6 Key Takeaways From the MIPS Proposed Rule for 2018
By Grant Huang, CPC, CPMA, Director of Content at DoctorsMangement
CMS has just unveiled its 2018 Quality Payment Program (QPP) proposed rule, which contains changes to the Merit-based Incentive Payment System (MIPS), making it the first major proposed rule released by the agency under the Trump administration.
The 1,058-page document, now available online for your review, shows that CMS remains committed to MACRA, MIPS, and the concept of pay-for-performance even as the Trump administration moves to roll back Obama-era regulations in other industries.
Overall, the 2018 QPP proposed rule appears to increase flexibility for MIPS reporting and expand the number of exempted providers, reflecting feedback CMS was already processing under the Obama administration, says Bradley Coffey, government affairs manager for the American Association of Orthopaedic Executives (AAOE) in Indianapolis.
Here are the key proposals in the rule:
- Expansion of the low-volume threshold. CMS established a “low-volume threshold” to filter out those Medicare Part B providers who don’t see enough Medicare patients to warrant their participation in MIPS. This rule was largely responsible for exempting more than 800,000 providers from MIPS in 2017 (newly-enrolled providers were also exempt). The current threshold is either $30,000 in Medicare Part B charges or 100 Medicare patients. Providers who bill less than that amount or see fewer than that number of patients are exempt. The proposed threshold bumps up the dollar amount to $90,000 and doubles the patient threshold to 200 patients. “I think it’s good as far as giving more providers exemption and flexibility in the short term, but there’s a point to be made about lack of readiness for the long term,” Coffey says.
- Virtual reporting groups for small practices. CMS is proposing to create a new reporting option for 2018 called “virtual group reporting.” The proposed rule defines a virtual group as a group comprised of two or more practices with 10 or fewer practitioners each, who combine their performance for the full year reporting period. Interestingly, the proposed rule states that a practice with 10 or fewer practitioners is eligible to participate in MIPS as part of a virtual group if they exceed the low-volume threshold at the group level. Thus a provider who is individually MIPS-exempt can still participate in MIPS and receive bonus payments if his/her group combines their Part B patients and charges to exceed the low-volume threshold. Note: A provider who is MIPS-exempt under the low-volume threshold is not otherwise eligible to receive bonus payments if he/she chooses to participate despite being exempt. “We’re very happy to see CMS pursuing this method,” Coffey says. “We believe it will allow many smaller practices to successfully report all the data that’s required under MIPS.”
- Reduced EHR certification requirements. CMS wants to make EHR requirements less onerous for MIPS purposes. For meaningful use reporting under MIPS, the proposed rule would only require EHRs certified under 2014 Edition guidelines instead of the latest 2015 Edition. Now that the EHR Meaningful Use Program has been folded into MIPS (it has been redesigned as the “Advancing Care Information” component of MIPS), this makes sense. Many EHR vendors have not yet obtained 2015 Edition certification.
- Give MIPS bonus points for complex patients. This proposal would add 1-3 points to the MIPS composite score of providers who see “complex” patients. The term “complex” would be defined based on the average Hierarchical Conditions Category (HCC) risk score of patients seen, though CMS is also open to using the number of “dual-eligible” (i.e., individuals who qualify for both Medicare and Medicaid) patients seen as an alternative way to define complex. CMS wants your comments and feedback on which method would be most effective in determining patient complexity. Because this type of bonus did not exist in the original rule, it is being created as a one-time provision for the 2018 reporting year only, though CMS leaves the door open to repeating this bonus in future years if successful.
- Give MIPS bonus points to participating small practices. Similar to the complex patients bonus, the small practice bonus would add 5 bonus points to the MIPS score of providers practicing in a small practice. The proposed rule defines a “small practice” as one with 15 or fewer total providers. A virtual group would also qualify as a small practice and receive the bonus for all of its member providers if the group totals 15 or fewer providers. This bonus would be calculated automatically by CMS and provider scores would be adjusted accordingly. “Eligible clinicians and groups who work in small practices are a crucial part of the health care system,” CMS writes in the proposed rule. The agency goes on to say that its analysis of performance data in past quality reporting programs shows that small practices lag far behind larger groups in participation and in performance for those that do participate. While the AAOE is supportive of the bonus, Coffey believes that the smallest practices require even more assistance. “I’d like to see more bonus points for the truly small practices, the one to five provider practices,” he says. “A practice with 10 or 15 physicians is a very different practice in terms of revenue, resources, and patient mix than a solo or two to three-physician practice that might be just now implementing EHR and is attempting quality reporting for the first time.”
- Continue to calculate MIPS score without Cost component. For the 2017 reporting year, the fourth component of MIPS, the “Cost” category, is not being counted towards providers’ final MIPS scores. The “Quality” category, which stands in for quality reporting, has been weighted upward to 60% to account for the fact that Cost will be weighted at 0% for 2017. In the proposed rule, CMS would continue this for 2018. For both years, the Cost category will still be calculated and appear in providers’ MIPS reports at the end of the reporting year. In 2019, the Cost category will account for 30% of the MIPS score, as required under MACRA.
You can find a bullet-by-bullet summary of the major provisions in the proposed rule created by CMS on its QPP website here.
Final rule to be released in Q4
Next year will mark the start of the second MIPS performance year, which will affect Medicare payments for 2020 (this year’s performance alters 2019 payments). CMS expects to release the final rule for 2018 sometime in November. In the meantime, the agency is accepting all public comments, which are due by Aug. 21. You can submit comments via mail or, more quickly, via the Federal Register website for the QPP proposed rule.