Quality Payment Program (QPP) Year III: Key Takeaways and 10 ways CMS Rule Impacts Clinicians

QPP Year III Final Rule: Highlights

CMS published the Final Rule as part of its Quality Payment Program (QPP) for Year III (2019) on Nov 1, 2018. The QPP Final Rule updates Physician Fee Schedule (PFS) and other Medicare Part B payments for MIPS eligible clinicians participating in the program.

Some of the significant changes in Year III of QPP are:

1. The participation base has been expanded to include new clinician types.
2. Weights have been redefined in the MIPS Final Score to factor the increased importance of cost. (Quality – 45%, Cost – 15%, IA – 15%, PI – 25%).
3. Terminology has been changed to align with how clinicians / vendors interact with MIPS (Collection Type, Submitter Type, Submission Types).
4. Eligible clinicians can now participate through Facility Based Scoring for the Quality and Cost Performance Category.
5. The scoring methodology of PI Performance category has been restructured to calculate scores based on individual measure-level performance.
6. The clinicians’ performance threshold to receive a positive payment adjustment has been increased. Payment adjustments have also been increased to align with the implementation progress of QPP.
7. Usage of ONC 2015 CEHRT is mandated for participating MIPS eligible clinicians. For clinicians participating through Advanced APM track, 75% of the clinicians are mandated to use ONC 2015 CEHRT and for clinicians participating through other Payer APMs, 75% of the same has to be implemented by Jan 1, 2020.

Impact of QPP Year III on Key Stakeholders

Moving into the third year of the Quality Payment Program, CMS has continued to reduce the reporting burden on clinicians by streamlining the program, reducing complexities and lowering the number of measures to be reported under Meaningful Measure Initiative. With significant changes in interoperability, the focus has changed from seamless and secure exchange of healthcare information to empowering patients. This is evident from the MyHealthEData initiative launched in 2018 through which a patient can decide how their data should be used or shared. With the renaming of Advancing Care Information (ACI) to Promoting Interoperability (PI), CMS is emphasizing greater synchronization with hospital-based interoperability programs.

More clinicians to participate in Year III than previous years:

1. Opt-in option: Clinicians who meet eligibility in any one of the three eligibility criteria can participate.
2. Addition of new clinician types: Expanded the MIPS eligible clinician base by adding new clinician types (highlighted in italics) such as Physical therapist, Occupational therapist, Qualified speech-language pathologist, Qualified audiologist, Clinical psychologist and Registered dietitian or nutrition professionals.

MIPS Track

1. Fewer measures to report to (Less reporting burden): Fewer objectives in PI category: Number of objectives to report to in PI category is reduced to 4.

2. Flexibility to choose measures: CMS now allows for measures to be chosen from any or more than one of the Collection Types (eCQMs, CQMs, QCDR measures, Medicare Part B Claims, CMS Web Interface measures) to report in the Quality Performance Category.

3. Ease of participation: Eligible clinicians have the option to participate through facility-based scoring in the Quality or Cost Performance Category. They need not submit data for this option. The Eligible clinician will be attributed to the hospital where the clinician provides the most Medicare services.

4. Flexibility in quality measure submission: Quality measures can be submitted from Multiple Collection Types (CMS Web Interface measures for large practices, Medicare Part B Claim measures for Small Practices).

5. ONC 2015 CEHRT Usage: Eligible clinicians must use ONC 2015 CEHRT to participate in QPP Year III.

6. Revised measure list and requirements:

• • Discontinuation of extremely topped-out measures: Quality Measures with very high performance scores are discontinued, to keep the measure list relevant
  • Topped-out QCDR measures to follow a different path: QCDR measures if identified as topped-out, can be discontinued for the same performance period, and need not follow topped-out measure life cycle of 4 years
  • Revision of high priority measure list: Opioid measures have been added to high priority measure list
  • Addition of measures in cost category: In addition to the 2 existing measures, CMS has identified and added 8 new episode-based measures that can capture maximum clinicians and patients

7. Restructured scoring:

• • No scoring for clinical guidelines impacted measures: Measures impacted by clinical guideline changes will be exempted during Quality Score calculation. Quality Score is calculated based on the remaining measures
  • No bonus points for CMS web interface high priority measures: No bonus points will be awarded for High Priority measures submitted through the CMS Web Interface
  • Small Practice Bonus added to Quality Category: Bonus points for Small Practices is increased to 6 points, but the bonus points will be added to Quality Score instead of the Final Score
  • Discontinuing Bonus points for CEHRT use: Discontinued bonus points for CEHRT use in IA activities as ONC 2015 CEHRT is a base criterion in Year III participation
  • Restructuring scoring for PI: Eliminated Base, Performance, and Bonus scores for PI measures. Introduction of scoring methodology based on performance

8. Addition of new improvement activities: Introduced 6 new improvement activities, modified 5 improvement activities and removed 1 improvement activity.

9. Increase in performance threshold: Increased the exceptional performance threshold value from 70 to 75 points.

10. Payment adjustment: The maximum negative and positive payment adjustment is set at -7% and +7% respectively.

APMs Track

1. ONC 2015 CEHRT Usage: At least 75% of eligible clinicians in each advanced APMs and other payers APMs must use ONC 2015 CEHRT. Other payer APMs will have to submit evidence that 75% clinician threshold is met, as of Jan 1 2020.
2. Revised Measure Requirements: APMs are required to have at least one of the quality measures on MIPS list or consensus-based entity, or evidence-based, reliable and valid quality measures as determined by CMS. This begins to apply in 2020.
3. Payment Adjustment: The maximum negative and positive payment adjustment is set at -7% and 7% respectively.

The framework below helps healthcare IT vendors and MIPS eligible clinicians participating in QPP to understand the significant changes in participation requirements, performance categories as per QPP Year III (2019).

Next Steps

With the final rule published and CMS key take-away analyzed, clinicians need to work on multiple areas:

Healthcare IT organizations must have the expertise of adapting to dynamic regulatory requirements, and thus enable clinicians to focus on quality care delivery. Healthcare IT vendors must provide solutions to support calculation and benchmarking of measure scores, thus helping clinicians to secure maximum payment adjustment.

1. Clinicians participating in MIPS

• • Upgrade to ONC 2015 CEHRT: Most clinicians have used either ONC 2014 EHR or a combination of ONC 2014 or ONC 2015 EHR to participate in Year II. Clinicians must use ONC 2015 EHR to participate in Year III
  • Reconsider the Quality Measures to Report to: As clinicians have the flexibility to choose measures from different collection types, clinicians should reconsider the measures to be reported
  • Opt for Multiple Submission Mechanisms: Participating clinicians are allowed to submit measures via various mechanisms and the highest score out of all the scores will be taken into consideration
  • Leverage the Updated Improvement Activities: With the modification of available improvement activities, clinician is recommended to reconsider the improvement activities to report to, based on relevance, specialty, etc.
  • Opt-in Participating Option: For clinicians with low volume threshold, CMS has opened up an option to participate in QPP

2. Clinicians participating through APMs:

• • Submit evidence to CMS: Submit evidence that 75% of eligible clinicians are using CEHRT 2015 to participate in the program starting Jan 1, 2020

Healthcare IT organizations must have the expertise of adapting to dynamic regulatory requirements, and thus enable clinicians to focus on quality care delivery. Healthcare IT vendors must provide solutions to support calculation and benchmarking of measure scores, thus helping clinicians to secure maximum payment adjustment.