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November 2016

Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program Final Rule

On October 14, 2016, the Centers for Medicare & Medicaid Services (CMS) released the final rule with comment period to implement MACRA’s Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). Collectively, these programs are part of what CMS now calls the Quality Payment Program (QPP). CMS has also issued a fact sheet, an executive summary, and an online toolkit on the payment program.

Quality Payment Program Overview

CMS finalized a transition year for the 2017 performance period, during which the only physicians who will experience a -4 percent payment penalty in 2019 are those who choose not to report any performance data. Physicians can avoid the payment penalty in 2019 by reporting for one patient on one quality measure, one improvement activity, or the 4 required Advancing Care Information (ACI) measures in 2017. Physicians who wish to possibly qualify for a positive payment adjustment must report more than the minimum one patient for one quality measure, improvement activity or the 4 required ACI measures.

Merit-Based Incentive Payment System (MIPS)

Overarching Issues

• Shortens performance period: Physicians who report for at least 90 continuous days in any of the three categories that will be included in the 2017 score will be eligible for positive payment adjustments. • Increases low-volume threshold: CMS raised the low-volume threshold in the proposed rule to exempt physicians from all performance reporting to $30,000 in annual Medicare revenue or 100 or fewer Part B-enrolled Medicare beneficiaries. CMS estimates that this change will exempt 32.5 percent of eligible clinicians from the program. • Increases non-patient facing eligible clinicians encounter threshold: CMS expanded the definition of a non-patient facing physician as an individual clinician that bills 100 or fewer patient-facing encounters during the non-patient facing determination period. • Provides for individual or group reporting: The final rule retains a provision allowing data submission and performance assessment to be done at either the individual or group level. Physicians must choose to report as an individual or group consistently across all MIPS categories. CMS also plans to allow physicians to participate in virtual groups beginning in 2018.


• Reduces reporting burden: Physicians are required to report on 6 measures or a specialty measure set, one of which must be an outcome measure or, if no outcome measures are available, a high priority measure. • Reduces administrative claims measures: An all-cause hospital readmissions measure was finalized for groups of 15 (up from 10 in the proposed rule) or more physicians and with 200 attributed cases. The measure will be calculated based off of administrative claims data. • Reduces data completeness criteria: In 2017, any physician who reports on one quality measure for at least one patient will receive at least 3 points on the measure, thereby avoiding a payment adjustment in 2019. • Reduces reporting thresholds: In 2017, physicians have to report on a measure successfully on 50 percent of patients, and in 2018, physicians have to report on a measure successfully on 60 percent of patients. CMS intends to increase the measure thresholds over time. If a physician is only avoiding a penalty and not attempting to earn an incentive, they are only required to report on one patient in 2017. • Increases quality percent of composite performance score: 60 percent of the composite performance score will be based on the quality performance category in 2017, due to the reduction of the cost performance category weight to zero percent. 50 percent of the composite performance score will be based on the quality performance category in 2018. In 2019 and beyond, 30 percent of the composite performance score will be based on the quality performance category. • Encourages the use of QCDRs and electronic sources: CMS provides preferential scoring for physicians who report quality measures through an EHR, qualified registry, QCDR, or web-interface.


• Reduces weight of composite performance 2: In 2017, the cost performance category is reduced to zero percent of the composite performance score. In 2018, the cost performance category is reduced to 10 percent of the composite performance score. In 2019 and beyond, the cost performance category will make up 30 percent of the composite performance score as required by MACRA. Although this category will not count in the composite performance score, CMS will calculate scores on the cost measures and provide them as informational to physicians in 2017. • Phases in episode-based measures: CMS finalized 10 episode based measures in 2017, and plans to finalize additional episode-based measures in future years. • Retains two problematic cost measures currently used in the value modifier: CMS finalized the total per capita cost and Medicare Spending Per Beneficiary (MSPB) administrative claims cost measures. The minimum number of cases required to count the total cost measure is 20. The minimum case threshold for the MSPB measure is 35. • Tools to improve cost measurement are under development: CMS is developing patient condition groups and patient relationship codes to assist with attribution beginning in 2018, as well as working for future years to refine its risk-adjustment methodologies.

