The Centers for Medicare & Medicaid Services (CMS) released updated policies for the 2019 Quality Payment Program (QPP) as part of the Medicare physician fee schedule (MPFS) final rule issued November 1, 2018.1 This article explores the finalized policies affecting the QPP and the American College of Surgeons’ (ACS) positions on select portions of the final regulation.
The Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA) replaced the sustainable growth rate (SGR) with the QPP. The QPP was first implemented in 2017 and offers two pathways for participation—the Merit-based Incentive Payment System (MIPS) and qualifying participation in an Advanced Alternative Payment Model (APM). The MIPS program consolidated three legacy programs—the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VBM), and Electronic Health Record (EHR) Incentive Program—and recast them as Quality, Cost, and Promoting Interoperability (PI) (previously known as Advancing Care Information [ACI]). MIPS also included a new component—Improvement Activities (IA).
The ACS submitted comments to CMS September 10, 2018, on the MPFS proposed rule, including comments on the proposed provisions related to the QPP.2
CMS increases MIPS performance threshold
CMS finalized a number of MIPS policies, including an increase in the MIPS performance threshold required to avoid a payment penalty in the 2021 payment year; the 2019 performance will determine the payment adjustment in 2021. Surgeons who participate in the MIPS program will receive a final score between 0 and 100 points based on their performance in the four MIPS performance categories of Quality, Cost, IA, and PI. The MIPS final score informs the payment adjustment a surgeon will receive in 2021, and surgeons who score at least 30 points in total in 2019 will avoid any penalties. It is important to note that this is a budget-neutral program, meaning that the estimated increase in allowed charges from the positive MIPS payment adjustments must equal the estimated decrease resulting from the negative MIPS payment adjustments.
CMS doubled the overall performance threshold for 2019 from the requirements in 2018. In the 2018 performance year, physicians could avoid a penalty by reporting in only one category (IA); however, in the 2019 performance year, physicians will need to submit data in multiple MIPS categories. The ACS strongly opposed the drastic increase in the performance threshold and recommended a more modest increase. The ACS expressed concerns that the measure constructs used in the QPP were designed for a payment program and do not represent a true quality improvement program, thereby falling far short of accurately and meaningfully measuring surgical care. The College recommended that CMS focus on how MIPS can meaningfully drive true quality improvement across an episode of care with reliability and validity in measurement before significantly increasing the resources needed to avoid a penalty.
Changes in the MIPS low-volume threshold
When CMS first implemented the QPP, the agency established the low-volume threshold to exclude clinicians from the program who do not interact with a substantial number of Medicare beneficiaries or who do not have sufficient Medicare B charges. In 2018, CMS increased the low-volume threshold to exclude physicians who have Medicare Part B allowed charges of $90,000 or less or who provide care to 200 or fewer Medicare Part B beneficiaries. With the increase in the low-volume threshold, CMS estimated that an additional 585,560 clinicians would be exempt from MIPS in 2018.
More recently, the Bipartisan Budget Act of 2018 amended the definition of the low-volume threshold starting in 2019 and finalized the inclusion of a third criterion. The third criterion was included based on feedback from physicians who were excluded from the program in previous years but would like the opportunity to participate in the program. Therefore, to be excluded from MIPS, clinicians or groups must meet one or more of the following three criteria:
- Have ≤$90,000 in Part B-allowed charges for covered professional services
- Provide care to ≤200 Part B-enrolled beneficiaries, or
- Provide ≤200 covered professional services under the MPFS
In addition to introducing a third criterion, CMS finalized a policy that will allow clinicians or groups to opt in to MIPS if they meet or exceed at least one, but not all three, of the low-volume threshold criteria. This policy responds to feedback CMS received from providers who were excluded from MIPS but wanted to participate. CMS estimates that the adoption of the opt-in policy will not exclude any additional clinicians from the program, but approximately 42,000 additional clinicians will be eligible to participate. As a result of these changes, the ACS recommends surgeons use their National Provider Identification (NPI) numbers to determine their participation status in 2019 with the QPP Participation Lookup tool.
Each of the four MIPS performance categories is assigned a weight, which contributes to the MIPS final score. Starting in 2019, CMS will decrease the MIPS Quality category from 50 percent to 45 percent of the overall MIPS score and the MIPS Cost category will increase to 15 percent from 10 percent (see Figure 1). The weights for IA and PI will remain unchanged from 2018 to 2019. The ACS strongly opposed these changes and advocated for a continuation of the category weights from 2018 to 2019 to allow for stability in MIPS in order to prevent additional confusion and administrative burdens associated with the already complex MIPS program.
