exemption that will weight all four performance categories to zero
percent in 2017 and 2018. Clinicians in affected areas will not need to
submit data to avoid a negative payment adjustment, but must submit a hardship exemption request. The specific locations—
including counties and parishes in the US mainland, and territories and
municipalities in Puerto Rico—are listed in the 2018 QPP Final Rule.
21st Century Cures Act
Certain provisions within the 21st Century Cures Act are being
implemented in 2018. These include the reweighting of the ACI
category to zero percent for eligible clinicians based in ambulatory surgical centers and hospitals. Hospital-based clinicians
who will have their ACI performance category weighted to zero
percent include those that see 75 percent or more of their patients in an inpatient, on-campus outpatient, off-campus outpatient, or emergency department setting.
Multiple Reporting Mechanisms will be Allowed in 2019
Practices will be allowed to use multiple reporting mechanisms
when submitting measures from one performance category in
2019. For the 2017 and 2018 MIPS performance periods, practices must choose one reporting mechanism per performance
category. This can create challenges when submitting data for
the Quality category in particular. Quality measures have limitations on their reporting mechanisms. Being allowed to report
through one mechanism limits the Quality measure choices
for practices. In addition, Quality measure benchmarks vary by
performing mechanism. Quality measure benchmarks are used
to determine the final score for Quality measures when benchmarks are available, and the ability to choose measures that have
more favorable benchmarks based on reporting mechanism
could potentially improve MIPS quality performance scores.
MIPS APM Participation Considerations
MIPS APMs are entities that include clinicians that are participating in an APM that is not recognized by CMS as an Advanced
APM and clinicians that do not have adequate APM patient volumes or revenues tied to an Advanced APM to achieve the status of Qualifying Participant.
Since this includes essentially all participants in Track 1 Medicare Accountable Care Organizations, it represents a significant
number of clinicians. Clinicians participating in MIPS APMs
will receive a MIPS score based on the following weightings, regardless of what type of APM they are participating with: Quality
50 percent, ACI 30 percent, Improvement Activities 20 percent,
and Cost zero percent. The quality score is determined by APM
performance on the APM’s quality measures. The ACI score is
derived from aggregated data across all MIPS APM participants.
CMS will determine if the APM’s Improvement Activities are
consistent with MIPS requirements and award between 50 percent and 100 percent of the points in this category. If an APM
entity is not given full credit it has the option of participating in
an additional Improvement Activities to reach the 100 percent
performance threshold for this category.
Clinicians that optionally participate in MIPS APM entities
should evaluate the performance of the MIPS APM in prepara-
tion for 2019. MIPS APMs have the advantage of reduced report-
ing requirements for the practice and high-performing MIPS
APMs may yield significant positive payment adjustments for
the practice. However, participation in low-performing MIPS
APMs that do not achieve a MIPS score that meets or exceeds
the performance threshold in 2019 will result in negative pay-
ment adjustments. As a reference point, MIPS scores in the vi-
cinity of 80 points may be required in 2019 and future years to
avoid negative payment adjustments.
Clinicians on an APM participation list on the snapshot dates
of March 31, June 30, August 31, or December 31 are obligated
to receive the MIPS score assigned to the MIPS APM and the associated payment adjustments for that performance period. The
December 31 snapshot date was added in the 2018 MACRA Final
Rule, but is only applicable to MIPS APMs that require all members of a TIN to participate in the APM, such as Track 1 ACOs.
Other Miscellaneous Strategic Considerations
Six Quality measures have been identified as “topped out” and
will receive a maximum of seven points per measure. CMS has
determined that several measures have historically very high
performance rates and are no longer optimal for quality improvement efforts. These measures will be identified, given reduced maximum potential scores, and eventually removed from
the list of MIPS Quality measures published annually by CMS.
CMS will begin reporting practices for improvements in scoring in the Quality and Cost performance categories. A practice
may earn up to 10 percentage points in the Quality performance
category for scoring improvements. For Cost, up to one percentage point may be awarded in this category.
The number of approved Improvement Activities for the 2018
performance year have increased from 93 to 112 activities. This
includes new highly-weighted and medium-weighted Improvement Activities, as well as new activities that require practices to
use features of their EHR and qualify for a 10 percent ACI bonus.
Advanced Alternative Payment Models: Strategic
Participation in an Advanced APM is in general an attractive option when available. CMS anticipates a continuous shift towards
enrollment in advanced APMs. CMS anticipates that between
185,000 and 250,000 clinicians will become QPs in 2018, as compared to 622,000 that will be eligible for the MIPS.
In the early years of the QPP there were limited options available to clinicians to join Advanced APMs, but opportunities are
increasing as new Advanced APMs (e.g., Track 1+ ACOs) are approved by CMS and existing Advanced APMs (CPC+ and Next
Generation ACOs) increase their clinician enrollment.
Becoming a Qualifying Participant (QP) in an Advanced APM
enables the clinician to be eligible for a five percent lump sum bo-
nus payment based on historical Part B Medicare payments at the
beginning of the corresponding payment year. This will continue
for the first six years of the QPP; following this, QPs will receive a
0.75 percent Part B Medicare positive payment adjustment.
QPs are excluded from MIPS payment adjustments and public
reporting of MIPS performance scores. To become a QP, clinicians
MACRA Strategies for