On November 2nd, CMS made several announcements indicating that they are moving forward with MIPS rather than backtracking, although some additional flexibilities were included.  As a provider, here is what you need to know.

The Major Changes

1. In 2018, the cost evaluation criterion has been added, adjusting the existing percentages from 2017. See above; major changes are highlighted.
2. CMS has increased the reporting period for Quality data from 90 days to 12 MONTHS starting in 2018. The ACI and IA categories remain at 90 days.  
3. Practices are now only permitted to use one mechanism for reporting quality measures in 2018, a somewhat shocking departure from the proposed rule. CMS acknowledges the need for more flexibility in this category but will not implement that change until 2019.  

Important Note:  With the reporting period for quality measures also being a full year, these two aspects combined will create some additional quality reporting complexity for those providers and practices converting EHR systems; the quality metrics will need to be aligned and consolidated before being reported.  If you are a provider with a practice that is converting your EHR to a new platform in 2018, you will have to use quality data from both systems to meet the full-year reporting standard for quality.  

4. Several quality metrics have been topped out. For quality metrics such as Medication Reconciliation or BMI calculation, if you do not meet the benchmark, you will be considered a low performer.  For quality metrics that do not have benchmarks, which are approximately half of the metrics, providers will only score a maximum of 3 out of 10 points – forgoing 7 points for each metric regardless of how well you perform.
   • Topped-out measures will be removed and scored on a 4-year timeline.
   • Topped out measures with benchmarks that have been topped out for at least 2 consecutive years will earn up to 7 points.
5. While the reporting period for the quality and cost measures is 12 months in 2018, the ACI and IA categories remain at 90 days. Since many quality measures have “topped out,†meaning most won’t score at the highest level, even with a near-perfect performance, there is now greater emphasis on selecting and monitoring the appropriate quality measures for a given clinician to help ensure a high MIPS score.  
6. The reporting period for Cost is also 12 months, but providers have no reporting requirement for this measurement.
7. To manage the Cost Category, providers need to code the full picture of health for each patient at every encounter, not just the episode of care they are involved with. Otherwise, the patient may appear better than they actually are, which could reduce the allowance for that beneficiary. 
8. 21 new improvement activities (some have changed) have been added, and CMS made changes to 27 previously adopted improvement activities for 2018.
9. Virtual groups can now be formed by joining with other practices in order to participate in MIPS.

Bonus Points

1. Providers can continue using their 2014-certified electronic health record (EHR); however, there are bonus points for reporting exclusively on the 2015 edition. 15 points (known as the MIPS threshold) are required to avoid the penalty in 2018, up from the mere three points needed during the 2017 transition year.  This raises the bar significantly from 2017 to 2018.
2. Small practices (those with 15 or fewer clinicians) will receive an automatic 5 bonus points. They also do not have to worry about data completeness for the quality measures, as they will receive an automatic 3 points per measure, even if small practices submit quality measure data below the completeness standards. One of the biggest surprises is that small practice size exempts them entirely from the ACI category, with an end-of-year deadline to apply for this new exception.
3. Five bonus points are available for the “treatment of complex patients,†with CMS using the dual eligibility ratio and average HCC risk score to come to this determination.
4. The bonus for additional high priority measures is up to 10% of the denominator for Quality, and the bonus for end-to-end electronic reporting is up to 10% of the denominator for Quality. (No change from year 2017)

Exemptions, Exclusions, and APM Participation Change

1. Ambulatory surgical center (ASC)-based physicians are exempt from ACI, and this exception is retroactive to the current (2017) reporting year.
2. Physicians practicing in off-campus-outpatient hospital (POS 19) sites are also exempt, as they are included in the “hospital-based physician†clinician category.
3. Another important retroactive exemption exists in the ACI category: clinicians who write less than 100 permissible prescriptions are excluded from the eRx objective and those who transfer a patient to another setting or refer a patient fewer than 100 times during the performance period are also exempt from the health information exchange/summary of care measures. These both apply to 2017, as well as future years, at this time.
4. Finally, providers in areas impacted by natural disasters in 2017 will receive a neutral payment adjustment in 2019. Per an interim final rule, providers in affected regions are not required to submit 2017 MIPS data, and they can automatically avoid the 2019 penalty. Or, they may choose to submit 2017 MIPS data to receive a MIPS score and payment adjustment based on category-by-category performance, similar to other eligible clinicians.
5. Also, If a practice joins an advanced APM in the middle or near the end of the reporting year, the practice can be officially incorporated in the aAPM based on a modification in CMS’ look-back periods, as long as they were able to participate for at least 60 continuous days during the reporting period.

This is a summary of the major areas impacted by the QPP 2018 Final Rule.  In short, CMS is not backing away from MIPS or MACRA, but it is allowing for more flexibility.

If you need help understanding how these and other regulatory movements affect your organization or how to adjust your strategy, operations, and technology to stay ahead, please reach out to Truitt Health for assistance or questions at [email protected] or using the Contact Us form.