Figure 1. Adjustments to MIPS Quality and Cost weights
Quality performance category changes
The Quality category is the most highly weighted in determining the MIPS final score and was included in the QPP to replace the PQRS program as a requirement of MACRA. This MIPS category measures health care processes, outcomes, and patient care experiences.3 CMS finalized many notable changes to the MIPS Quality category in the 2019 final rule. As previously mentioned, Quality will contribute to 45 percent of a clinician’s final score—a 5 percent decrease from previous years of the program. Unless reporting as part of the CMS Web Interface or Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS reporting options—which have different measure reporting requirements—to receive full credit in this category surgeons will need to report a minimum of six measures, including one high-priority or outcome measure for 60 percent of applicable patients over the calendar year. If six measures do not apply to the surgeon’s practice, the surgeon is only required to report the number of measures that are applicable to his or her care.
Many employed surgeons may participate in this program using the CMS Web Interface submission mechanism. If this is the case, surgeons may not know if their employer is submitting data on their behalf, since many of these measures are not relevant to surgical care. Surgeons should check with their employers to determine who will be reporting their data to be sure they are participating in the MIPS program if they are eligible. The ACS maintains that this program is onerous and burdensome, and therefore has recommended that CMS adopt a minimum 90-day reporting period to reduce reporting burden and to align with the 90-day reporting periods for the IA and PI components.
Removal of claims reporting
One major change that could affect how surgeons report to MIPS starting in 2019 is that the claims reporting mechanism will no longer be available to some surgeons. Next year, only clinicians in small practices will be permitted to submit Medicare Part B claims, whether participating as a group or individually. Other submission mechanisms include: qualified clinical data registries (QCDRs), qualified registries, EHRs, the CMS Web Interface (groups of 25 or more), and CMS-approved survey vendors for CAHPS for MIPS (must be reported in conjunction with another data submission mechanism). Surgeons who have historically reported via claims may want to consider new options, such as the ACS Surgeon Specific Registry (SSR)—a registry approved by CMS for MIPS reporting as a QCDR and a qualified registry.
Changes to the MIPS general surgery measure set
CMS offers 35 specialty measure sets, with focused measures specific to certain specialties, making it easier for physicians to choose the quality measures to report. Although physicians are not required to use these sets, they may report the measures included in their specialty measure set to meet the reporting requirement for the quality category.
CMS finalized a number of specialty-specific measure sets in the 2019 final rule, including a general surgery measure set. Surgeons can report these measures and others that are relevant to surgical care through the ACS SSR or through other registries listed in the QPP resource library on the CMS website. Table 1 shows the finalized general surgery measure set.
Table 1. 2019 MIPS general surgery measure set
CMS has taken steps to include more meaningful clinical quality measures (CQMs) in the MIPS program; however, the ACS continues to express concern that the QPP is not measuring true quality improvement. At present, the measures in the QPP are siloed, complex, and do not fit into surgical workflow. Since the implementation of the QPP, the ACS has proactively offered solutions that would promote meaningful quality measurement and significantly reduce the reporting burden associated with participation in the MIPS program, but to date, CMS has not provided support for testing these proposed solutions.
The Cost category borrowed elements of the VBM legacy program. The category was incorporated in MIPS to measure the resources clinicians use to care for patients in relation to Medicare payments.4 Next year, the MIPS Cost category will be weighted at 15 percent of a clinician’s final score for the 2019 performance year. CMS maintained the Medicare Spending Per Beneficiary (MSPB) and Total Per Capita Cost (TPCC) measures in this category from previous years, but has now added eight new episode-based cost measures. If none of these episodes apply to a surgeon’s practice, they will continue to be scored on the MSPB and TPCC measures if they are attributed a sufficient number of beneficiaries under either measure. A list of the new episode-based cost measures follows:
- Elective outpatient percutaneous coronary intervention (PCI)
- Knee arthroplasty
- Revascularization for lower extremity chronic critical limb ischemia
- Routine cataract removal with intraocular lens implantation
- Screening/surveillance colonoscopy
- Intracranial hemorrhage or cerebral infarction
- Simple pneumonia with hospitalization
- ST-Elevation Myocardial Infarction (STEMI) with PCI
Scores in the Cost category are derived from Medicare claims; therefore, clinicians do not have to report data to CMS to receive points for Cost. However, with the increase in the performance threshold and the Cost category’s weight increase to 15 percent, the ACS recommends that surgeons become familiar with their 2017 MIPS performance feedback reports, which includes confidential performance feedback on these measures, to get a better sense of how they may score in this category in 2018 and beyond. These reports can be accessed by logging in to qpp.cms.gov with their Enterprise Identity Data Management (EIDM) credentials. Surgeons can e-mail qualityDC@facs.org for assistance in understanding reports.
