Our regulatory advisor summarizes changes proposed in the Quality Payment Program rule. Submit your comments before the September 27 deadline.
On July 29, 2019, the Centers for Medicare & Medicaid Services (CMS) released the 2020 proposed Physician Fee Schedule (PFS) rule (CMS-1715-P) and other Part B changes, including the Quality Payment Program (QPP). Updates to the PFS are covered in a separate CLA Regulatory Advisor. The following includes a high level look of key provisions related to the QPP. CMS encourages stakeholders to provide feedback before the September 27, 2019, comment deadline.
Key takeaways
CMS proposes a new Merit-Based Incentive Payment System (MIPS) participation framework for the future called the MIPS Value Pathway. In proposing the new framework, CMS is seeking to align and streamline the program for the future. CMS also provides updates to MIPs measures, category weights, and Alternative Payment Models (APMs).
Table of Contents
I. Merit-Based Incentive Payment System
a. Quality performance category
b. Cost performance category
c. Improvement activities category
d. Promoting interoperability category
e. Third-party intermediaries
f. MIPS thresholds
g. MIPS APMs
II. MIPS Value Pathway
III. Alternative Payment Models
Merit-Based Incentive Payment System
CMS maintains current eligible providers as well as low-volume thresholds for 2020 (year four). Additionally, opt-in policies and MIPS determination periods remain the same.
For 2020, CMS proposes the following adjustments to the performance category weightings:
- Quality category to decrease from 45% to 40%
- Cost category to increase from 15% to 20%
- Improvement activities (IA) category remains the same at 15%
- Promoting interoperability (PI) category remains the same at 25%
CMS provides 2021 and 2022 weightings as well. Weights by year are listed below.
| Category | Category weights final 2019 | Category weights proposed 2020 | Category weights proposed 2021 | Category weights final 2022 (mandated) |
|---|---|---|---|---|
| Quality | 45% | 40% | 35% | 30% |
| Cost | 15% | 20% | 25% | 30% |
| Improvement activities | 15% | 15% | 15% | 15% |
| Promoting interoperability | 25% | 25% | 25% | 25% |
CMS proposes several changes to the hospital-based MIPS-eligible clinicians. Beginning with performance year 2020, CMS proposes a hospital-based MIPS-eligible clinician would be an individual furnishing 75% or more of covered professional services. A group would be identified as hospital-based if more than 75% of the National Provider Identifier (NPIs) in the group meet the definition of a hospital-based individual MIPS-eligible clinician. For non-patient facing groups (more than 75% of the MIPS-eligible clinicians in the group are classified as non-patient facing), reweighting would be automatic.
CMS proposes no change to the definition of an individual hospital-based MIPS-eligible clinician.
Quality performance category
CMS makes dozens of changes to various quality measures, and readers should review the proposed rule for more details. Overall, CMS proposes to remove low-bar standard of care process measures, focus more on outcome measures, and add new specialty sets for speech language pathology, chiropractic medicine, and pulmonology, among others.
CMS also proposes to continue increasing data completeness thresholds to 70% for the performance period. Qualified Clinical Data Registry (QCDR) measures, MIPS Clinical Quality Measures (CQMs), and electronic CQMs (eCQMs) would also be required to meet a 70% sample of a clinician’s or group’s patients across all payors for the performance period. CMS seeks comments on increasing the threshold to 80% in 2020.
Cost performance category
CMS proposes to include 10 new evidence-based cost measures to the 2020 performance period. The measures have been field tested and reviewed. CMS proposes revisions related to attribution methodology for Total Per Capita Cost of Care (TPCC) and for Medicare Spending Per Beneficiary Clinician (MSPB). Both revised measures would be used for the 2020 performance period.
Improvement activities category
CMS proposes various changes to the IA category, including adding two new activities: Drug Price Transparency and Completion of an Accredited Safety or Quality Improvement Program. In addition, CMS proposes modifying seven current activities and removing 15 others.
CMS also modifies its policy on group credit and requires increased participation levels. For 2020, CMS would require at least 50% of MIPS-eligible clinicians (in the group or virtual group) to participate in or perform the activity. At least 50% of a group’s NPIs must perform the same activity for the same continuous 90 days in the performance period.
Promoting interoperability category
In 2021 and 2022, CMS would maintain the PI performance period of a minimum, one continuous 90-day period.
CMS makes several changes to the 2019 performance period for e-prescribing objective measures:
- Query of Prescription Drug Monitoring Program (PDMP) measure would move to a yes/no response instead of using a numerator/denominator.
