Small physician practices will get greater flexibility—including the virtual practice and facility-based measurement options and a much higher low-volume threshold—under major changes proposed by CMS for calendar year 2018 of the Quality Payment Program (QPP), which was created under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10). The Proposed rule, if finalized, would recommend, but not require, physicians participating in the Merit-based Incentive Payment System (MIPS) to adopt upgraded electronic health record (EHR) systems. CMS also proposed more than doubling the number of practices eligible to participate in an Advanced Alternative Payment Model (Advanced APM). Comments are due by August 21, 2017 (Proposed rule, 82 FR 30010, June 30, 2017).
2017 is the first year of the QPP and is a "transition year" that does not require participation of any practices. When CMS finalized its regulations for 2017 (81 FR 77008, November 11, 2016), the agency lauded the flexibility of QPP’s "pick-your-pace" approach (see MACRA final regulations reflect input from ‘months-long listening tour’, November 4, 2016), which will be continuing for 2018. The Proposed rule also implements parts of the 21st Century Cures Act (Cures Act) (P.L. 114-255) pertaining to hospital-based MIPS eligible clinicians, ambulatory surgical center-based MIPS eligible clinicians, MIPS eligible clinicians using decertified EHR technology, and significant hardship exceptions under the MIPS.
Low-volume threshold. Under the Proposed rule, the low-volume threshold, which excludes providers who do not serve a certain number of Medicare Part B beneficiaries or bill a certain amount within a year, would markedly increase. For 2017, the low-volume threshold is $30,000 in Part B allowed charges or 100 Part B beneficiaries; for 2018, the Proposed rule would triple the billing amount to $90,000 in Part B allowed charges and double the beneficiary threshold to 200. However, it also proposes that starting in 2019, low-volume clinicians could opt-in to MIPS.
Virtual groups. The Proposed rule includes provisions to enact one of the most-anticipated provisions of MACRA, the availability of virtual groups, which can be created by solo practitioners and small group practices joining "virtually" to participate in MIPS. CMS’ goal is to make it easy to form virtual groups without regard to location or members’ specialties. Members must elect the virtual group participation option prior to the 2018 performance period.
Facility-based measurement. Another new option for 2018 would be the facility-based measurement, which implements an optional, voluntary scoring mechanism based on the hospital value-based purchasing program created by Sec. 3001 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The Proposed rule would make the option available only for facility-based clinicians who have at least 75 percent of their covered professional services supplied in the inpatient hospital setting or emergency department.
Other proposed MIPS changes. In a Fact Sheet, CMS laid out a chart showing how the Proposed rule would alter MIPS scoring for future calendar years. There are also updated scoring bonuses for complex patients and small practices, the removal of two Summary Survey Measures—specifically, "Helping You to Take Medication as Directed" and "Between Visit Communication"—from the quality survey, and additional technical assistance for smaller practices. The agency completed an updated regulatory impact analysis and concluded that, of small practices (defined as one to 15 providers), 80 percent would experience a positive or neutral payment adjustment under MIPS.
Proposed changes to Advanced APMs. Many of the transition-year policies for Advanced APMs will remain in place for 2018, but CMS did propose some changes and updates, including changes to the revenue-based nominal amount standard and the nominal amount standard for Medical Home Models. The Proposed rule also provides detail into implementation of the All-Payer Combination Option, which would allow clinicians to become Qualifying APM Participants by participating in a combination of activities beginning in 2019. The agency believes that the number of clinicians eligible for participation in an Advanced APM will increase to between 180,000 and 245,000 in 2018 from the 2017 numbers of 70,000 to 120,000.
Certified EHR technology. For 2018, CMS is proposing to allow clinicians to continue using the 2014 Edition Certified EHR Technology (CEHRT) criteria, though it recommends that they migrate to the implementation and use of the 2015 Edition. According to the agency, stakeholders requested the extension due to the lack of products certified to the 2015 Edition and the significant time and cost required to switch Editions. The HHS Office of the National Coordinator for Health Information Technology (ONC) certified that 53 percent of eligible clinicians and 80 percent of eligible hospitals have completed the transition to the 2015 Edition, and the agency is proposing a bonus in the scoring methodology for using 2015 Edition CEHRT exclusively, while not penalizing those continuing to use the 2014 Edition.
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