A Guide to Regulation and Legislation Volume Nineteen

Our regulatory advisor highlights some of the key modifications to MIPS and APMs, and outlines CMS’s QPP priorities for 2019.

Navigating health reform

Broad Changes Finalized for CMS’s 2019 Quality Payment Program

  • 1/15/2019

On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released the CY 2019 Quality Payment Program (QPP) Final Rule. The rule also contains the final provisions of the physician fee schedule, which is covered in Regulatory Advisor Volume 18.

2019 QPP priorities

CMS has identified the following priorities for year three of the QPP:

  • Reducing clinician burden
  • Implementing the Meaningful Measures Initiative
  • Promoting interoperability
  • Continuing support for small and rural practices
  • Empowering patients through the Patients Over Paperwork initiative
  • Promoting price transparency

CMS estimates approximately 650,000 clinicians will be MIPS-eligible clinicians in 2019, with another 160,000 to 215,000 clinicians qualifying as a Qualified Participant (QP) within APMs. The estimated APM incentive payments for the 2019 performance year is approximately $600-800 million. The MIPS payment adjustment for 2021 is +/- 7 percent.

As prefaced by the Bipartisan Budget Act of 2018 (BBA), CMS will continue to gradually implement MIPS for an additional three years to allow clinicians to ease into value-based payment. Prior to the BBA, year three of QPP was expected to bring full program implementation.

Eligible clinician definition expands to increase participation opportunities

Beginning with the 2019 performance year, the following provider types are finalized as eligible clinicians and will be required to participate in MIPS:

  • Physical therapists
  • Occupational therapists
  • Clinical psychologists
  • Qualified audiologists
  • Registered dietician or nutrition professional
  • Qualified speech language pathologist

Clinical social workers were not finalized as an eligible clinician type due to a lack of applicable measures for reporting.

Low-volume threshold expands and includes opt-in

For performance year 2019, MIPS exemptions include:

  • Eligible clinicians who provide covered services to 200 or fewer Medicare Part B beneficiaries
  • Eligible clinicians who provided less than or equal to $90,000 in covered services in the MIPS performance year
  • Eligible clinicians who provide 200 or fewer covered professional services to Part B-enrolled individuals

There are three reporting options for the 2019 performance year: required to participate in MIPS, opt-in participation, and voluntary reporting. Solo practitioners and groups that exceed one or more of the low-volume thresholds (but not all) may choose to “opt-in” to the QPP for performance year 2019. Those that do not exceed one or more of the exemptions may still voluntarily report, but they will not be eligible for an incentive payment. In order to make a selection, eligible clinicians will need to log into their QPP portal account and select their participation option.

View Table 31 of our supplemental material to view low-volume threshold determination opt-in scenarios.

Reweighting will result in a neutral payment adjustment
for some

A weight of zero percent will be assigned to all four performance categories (and a neutral payment adjustment will be applied) for clinicians in the following circumstances:

  • A MIPS eligible clinician joins an existing practice (existing tax identification number [TIN]) in the final three months of the performance period year and the practice is not participating in MIPS as a group
  • A MIPS eligible clinician joins a practice that is a newly-formed TIN in the final three months of the performance period year
Changes to virtual groups election process proposed for
year four

Beginning with the 2020 performance year, CMS finalized changes to the virtual group election process from a written submission process to an election that would occur in a manner specified by CMS. It is anticipated that CMS will use a web-based system focused on reducing burden and creating a seamless user experience.

