APM Participants (QPs), and Partial QPs participating in an ACO, regardless of track, satisfy all
of the following:
- Report the MIPS PI performance category measures and requirements to MIPS as either of the following
- All MIPS eligible clinicians, QPs, and partial QPs participating in the ACO as an individual, group, or virtual group; or
- The ACO as an APM entity.
- Earn a PI performance category score at the individual, group, virtual group, or APM entity level.
Use of CEHRT by APMs
Currently, 75% of eligible clinicians in each participating APM Entity must be required under the terms of the APM to use CEHRT in order for the APM to be an Advanced APM. CMS would remove this threshold under the proposed rule to specify that, to be an Advanced APM, the APM must require the use of certified EHR technology that meets the following:
- The 2015 Edition Base EHR definition, or any subsequent Base EHR definition; and
- Any such ONC health IT certification criteria that are determined applicable for the APM.
Cost Category Proposed Updates
Cost Improvement Scoring
The calculation for the Cost improvement score would be updated to ensure that improvement in the Cost category is more accurately scored and aligns with the Quality category scoring improvement methodology. Beginning with the 2023 performance period, the improvement scoring for the Cost performance category will be calculated at the category level, and statistical significance will not be used.
CMS is also proposing that the maximum cost improvement score of one percentage point out of 100 percentage points will be available beginning with the 2023 performance period and a maximum cost improvement of zero percentage points for the 2022 performance period.
Cost Measure Changes
Five new episode-based cost measures would be added for the 2024 performance period:
- Depression
- Emergency Medicine
- Heart Failure
- Low Back Pain
- Psychoses and Related Conditions
CMS also plans to remove the acute inpatient medical condition measure Simple Pneumonia with Hospitalization.
MIPS Value Pathways (MVPs)
CMS has previously expressed its intention to make MVPs the future of MIPS. In line with this vision, they are introducing five new MVPs for the 2024 performance year:
- Focusing on Women’s Health
- Quality Care for the Treatment of Ear, Nose, and Throat Disorders
- Prevention and Treatment of Infectious Disorders Including Hepatitis C and HIV
- Quality Care in Mental Health and Substance Use Disorders
- Rehabilitative Support for Musculoskeletal Care
CMS is also making modifications to 12 previously finalized MVPs.
Targeted Review Timeline
CMS is proposing to open the targeted review submission period upon release of the MIPS final
scores and to keep it open for 30 days after MIPS payment adjustments are released. This would maintain an approximately 60-day period for requesting a targeted review.
Additionally, if CMS requests information from clinicians under the targeted review process, the information must be provided to and received by CMS within 15 days of receipt of such request.
Next Steps
The 2024 Proposed Rule would make several changes to the Quality Payment Program, including reporting under the traditional MIPS program, APM and ACO reporting, and further development of MVP reporting. Clinicians should begin reviewing these changes now so they understand the potential impact on their reporting practices next year. A Final Rule is expected to be published later this fall.
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