- Points for the Support Electronic Referral Loops by Sending Health Information measure would be redistributed to the Provide Patients Access to Their Health Information measure if an exclusion is claimed.
For the 2020 performance period, CMS will:
- Remove Verify Opioid Treatment Agreement measure
- Retain Query of PDMP measure as optional and eligible for five bonus points for 2020.
For the health information exchange objective, CMS proposes revisions to the exclusion language for several measures.
Third-party intermediaries
CMS proposed various changes and new requirements for third-party intermediaries. For these entities, such as Qualified Clinical Data Registries (QCDRs) and Qualified Registries, CMS is generally proposing they:
- Support the Quality, IA, and PI performance categories;
- Provide enhanced performance feedback; and
- Deliver quality improvement services.
MIPS thresholds
With respect to potential MIPS payment adjustments, CMS proposes minimum MIPS performance and exceptional thresholds and the potential positive or negative adjustments.
| 2019 final | 2020 proposed | 2021 proposed | |
|---|---|---|---|
| Performance threshold | 30 | 45 | 60 |
| Exceptional threshold | 75 | 80 | 85 |
| Payment adjustment | +/- 7% | +/- 9% | Not provided in rule |
MIPS APMs
CMS lists the following 10 APMs as satisfying the requirements to be MIPS APMs for the 2020 MIPS performance period:
- Comprehensive ESRD Care Model (all tracks)
- Comprehensive Primary Care Plus Model (all tracks)
- Next Generation ACO Model
- Oncology Care Model (all tracks)
- Medicare Shared Savings Program (all tracks)
- Medicare ACO track 1+ Model
- Bundled Payments for Care Improvement Advanced
- Maryland Total Cost of Care Model (Maryland Primary Care Program)
- Vermont All-Payer ACO Model (Vermont Medicare ACO Initiative)
- Primary Care First (all tracks)
CMS is proposing various changes to the quality performance category. For example, CMS would allow MIPS-eligible clinicians participating in MIPS APMs to report on MIPS quality measures similar to what is done under PI performance category under the APM scoring standard. CMS proposes a MIPS APM quality reporting credit equal to 50% of the MIPS quality performance category weight for MIPS APMs that do not require reporting through MIPS quality reporting mechanisms.
MIPS Value Pathway
CMS notes there have been incremental changes to the MIPS program every year, but that perhaps the program is overly complex. CMS would like to make longer-term improvements to align and streamline the program for all participants. To do so, CMS proposes the MIPS Value Pathways (MVPs) as a new participation framework beginning with the 2021 performance year.
The new MVP framework would:
- Unite and connect measures and activities across the quality, cost, promoting interoperability, and IA performance categories of MIPS;
- Incorporate a set of administrative, claims-based quality measures that focus on population health and public health priorities; and
- Streamline MIPS reporting by limiting the number of required specialty or condition specific measures.
CMS provided this graphic illustration of the MVP pathway during a webinar on the proposed QPP:
CMS specifically encourages the health care community to review and provide feedback on the new framework.
Alternative Payment Models
CMS indicates the following would be an Advanced APM:
- Comprehensive Care for Joint Replacement Payment Model (CEHRT track)
- Comprehensive ESRD Care Model (two-sided risk arrangement)
- Comprehensive Primary Care Plus Model (all tracks)
- Next Generation ACO Model
- Oncology Care Model (two-sided risk arrangement)
- Medicare Shared Savings Program (Track 2, basic track Level E, and the ENHANCED track)
- Medicare ACO Track 1+ Model
- Bundled Payments for Care Improvement (BPCI) Advanced
- Maryland Total Cost of Care Model (Maryland Care Redesign Program, Maryland Primary Care Program)
- Vermont All-Payer ACO Model (Vermont Medicare ACO Initiative)
- Primary Care First (general and high-need population options)
CMS creates and defines Aligned Other Payer Medical Home Model under the All Payer APM Combination Option.
CMS addresses the marginal risk and expected expenditures policies for making Other Payer Advanced APM status determinations.
For 2020, CMS proposes that a clinician who is a Partial Qualifying Participant (QP) is only excluded from MIPS in the Tax Identification Number through which the clinician received Partial QP status.
CMS proposes that if an APM entity terminates before incurring financial risk (as necessary to be considered an Advanced APM), then an eligible clinician is not a QP or Partial QP for the year.
How we can help
CMS makes numerous technical policy and measure changes in this proposed rule. It also seeks comments, including Requests for Information on specific topics. CLA is on the forefront of these regulatory changes to help keep you up to date. All feedback must be submitted before the September 27, 2019, deadline.