2019 performance year MIPS reporting periods and other MIPS highlights
  • Quality and cost = full calendar year
  • Promoting interoperability and improvement activities = minimum, continuous 90 days
  • Data completeness requirements will also remain at 60 percent for claims-based qualified clinical data registries (QCDR), MIPS clinical quality measures (MIPS CQMs), and electronic clinical quality measures (eCQMS).
  • The complex patient bonus of up to five points is still available. This bonus is based on a Hierarchical Condition Category (HCC) risk score and a score based on the percentage of dual eligible beneficiaries.
  • In order to be eligible for an incentive in 2019, the performance threshold will increase to 30 points, with the exceptional bonus performance increased to 75 points.
Updated terminology finalized
  • Collection type refers to a set of quality measures with comparable specifications and data completeness criteria.
    • eCQMs, MIPS CQMs, QCDR measures, Medicare Part B claims measures, CMS web interface measures, Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey measures, and administrative claims measures are all considered collection types.
  • The term MIPS CQMs replaces what was formerly referred to as registry measures, since entities other than registries may submit data on these measures.
  • Submitter type refers to the MIPS eligible clinician, group, or third party intermediaries acting on behalf of a MIPS eligible clinician or group to submit data on measures and activities.
  • Submission type will be used to refer to mechanisms by which submitter types submit data to CMS.
    • Direct, log in and upload, log in and attest, Medicare Part B claims, and the CMS Web Interface are considered submission types.
Claims-based reporting for small practices

CMS finalized the Medicare Part B claims collection type for small practices beginning in 2019. This collection type applies to both individual reporters and groups of fewer than 15 eligible clinicians.

Small practices will continue with a bonus in 2019, but it will be shifted from reporting data in any MIPS category to the numerator of the quality performance category. MIPS eligible clinicians submitting data on at least one quality measure will receive three bonus points.

Quality measures focus on outcomes

CMS proposed the addition of 10 new MIPS quality measures and finalized eight, including four patient reported outcome measures, six high priority measures, and two other measures aligned to the Meaningful Measures framework. Of the 34 quality measures proposed for elimination, 26 were finalized. The final weight for the quality composite in 2019 is 45 percent, and MIPS reporters will continue to submit six applicable quality measures, including one outcome or high priority measure.

Facility-based measurement

In order to implement facility-based measurement criteria adopted in the 2018 PFS Final Rule, CMS finalized facility-based measurement criterion, including:

  • Adding on-campus hospital outpatient (POS 22) to the list of locations that determine the location of an eligible clinician.
  • Requiring a facility-based clinician to have a minimum of one service billed in the inpatient (POS 21) or emergency department (ED) (POS 23) setting to be considered hospital-based; therefore, an eligible clinician that bills 100 percent of hospital services in the outpatient setting will not qualify as a facility-based clinician.
  • Requiring eligible clinicians to be attributed to a facility with a VBP Program Total Performance Score or to report MIPS using an alternative method.
  • Aligning the eligibility determination periods across the program.

Topped out measures

Due to extremely high performance, where meaningful improvement in performance can no longer be made, once a measure has reached an extremely topped out status (98th to 100th percentile range), the measure will be removed in the next rulemaking cycle, regardless of whether it is in the midst of the topped out measure lifecycle. Exceptions will be made if there is a compelling reason for keeping the measure.

Cost category brings back episode-based measures

The finalized weight for 2019 will be 15 percent of a MIPS eligible clinicians’ final score for the 2021 MIPS payment year. CMS anticipates increasing this by 5 percent per year until they meet the required 30 percent by 2024. In an effort to increase clinician-focused measurement of cost performance, CMS also finalized eight episode-based measures following field testing of these measures in the fall of 2017.

Episode-based measures differ from the total per capita cost measure and Medicare Spending per Beneficiary measure, as it includes items and services that are related to a specific episode of care for a clinical condition or procedure. These measures represent the cost to Medicare, equal to the allowed amount, related to the initial treatment of a patient and throughout the timeframe of the episode. In general, episode groups:

  • Represent a clinically cohesive set of medical services rendered to treat a given medical condition
  • Aggregate all items and services provided for a defined patient cohort to assess the total cost of care
  • Are defined around treatment for a condition (acute or chronic) or performance of a procedure

Items and services can include medical and surgical services, diagnostic services, and ancillary items directly related to treatment. Also included are items and services that occur after the initial treatment, furnished as follow-up care or related complications resulting from the procedure or condition. Episode costs are payment standardized and risk adjusted, and each episode has a case minimum for statistical reliability. Below is the final list of Episode-Based Measures for the 2019 Performance Period. There are slight differences in the attribution of procedural versus acute inpatient medical condition episode based measures, but the plurality of Evaluation and Management (E&M) services and the concept of a procedure code trigger are still core tenants.