Improvement Activities

• Reduces reporting burden: Physicians must attest to two 20-point high weighted activities, four 10-point medium-weighted activities, or another combination of high and medium weighted activities equaling 40 points or more to achieve full credit in the CPIA category. • Provides accommodations for small, rural, health professional shortage areas (HPSAs) and non-patient facing physicians: A lower reporting threshold of two medium-weighted or one high-weighted improvement activities are required for small, rural, HPSA and non-patient facing physicians to receive full credit. • Finalizes 90-day reporting period: CMS finalized its proposal to only require a 90-day performance period for Improvement Activities. • Increases number of highly-weighted activities: The final rule increases the number of highly-weighted activities available to physicians, including participation in rural health clinics. • Expands definition of medical homes eligible for full Improvement Activity credit: Participants that have received certification or accreditation as a Patient Centered Medical Homes (PCMH), or comparable specialty practices, including those certified by a national, regional or state program, private payer or other body that administers PCMH accreditation and certifies 500 or more practices for PCMH accreditation or comparable specialty practice certification will receive full credit in the CPIA performance category. • Provides full credit for MIPS APMs: APM Entities participating in the 2017 MIPS APMs receive a full score for the Improvement Activities in 2017. The eligible MIPS APMs are subject to change in future years. Other APMs are eligible for at least half-credit. • Incentivizes use of certified electronic health record technology (CEHRT): Physicians may receive preferential scoring in the ACI category by using CEHRT to perform one or more of 18 designated improvement activities.

Advancing Care Information

• Reduces reporting burden: Physicians must report on all required ACI measures in the Base Score (4 in 2017 and 5 thereafter), with up to an additional 9 optional measures in the Performance Score, for which physicians may receive additional percentage points. The Base Score measures are met via one unique patient or attestation to a “yes” option. The Performance Score measures are eligible for partial credit. • Temporarily shortens reporting period: In 2017 and 2018, physicians must report the ACI measures for a minimum of 90-days. • Promotes coordination between performance categories: Physicians can earn preferential scoring in the ACI performance category by reporting to public health and clinical data registries, and by using CEHRT to complete certain activities in the improvement activities performance category. • Eliminates measures: CMS finalized its proposal to eliminate the Clinical Decision Support (CDS) and Computerized Physician Order Entry (CPOE) measures from the Advancing Care Information measures. • Retains a pass-fail element: CMS finalized a pass-fail element in the base performance score, as physicians must report on all measures in the base score in order to earn a score in the ACI performance category.

Alternative Payment Models (APM)

Advanced APMs • Reduces the amount of losses defined as “more than nominal” in Advanced APMs: An APM will qualify as an Advanced APM in 2019 and 2020 if the APM Entity is either (1) at risk of losing 8 percent of its own revenues when Medicare expenditures are higher than expected, or (2) at risk of repaying CMS up to 3 percent of total Medicare expenditures, whichever is lower. CMS states that it plans to increase the risk standard to 10 or 15 percent of revenues in future years. • Simplifies the definition of “more than nominal financial risk”: To qualify as a Medicare Advanced APM, the APM must only meet the requirement for total risk. • Adopts flexible CEHRT and quality requirements: In 2017, 50 percent of participants in Advanced APMs would need to use CEHRT. To satisfy quality measure requirements, Advanced APM participants would be required to report quality measures similar to those used in the MIPS quality performance category. • Indicates future APM expansion: CMS acknowledged the need to expand the number of APMs quickly in the final rule. CMS indicates that it plans to modify existing programs, such as the Bundled Payments for Care Improvement initiative, so they meet the Advanced APM requirements. It also plans to develop a new MSSP ACO Track 1+ that requires less downside risk than current Track 2 and Track 3 ACOs, but sufficient risk to meet the Advanced APM standards. MIPS APMs MIPS APM requirements: MIPS APM participants can improve their MIPS scores in APMs that do not meet criteria to be Advanced APMs or if the physicians are participating in Advanced APMs but do not meet the revenue or patient thresholds to be exempt from MIPS. • Medicare Shared Savings Program and Next Generation ACOs would report quality for participants and the CPIA and ACI performance categories will be reweighted to 20 percent and 80 percent respectively. • Non-ACO MIPS APM participants will have their quality score reweighted to zero for the 2017 performance period and the CPIA and ACI performance categories will be reweighted to 25 percent and 75 percent respectively. • Each year, CMS will compare the requirements of the APM with the list of Improvement Activities and score those measures in the same manner they are otherwise scored for MIPS eligible clinicians. Prior to the start of each performance period, CMS will publish a list of the pre-assigned Improvement Activities score for each MIPS APM. If the assigned score does not represent the maximum Improvement Activities score, APM Entities will have the opportunity to report additional Improvement Activities. Patient-Centered Medical Homes definition: Medical homes that have received certification or accreditation as a patient-centered medical home (PCMH) or comparable specialty practices, including those certified by a national program, regional or state program, private payer, or other body that administers PCMH accreditation and certifies 500 or more practices, will receive full credit in the CPIA performance category.

