July 17, 2017

The Centers for Medicare and Medicaid Services (CMS) has published a proposed rule for the second year of the Quality Payment Program (QPP), performance year 2018 (payment year 2020).  The agency says it is “continuing to go slow and use stakeholder feedback to find ways to streamline and reduce clinician burden, and make it easier for clinicians to participate and put their patients first.”  Comments on the proposed rule are invited by August 21, 2017.

The proposal reveals few surprises for anesthesiologists, nurse anesthetists and other eligible clinicians (ECs), but raises performance expectations in some areas and offers some new options and flexibility.  

Following are highlights of selected proposed changes for QPP Year 2, gleaned from a recent CMS webinar.  We focus here on proposals with the most relevance to ABC clients as well as proposals related to the Merit-Based Incentive Payment System (MIPS), the QPP track in which the majority of ABC clients, anesthesiologists and nurse anesthetists are participating.  As discussed in our May 1, 2017 eAlert, we continue to recommend the Qualified Clinical Data Registry (QCDR) as the most effective MIPS data reporting mechanism for anesthesia providers.  (CMS has approved ABC as a QCDR for the second consecutive year.)

For QPP Year 2—performance year 2018 (payment year 2020)—CMS proposes to:

• Increase the low-volume threshold for exclusion from the QPP to less than or equal to $90,000 in Medicare Part B allowed charges or providing care for fewer than or equal to 200 Part B beneficiaries. (The threshold for QPP Year 1 is $30,000 or 100 beneficiaries.) The low-volume threshold would apply either at the individual or group level as it does currently.  Raising this threshold would allow more small practices and ECs in rural and Health Professional Shortage (HPS) areas to be exempt from the QPP.  These new guidelines will exempt many (but not all) anesthesia providers from the requirement to participate in QPP Year 2.
• Continue to define ECs as credentialed physicians, physician assistants, nurse practitioners, clinical nurse specialists and CRNAs (including anesthesia assistants credentialed as nurse practitioners), and keep the same exclusions as in 2017, including ECs who become qualified participants under an advanced alternative payment model (APM) or who become newly enrolled in Medicare during the performance period.
• Keep the current definition and exemption for non patient-facing clinicians and groups.  A non patient-facing clinician is defined as a MIPS-eligible clinician who bills 100 or fewer patient-facing codes CPT^® codes annually.  A non patient-facing group is one in which 75 percent or more members are non patient-facing clinicians.  A list of patient-facing codes can be found in the Resource Library at the QPP website.  If you have any questions about this, we suggest you contact your billing company to determine your status by comparing codes on the list with your practice’s billing data.
• Raise the performance period from 90 days in Year 1 to the full 2018 calendar year in the Quality and Cost categories, while keeping the 90-day performance period for the Improvement Activities and Advancing Care Information (ACI) categories.
• Incorporate the option for facility-based clinicians to use facility-based scoring.  A facility-based clinician is defined as a clinician who provides at least 75 percent of their services in an inpatient hospital or emergency room setting.  This includes many anesthesiologists and nurse anesthetists. Facility-based groups are defined as groups in which at least 75 percent of the individuals are facility-based clinicians.  CMS hopes to align facility-based scoring with the Hospital Value-Based Purchasing (VBP) Program.  The total performance score for the hospital VBP measure set would be applied to a clinician’s Quality and Cost performance categories.
• Apply a scoring cap to a small subset of topped out measures.  The scoring cap would limit an individual topped out measure’s contribution to the MIPS Final Score to 6 points out of 10.  A topped out measure is one in which the measurement of variability is difficult because the compliance rate high is so high.  CMS also proposes applying a topped out measure life cycle.  In the first year, a measure would simply be identified as topped out.  In the second and third years, a scoring cap of 6 points would be applied to the measure. In the fourth year, the measure would be removed from the program.
• Keep the point value for Cost at zero points, but replace the set of efficacy measures developed for Year 1.  CMS is again proposing to include the Medicare spending per beneficiary measure and the total per capita measure and is working to develop new efficacy measures with more involvement and feedback from clinicians.  The goal is to give clinicians the opportunity to provide more direct feedback on how these measures should be constructed and how they would apply to their practices.
• Continue to exempt most non patient-facing clinicians from reporting requirements in the ACI category.
• Offer a scoring bonus for clinicians who treat the most vulnerable and complex patients.  CMS proposes to apply up to three bonus points using the Health Practice Council’s (HPC’s) risk pool approach and is seeking comment on whether an alternate methodology using patient dual eligibility status would be preferable.
• Offer a scoring bonus for clinicians in small practices, defined as practices with 15 or fewer clinicians.  Clinicians in a small practice would receive an additional five points toward their final score as long as they participate in one performance category.  CMS invites feedback on whether bonus points should also be provided to clinicians who practice in rural areas.  

Please note that being exempt from MIPS does not prohibit you from reporting your data and participating in the program.  In fact, there may be reputational, competitive and other advantages to doing so, including, in some cases, seeking the bonus payment adjustment.

ABC clients:  If you have questions about QPP Year 2, please contact the ABC/MiraMed QCDR at qcdr@anesthesiallc.com.

With best wishes,

Tony Mira
President and CEO