THE CENTERS FOR Medicare and Medicaid Services (CMS)
Quality Payment Program (QPP) was created in response to the
Medicare Access and CHIP Reauthorization Act of 2015 (MA-
CRA). It has two tracks: the Merit-based Incentive Payment Sys-
tem (MIPS) and Advanced Alternative Payment Models. These
programs started on January 1, 2017 and the first year of the QPP
was referred to as the “Transition Year.”
The QPP 2018 Final Rule was released on November 2, 2017
and provided details on polices for “Quality Payment Program
Year 2.” CMS is continuing with many of the policies established
for the 2017 performance year with some notable differences.
The 2018 MACRA Rule also provided information on selected
policies for the 2019 performance year.
The majority of eligible clinicians will find themselves in the
MIPS for the first few years of the QPP. For these practices, 2018
represents a low-risk opportunity to develop or refine approaches
to achieving high levels of performance before 2019, when MIPS
goes fully into effect, and attain relatively high MIPS performance
scores and positive payment adjustments in 2020. Nearly 50 percent of eligible practices will, by design, receive negative payment
adjustments of up to seven percent in 2021 based on MIPS performance in 2019.
This article will discuss key components of the QPP with an
emphasis on changes to the policy for the 2018 performance
year, and—to the degree known—2019. For additional information please refer to the 2018 QPP Final Rule.
MIPS: Strategic Considerations
There are several strategic considerations related to modification to MIPS for the 2018 performance year that will be addressed in this overview document. These include changes to
exclusion criteria thresholds, the MIPS performance threshold,
MIPS performance category weightings, quality performance
category reporting period and data completeness criteria, qualifying CEHRT versions, complex patient bonuses, small practice
bonuses, virtual groups, hardship exemptions for extreme circumstances, and other elements of the QPP.
Threshold Criteria for Exclusion
The threshold criteria for exclusion from the MIPS has been increased. In the 2018 performance year CMS will exclude otherwise eligible clinicians and groups (based on cumulative
numbers, not on averages) from the MIPS if they are less than
or equal to $90,000 in Part B allowed charges or have fewer than
201 Part B beneficiaries. A primary reason why Medicare raised
these thresholds was to reduce the burden on rural clinicians.
Qualifying Alternative Payment Model (APM) Participants (QPs),
Partial QPs, and clinicians new to Medicare are also excluded from
MIPS, as they were for the 2017 performance year. Partial QPs have
the option of participating in MIPS. Partial QPs are defined as they
were in 2017 as eligible clinicians in Advanced APMs who have at
least 20 percent, but less than 25 percent, of their payments for Part
B covered professional services through an Advanced APM Entity,
or furnish Part B covered professional services to at least 10 percent,
but less than 20 percent, of their Medicare beneficiaries through an
Advanced APM Entity. If they elect to participate they will receive
MIPS APM scoring determinations).
MIPS Performance Threshold
The MIPS performance threshold is the MIPS score that results in
neutral payment adjustments. Scores above the payment threshold receive positive payment adjustments and scores below the
payment threshold receive negative payment adjustments in the
corresponding payment year, which is two years after the performance year. The MIPS performance threshold is chosen by CMS
during the first two years of the QPP. It was established at three
points in the 2017 performance year and has been raised to 15
points in 2018. Starting in the 2019 performance year, the performance threshold will be determined by the mean or median
scores of all MIPS-eligible practices. It will likely be a value that
is considerably higher than 15 points, with CMS data suggesting
the 2019 performance threshold could be in excess of 75 points.
Achieving a MIPS Score of 15 points in 2018 can be done
through a variety of mechanisms. For example, achieving the