Starting in 2018, CMS changed the ACI category name to PI. This category will undergo major changes next year. CMS finalized the implementation of a new scoring methodology, moving toward a performance-based scoring system at the individual measure level. The new methodology requires all-or-nothing participation, meaning that clinicians will have to report on each measure to achieve a score for PI. In conjunction with the new methodology, CMS reduced the number of measures, while also adding two new optional opioid-related measures that can be completed for bonus points in 2019. CMS will still require physicians to attest to the completion of a security risk analysis to receive a score in PI next year. CMS also will require that surgeons submit all MIPS data using 2015 Edition Certified EHR Technology (CEHRT). Next year, surgeons who do not report data with 2015 Edition CEHRT will not be scored in PI. The ACS opposed this policy and advocated for the continued use of both 2014 and 2015 CEHRT as the means of reporting data for PI. The College believes that the initial and continued costs to upgrade and maintain CEHRT for MIPS are a barrier for many clinicians. Even with the addition of an API function in the 2015 Edition, it is still not useful to surgeons because of the lack of developed apps that align with surgical care.
It is important to understand that participation in this category is still not required to avoid a MIPS penalty, and surgeons may be able to meet the performance threshold through participation in Quality and IA. Furthermore, clinicians or groups participating in MIPS that meet the definition of “hospital-based” are automatically exempt from this category; others who meet certain criteria may apply for a hardship exception to avoid the reporting requirement for PI. To apply for a hardship exemption, go to the QPP website.
The IA performance category allows surgeons to demonstrate how they are improving care processes, enhancing patient engagement, and increasing access to care.5 Surgeons can choose from 113 IA and meet the requirements for this category through simple attestation. The IA category will generally remain the same from 2018 to 2019 with minor changes to the list of qualifying activities. The category will continue to be weighted at 15 percent of the MIPS final score, and most surgeons must select and attest to having completed one to four activities for a total of 40 points to achieve full credit. Each activity will continue to be assigned medium (10–20 points) or high (20–40 points) weights. By earning the maximum score in this category, a clinician will receive half of the points needed to meet the new 30-point performance threshold. In 2019, the ACS supported the inclusion of comprehensive eye exams and advocated for changes to the participation in Maintenance of Certification Part IV IA, which have been finalized for 2019. Surgeons can attest to completing IA via the SSR or on the QPP website with their EIDM credentials.
Burden reduction for facility-based clinicians
To reduce administrative burdens for facility-based clinicians, beginning in 2019, surgeons eligible for facility-based MIPS measurement will have their facility’s Hospital Value-Based Purchasing (VBP) Program performance automatically applied in place of their own MIPS Quality and Cost scores. This policy applies to surgeons attributed to a facility that has a higher VBP Program score than the clinician’s or group’s own combined MIPS Quality and Cost Scores. Upon implementation in 2019, eligible facility-based clinicians will not have to meet MIPS data submission requirements for these performance categories. The ACS supported this policy because it will reduce MIPS reporting burden and align CMS hospital and physician quality reporting programs.
This final rule also included policies related to APMs. Clinicians who participate sufficiently in Advanced APMs are considered Qualifying Advanced APM participants, and are exempt from MIPS and eligible for a 5 percent lump sum Medicare bonus. In 2017 and 2018, sufficient participation was assessed based on the number of Medicare patients or amount of Medicare revenue earned through the Advanced APM. In accordance with MACRA, this rule expands opportunities for clinicians to become Qualifying Advanced APM participants by allowing them to qualify through an All-Payer Combination Option, which lets physicians meet the participation threshold through a combination of both Medicare and other-payor APMs beginning next year.
- Department of Health and Human Services. Centers for Medicare & Medicaid Services. 42 CFR Parts 405, 410, 411, 414, 415, 425, and 495. Available at: http://hhs.com/assets/docs/2018-24170.pdf. Accessed December 4, 2018.
- American College of Surgeons. Comment letter to Seema Verma, MPH, Administrator, Centers for Medicare & Medicaid Services. CMS-1693-P September 18, 2018. Available at: facs.org/~/media/files/advocacy/regulatory/cy_2019_mpfs_comment_letter_acs.ashx. Accessed December 4, 2018.
- Department of Health and Human Services. Quality Payment Program. Quality measures requirements. Available at: https://qpp.cms.gov/mips/quality-measures. Accessed December 4, 2018.
- Department of Health and Human Services. Quality Payment Program. Cost requirements. Available at: https://qpp.cms.gov/mips/cost. Accessed December 4, 2018.
- Department of Health and Human Services. Quality Payment Program. Improvement activities requirements. Available at: https://qpp.cms.gov/mips/improvement-activities. Accessed December 4, 2018.