2018 Updates to the MACRA Quality Payment Program

Manatt on Health

On November 2, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a Final Rule with Comment updating the Quality Payment Program (QPP) under the Medicare and CHIP Reauthorization Act of 2015 (MACRA).

MACRA was signed into law on April 16, 2015, ending the Sustained Growth Rate (SGR) formula for determining Medicare spending on physician services. MACRA created two provider payment tracks—the Medicare Incentive Payment System (MIPS), and the Advanced Alternative Payment Models (A-APM) track. Under MIPS, clinicians receive an annual composite score, which drives either an upward or downward rate adjustment two years after the performance period. Under the A-APM track, participants in Medicare Alternative Payment Models that exceed specified levels of clinician risk become MIPS-exempt and receive special bonuses equivalent to 5% of their annual Part B revenue.

MACRA requirements on clinicians are already in effect for calendar year 2017, with payment adjustments under the new system due to start in 2019. However, in rulemaking last year, CMS significantly scaled back MIPS requirements for Performance Year 2017 to address concerns about physician buy-in and participation. Under the Final Rule, CMS would continue this “go slow” trajectory for MIPS, notably by increasing MIPS exemptions and once again scaling back potential downside payment adjustments through design of the MIPS scoring system.

The key changes finalized for Performance Year 2018 and onward provide that CMS will:

  • Implement the concept of “virtual groups” to allow clinicians and practices to band together for MIPS reporting and scoring (i.e., the virtual group receives a single score);
  • Raise the minimum Medicare volume threshold for participation in MIPS, relative to Performance Year 2017 (to $90,000 in allowed charges, or 200 Part B beneficiaries), which would exempt more than 60% of otherwise-eligible clinicians from the program;
  • Score clinicians and practices in part on their improvement on MIPS categories, relative to their own past scores;
  • Delay the requirement for use of 2015 Certified EHR Technology under MIPS;
  • Introduce an alternative MIPS scoring methodology, aligned with the Hospital Value-Based Purchasing program in Medicare Part A, for facility-based clinicians (originally proposed for Performance Year 2018, but delayed in the final rule to Performance Year 2019);
  • Raise the MIPS threshold score (i.e., the score below which a participant would receive a negative payment adjustment) to 15 out of a possible 100, up from a score of 3 for Performance Year 2017;
  • Develop the “All Payer Combination Option” to allow participants in Advanced Alternative Payment Models to receive credit for non-Medicare models, including by examining Medicaid payment models to predetermine which models could count toward “Qualifying Participant” status;
  • Allow participation in certain risk-bearing arrangements with Medicare Advantage plans to count alongside participation in Medicare’s own portfolio of Advanced Alternative Payment Models (the proposed rule solicited feedback on this topic, and the final rule announced CMS’ intention to launch a demonstration prior to 2019);
  • Weight the cost performance category at 10%, as a transition to the 30% weight required by statute in Performance Year 2019. (The proposed rule had contemplated maintaining the 0% weight from Performance Year 2017 for an additional year.);
  • Clarify with respect to Part B drugs that it will apply MIPS payment adjustment factors to a MIPS base payment, which includes Part B drugs furnished incident to the services of a MIPS-eligible clinician to the extent those Part B drugs can be linked to a MIPS-eligible clinician.