CMS Finalizes the New Medicare Quality Payment Program

On October 14, the Centers for Medicare & Medicaid Services (CMS) finalized its policy implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively referred to as the Quality Payment Program (QPP). The new QPP will gradually transform Medicare payments for more than 600,000 clinicians across the country.

The final rule centers payments around the care that is best for the patients, providing more options to clinicians for innovative care and payment approaches, and reducing administrative burden to give clinicians more time to spend with their patients, instead of on paperwork.

Accompanying the announcement is a new Quality Payment Program website, which will explain the new program and help clinicians easily identify the measures most meaningful to their practice or specialty.

The initial period of the QPP implementation will allow physicians to pick their pace for participation for the first performance period that begins January 1, 2017. Eligible clinicians will have three flexible options to submit data to MIPS and a fourth option to join Advanced APMs in order to become Qualifying APM Participants (QPs), which would ensure they do not receive a negative payment adjustment in 2019.

In the transition year CY 2017 of the program, this rule finalizes a period during which clinicians and CMS will build capabilities to report and gain experience with the program. Clinicians can choose their course of participation in this year with four options.

1. Clinicians can choose to report to MIPS for a full 90-day period or, ideally, the full year and maximize the MIPS eligible clinician’s chances to qualify for a positive adjustment. In addition, MIPS eligible clinicians who are exceptional performers in MIPS, as shown by the practice information that they submit, are eligible for an additional positive adjustment for each year of the first 6 years of the program.
2. Clinicians can choose to report to MIPS for a period of time less than the full year performance period 2017 but for a full 90-day period at a minimum and report more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information performance category, in order to avoid a negative MIPS payment adjustment and to possibly receive a positive MIPS payment adjustment.
3. Clinicians can choose to report one measure in the quality performance category; one activity in the improvement activities performance category; or report the required measures of the advancing care information performance category and avoid a negative MIPS payment adjustment. Alternatively, if MIPS eligible clinicians choose to not report even one measure or activity, they will receive the full negative 4 percent adjustment.
4. MIPS eligible clinicians can participate in Advanced APMs, and if they receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM, they will qualify for a 5 percent bonus incentive payment in 2019.

CMS finalized their proposal to use modified attribution methods from the Value Modifier for the total per capita cost measure and the Medicare spending per beneficiary. Specifically, they are finalizing for MIPS:

• Including transitional care management codes (99495 and 99496) and the chronic care management code (99490)
• Removal of SNF services billed under 99304-99318 when the claim includes the POS 31 modifier.

CMS said that making these two modifications would help align the primary care service definition between MIPS and Shared Savings Program and would improve the results from the two-step attribution process.

The Society was supportive of this proposal but noted that they “remain concerned that it does not solve the issue of comparing clinicians who treat similar populations. Resources necessary to take care of patients in the long-term custodial nursing facility (NF) setting defined by place of service (POS) 32 modifier are very different from internal/family medicine clinicians seeing patients in office-based or other outpatient/ambulatory or long-term care (e.g., domiciliary/assisted living) settings. Most long-term custodial (POS 32) nursing home residents have limited life expectancy and multiple morbidities, and are likely to have higher resource utilization. We strongly urge CMS to study risk adjustment methodologies that would ensure a more equitable comparison groups.”

CMS noted that they will continue to explore methods to refine risk adjustment to accommodate the different types of patients treated by clinicians in Medicare. “We are applying a specialty adjustment to the total per capita cost measure because we found, when implementing this measure as part of the Value Modifier, that there were widely divergent costs among patients treated by various specialties that were not addressed by other risk adjustment methods. The other measures we are including in the cost performance category for the CY 2017 performance period accommodate clinical differences in other ways.”

The Society is continuing to review the final rule and will have full analysis as well as education soon. The Society’s comments on the proposed rule can be found here. Click here to access the new CMS QPP website.