Exploring Changes to the Quality Payment Program in 2019

November 06, 2018 - The final 2019 Medicare Physician Fee Schedule (PFS) rule contained a number of changes to evaluation and management (E/M) payment rates, site-neutral payments, and remote patient monitoring coverage. But the rule also included key MACRA implementation rules for the Quality Payment Program’s third year.

According to CMS, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015. The law replaced the Sustainable Growth Rate formula with the Quality Payment Program, which pays clinicians based on the value of care delivered rather than the volume of services furnished.

Since 2015, CMS has been gradually implementing the historic value-based reimbursement program.

And in 2019, the federal agency will still be instituting rules that will continue the implementation process for the Quality Payment Program and its two payment tracks: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) pathway.

In the latest final rule on the Medicare PFS, CMS included major changes to how the federal agency enforces the Quality Payment Program. In the following article, RevCycleIntelligence.com will explore the key changes to MIPS and the Advanced APM track in the third year of the Quality Payment Program.

MIPS participation changes in 2019

READ MORE: Exploring Virtual Groups in the Quality Payment Program, MIPS

MIPS is the Quality Payment Program’s largest payment track. CMS estimates that approximately 798,000 clinicians will be eligible to participate in MIPS in the 2019 performance period, the final rule stated.

The number of MIPS eligible clinicians in the Quality Payment Program’s third year is up 148,000 clinicians from the estimate provided in the proposed 2019 Medicare PFS rule. CMS anticipates more clinicians to participate in 2019 because of new participation rules finalized in the most recent PFS rule.

First, CMS finalized MIPS participation rules for new clinician types. In 2019, physical therapists, occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and registered dietitians or nutrition professionals will qualify for MIPS participation.

Second, clinicians can choose to participate in MIPS in 2019 even if they are excluded from the program based on the low-volume threshold.

Clinicians are excluded from MIPS if they have $90,000 or less in Part B allowed charges for covered professional services or they provide care for 200 or fewer Part B-enrolled beneficiaries.

READ MORE: How Can CMS Improve MACRA’s Quality Payment Program, MIPS?

For the third year, CMS also finalized a third low-volume threshold. Clinicians who furnish 200 or less covered professional services paid under the PFS are also excluded from MIPS.

While CMS expanded the low-volume threshold, eligible clinicians who meet or exceed one or two of the exclusion elements can opt-in to MIPS in 2019.

MIPS performance updates

As part of the gradual MACRA implementation process, CMS has incrementally increased the MIPS performance threshold to help eligible clinicians adjust to the new value-based reimbursement program.

In the final 2019 Medicare PFS rule, CMS increased the MIPS performance threshold to 30 points, up from the 15-point threshold in the second year of the Quality Payment Program.

The exceptional performance threshold will also increase from 70 points to 75 points in 2019.

READ MORE: Key Ways to Succeed Under MACRA’s Quality Payment Program

CMS pointed out in the final rule that it will continue to be flexible with establishing the performance thresholds for the next three performance periods (program years 3, 4, and 5). The federal agency will “ensure a gradual and incremental transition to the estimated performance threshold for the sixth year of the program based on the mean or median of final scores from a prior period.”

In addition to higher MIPS performance thresholds, CMS also finalized changes to specific performance categories.

For example, CMS will weigh the Cost performance category at 15 points in the 2019 performance period. The performance category weighed just 10 points in the Quality Payment Program’s second year.

The federal agency will also add eight new episode-based measures to the Cost performance category in 2019. The measures will be in addition to the legacy Total Per Capita Cost (TPCC) and Medicare Spending Per Beneficiary (MSPB) measures.

Additionally, CMS finalized facility-based Quality and Cost performance measures for certain eligible clinicians.

The new Quality Payment Program feature will allow MIPS eligible clinicians who furnish 75 percent or more of their covered professional services in inpatient hospital, on-campus outpatient hospital, or an emergency department to use facility-based scoring.

Advanced APM changes

CMS estimates between 165,000 to 220,000 clinicians to become Qualifying APM Participants during the 2019 performance period. These clinicians will participate in an approved Advanced APM to qualify for the 5 percent bonus payment in the 2021 payment year.

Like MIPS, CMS has gradually implemented the Advanced APM pathway to ensure clinician success in the risk-based reimbursement program. Updates to the Quality Payment Program pathway in 2019 include:

• Applying the Certified Electronic Health Record Technology (CEHRT) threshold of at least 75 percent of eligible clinicians to the Other Payer Advanced APM opportunity
• Extending the 8 percent revenue-based nominal amount standard for Advanced APMs and Other Payer Advanced APMs through the 2024 performance year
• Streamlining the definition of a MIPS comparable measure in the Advanced APM and Other Payer Advanced APM criteria to reduce confusion and burden for payers and eligible clinicians submitting payment arrangement information to CMS
• Clarifying the requirement for MIPS APMs to assess performance on quality measures and cost/utilization
• Updating the MIPS APM measure sets for the APM scoring standard

Additionally, CMS finalized additional flexibilities for the All-Payer Combination option and Other Payer Advanced APMs for non-Medicare payers to participate in the Quality Payment Program.

For example, CMS developed a multi-year determination process for the Advanced APM options in which payers and eligible clinicians can provide information on the length of the agreement as part of their initial Other Payer Advanced APM submission. The clinicians and payers can then have any resulting determination be effective for the duration of the agreement, or up to five years.

CMS will also allow Qualifying Participant determinations at the tax identification number (TIN) level and allow all payer types to be included in the 2019 Payer Initiative Other Payer Advanced APM determination process for the 2020 performance period.

To read all the updates and changes to the Quality Payment Program for the 2019 performance period, please click here.