Physician-Focused Payment Models (PFPMs)

PFPMs: The final rule expanded the definition of PFPM to include practitioners other than physicians. Payment models can target the quality and costs of services that other practitioners provide, order, or significantly influence, rather than just physician services. Physician Attestation Requirements The Office of the National Coordinator for Health Information Technology (ONC) Direct Review: • Physicians must attest that they engaged in good faith in “Supporting Providers with the Performance of Certified Electronic Health Record (EHR) technology” (SPPC) activities related to ONC’s direct in-the-field review of EHRs. • Physicians must attest to their acknowledgment of the requirement to cooperate in good faith with ONC’s direct review of EHRs if a request to assist in ONC direct review is received. • A physician who receives a request must also attest that they cooperated in good faith with ONC’s direct review of EHRs. Prevention of Information Blocking: To be a meaningful EHR user, a physician must demonstrate that they have not knowingly and willfully taken action (such as to disable functionality) to limit or restrict the interoperability of their EHR. Including attestation that they: • did not knowingly and willfully take to limit or restrict the interoperability of their EHR; • implemented technologies, standards, policies, practices, and agreements to ensure—and did not limit restrict—the exchange of electronic patient data in their EHR; and • responded in good faith and in a timely manner to requests to retrieve or exchange electronic patient information—including from patients, health care providers and other persons regardless of the requestor’s affiliation or EHR vendor. Current CMS Resources CMS’ Quality Payment Program Website CMS’ Small Practice Fact Sheet CMS’ Comprehensive List of APMs

CMS Finalizes Overhauled Policy on Global Codes Data Collection

The Centers for Medicare & Medicaid Services (CMS) released an improved policy November 2 on the collection of data that will eventually be used to revalue global codes. Under the final rule, physicians in large practices who perform 10- and 90-day global services in a representative sample of nine states will be required to report Current Procedural Terminology (CPT) code 99024 to report data on the number of postoperative visits they provide. CMS is limiting reporting to codes that the agency has determined are high-volume or high-expenditure Medicare services. This reporting requirement is scheduled to take effect July 1, 2017. CMS is implementing a requirement for reporting on services that are furnished by more than 100 practitioners and are either furnished more than 10,000 times or have allowed charges of more than $10 million annually as recommended by the RUC and many other commenters. Under this policy, CMS would collect data on about 260 codes that describe approximately 87 percent of all furnished 10- and 90-day global services and about 77 percent of all Medicare expenditures for 10- and 90-day global services under the PFS. Given that this data would provide information on the codes describing the vast majority of 10- and 90-day global services and expenditures, it will provide significant data for valuation. CMS will require reporting that only applies to practitioners in selected states. In addition, those practicing only in small practices are excluded from required reporting. Those not required to report can do so voluntarily and we encourage them to do so. Those states are Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island. CMS is not implementing the statutory provision that authorizes a 5 percent withhold of payment for the global services until claims are filed for the post-operative care, if required. This final policy is a complete overhaul of the proposed rule released in July, which would have required that all physicians in all states report data on all 10- and 90-day services that they provide. Physicians would have been required to report their pre- and postoperative care in 10-minute increments—an untenable requirement that is not aligned with clinician workflow—beginning January 1. The final rule is available online; the section related to global codes begins on page 149.