Table 33 of the proposed rule illustrates the episode-based measures finalized for performance year 2019. The case minimum for the procedural episodes will be 10, while the acute inpatient episodes will have a case minimum of 20.

View Table 33 of our supplemental material to view episode-based measures proposed for the 2019 MIPS performance period and future performance periods.

Improvement activities see minor changes

CMS finalized the addition of six new improvement activities, modified five existing improvement activities, and removed one improvement activity, resulting in 118 measures available for performance year 2019. Improvement activities will continue to be weighted at 15 percent, and small practices, non-patient facing clinicians, and clinicians located in rural or HPSAs will continue to receive double points.

Promoting interoperability has new scoring methodology

The Promoting Interoperability (PI) performance category moves away from the base, performance, and bonus score methodology in 2019 and is replaced with performance-based scoring at the individual measure level. The finalized weight for PI is 25 percent.

The new scoring methodology eliminates the concept of base and performance scoring, and includes new measures, as well as the existing PI measures, broken into a smaller set of four objectives to be scored based on performance. The smaller set of objectives include:

  • e-Prescribing
  • Health information exchange (HIE)
  • Provider to patient exchange
  • Public health and clinical data exchange

MIPS eligible clinicians are required to report certain measures from each of the four objectives, with performance-based scoring at the individual measure-level. If clinicians fail to report on a required measure or claim an exclusion, a total score of zero is earned for the PI component.

One slight modification from the proposed rule includes changing the point value for the Provide Patients Electronic Access to Their Health Information measure, which will be worth up to 40 points beginning in CY 2019, up from the proposed 35 points.

New opioid measures for e-prescribing in 2019

CMS finalized two new optional measures within the e-Prescribing objective:

  • Query of Prescription Drug Monitoring Program (PDMP)
  • Verify opioid treatment agreement

These measures can be reported in 2019 for up to five bonus points each. Querying the PDMP will be required in 2020.

Changes to the health information exchange objective

In an effort to emphasize the importance of sharing health information through interoperable exchange efforts, CMS finalized the renaming of the Send a Summary of Care measure to Support Electronic Referral Loops by Sending Health Information. In addition, CMS has finalized a new measure that combines the functionality of the existing Request/Accept Summary of Care and Clinical Information Reconciliation measures into a new measure, Support Electronic Referral Loops by Receiving and Incorporating Health Information.

Each of these measures is worth 20 points. The final rule outlines two potential exemptions for the Support Electronic Referral Loops by Receiving and Incorporating Health Information measures:

  • Any MIPS eligible clinician who is unable to implement the measure for a MIPS performance period in 2019
  • Any MIPS eligible clinician who receives fewer than 100 transitions of care or referrals or has fewer than 100 encounters with patients never before encountered during the performance period

View Table 41 in the final rule, which summarizes the scoring methodology for 2019.

Security risk analysis required but no longer counted in performance score

The Protect Patient Health Information objective and its associated measure, Security Risk Analysis, remain part of the requirements in 2019, but will no longer be scored as a measure and will contribute to a clinician’s overall PI score. Clinicians will still need to report that security risk analysis actions were completed during the calendar year in which the performance period occurs.

2015 CEHRT required in 2019

Beginning in 2019, MIPS eligible clinicians must use 2015 certified electronic health record technology (CEHRT). CMS states the 2014 Edition certification criterion are out of date and insufficient for clinician needs in the evolving health information technology (IT) industry. CMS cites major improvements of the 2015 technology, as the catalyst, including the Application Programming Interface (API) functionality and the US Core Data for Interoperability (USCDI).

2019 PI submission options

Three submission options were finalized to submit PI category data for MIPS:

  1. Direct submission to CMS via an API integrated in the EHR
  2. Log in to the Enterprise Identity Data Management (EIDM) account and upload the data
  3. Log in to the EIDM account and attest
Advanced APMs

Certified EHR technology and quality measure clarifications

CMS finalized that beginning for CY 2019, in order to be an Advanced APM, the APM must require at least 75 percent of eligible clinicians in each APM entity to use CEHRT. This is up from 50 percent in 2018. CMS finalized the QPP rule for 2018 surrounding the definition of MIPS comparable quality measures. Effective January 1, 2020, CMS will require at least one of the quality measures that an Advanced ACO bases payment on should be on the MIPS final list of measures, or endorsed by a consensus-based entity, or otherwise determined by CMS to be evidenced-based, reliable, and valid.

All other measures would need to be independently determined by CMS to be evidence-based, reliable, and valid in order to be considered MIPS comparable quality measures. CMS will apply this same approach to the requirement for an outcome measure — it must be evidence-based, reliable, and valid (unless there is no available or applicable outcome measure). This also applies to the All-Payer APM option, with some exceptions. This requirement does not apply if CMS determines that there are no available or applicable outcome measures included in the MIPS quality measures list for the Advanced APM's first QP Performance Period.

Other payer advance APM changes

To add consistency and to reduce burden, CMS will require that other payers meet the same criteria as Medicare APMs by January 1, 2020. CMS will also phase in the CEHRT requirement by requiring at least 50 percent of Other Payer Advanced APMs use CEHRT to document and communicate clinical care in 2019 and then 75 percent for 2020 and beyond.

CMS will also allow QP determinations to be requested at the TIN level in addition to the APM Entity and individual eligible clinician levels. QP determinations made at the TIN level require all clinicians to reassign their billing rights to the APM Entity. CMS further clarifies that in making QP determinations using the All-Payer Combination Option, eligible clinicians can meet the minimum Medicare threshold using one method, and the All-Payer threshold using the same or a different method.

CMS mirrors the MIPS comparable quality measure language for all payer combo APMs. It designates that at least one quality outcome measure:

  • Be included in the MIPS final list of measures;
  • Has been endorsed by a consensus-based entity as presumptively evidence-based, reliable, and valid; or
  • Has been determined by CMS to be evidence-based, reliable, and valid.

There is an exception, in that CMS will not apply this criteria until 2020.

For submitting multi-year payer determination, CMS finalized the proposal to modify its requirement of an annual submission by allowing both the eligible payer and eligible clinician-initiated process to submit multi-year payment arrangements. The first year would require submission as usual, but in subsequent years, only changes to the arrangement would be submitted. CMS finalized that for these multi-year arrangements, the certifying official must review the submission at least annually, assess any modifications, and submit those changes to CMS for up to five years.

QP determination

For the three QP determination dates (March 31, June 30, and August 31), CMS finalized a claims run-out of 60 days before calculating the threshold scores so that the three QP determinations will be completed approximately three months after the end of that determination time period. CMS is shortening the claims run-out period by 30 days so that eligible clinicians are notified of their QP status more quickly after each of the three QP determination snapshot dates, and prior to the beginning of the MIPS data submission period after the last determination.

Partial QP elections process

CMS finalized that when an eligible clinician is determined to be a Partial QP for a year at the individual eligible clinician level, the individual eligible clinician can choose to report to MIPS. If the eligible clinician reports to MIPS, they will be subject to all the reporting requirements and payment adjustments. If the eligible clinician elects not to report to MIPS, they are not subject to the MIPS reporting requirements and payment adjustment.

Calculating thresholds in All-Payer Combination Option

CMS finalized an approach that will allow eligible clinicians to become QPs by meeting the QP thresholds through a combination of both Medicare Part B covered professional services furnished through a Medicare Advanced APM and services furnished through other payer APMs. CMS will use the threshold score of either the payment amount or payment count — whichever is most advantageous toward achieving QP status for the year. Other APM entities or the eligible clinicians must submit the payment amount and patient count information to CMS by December 1 of the calendar year that is two years prior to the payment year (the QP Determination Submission Deadline). This is required because CMS does not have access to private payer data.