MACRA/Quality Payment Program in 2019: Finalized Changes

On November 1, the Centers for Medicare and Medicaid Services (CMS) released the 2019 Medicare Physician Fee Schedule. This document includes policy information for the third performance year of the CMS Quality Payment Program (QPP). CMS created the QPP in response to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Congress...

On November 1, the Centers for Medicare and Medicaid Services (CMS) released the 2019 Medicare Physician Fee Schedule. This document includes policy information for the third performance year of the CMS Quality Payment Program (QPP). CMS created the QPP in response to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Congress subsequently made significant modifications to the MACRA legislation via the Bipartisan Budget Act of 2018 that became public law on February 9, 2018.

The QPP has two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). This article will provide an overview of impactful changes to the QPP for 2019.

MIPS 2019 Performance Year Changes

The Bipartisan Budget Act of 2018 allowed CMS to gradually increase the weighting of the MIPS Cost category between 2019 and 2021. It will reach 30 points by the 2022 performance year. As shown in Figure 1, the cost category will have a weighting of 15 percent in the 2019 performance year, an increase from 10 percent in 2018. The quality category’s weighting has been reduced to 45 percent from 50 percent in 2018.

The performance periods have remained the same: 90 continuous days for the Promoting Interoperability and Cost categories, and 365 days for the Quality and Cost categories.
Expansion of MIPS Eligible Clinician Types

CMS has exercised its option under the MACRA legislation to increase the number of clinician types eligible for MIPS in the third year of the program (2019). The current and newly added clinician types are show in Table 1.

Starting on January 1, 2019, these additional clinicians become MIPS eligible whether reporting as individuals or a part of a group—unless they meet the exclusion criteria described below. If they report as individuals or as a group made up of only the clinician types newly eligible in 2019 their score will be determined by the performance in the Quality and Cost categories alone. The Quality performance category would then have a weighting of 85 percent or 100 percent depending on whether the provider is eligible for Cost measure attribution.

However, it is important to note that a high percentage of newly added clinician types in 2019 will report as part of a group that includes physicians. When reporting as a group that includes one or more eligible physicians, data from all members of the group in all four MIPS performance categories is used to determine the final MIPS score. Some practices may wish to provide additional training to clinicians in the newly eligible type category if their activities involve performance in the Promoting Interoperability category (e.g., the “Provide Patients Electronic Access to Their Health Information” measure).

MIPS Exclusion Criteria

The two threshold criteria for exclusion from the MIPS that are based on allowed charges and patient volumes have not changed. However, CMS has added a third exclusion criteria based on service volumes. In the 2019 performance year CMS will exclude otherwise eligible clinicians and groups from the MIPS if they meet any one of the following criteria:

  • ≤ $90,000 in allowed Part B charges
  • ≤ 200 Part B beneficiaries seen during the determination period
  • ≤ 200 in allowed Part B professional services

As noted above, the third criteria, ≤ 200 allowed Part B services, is new in 2019. It will reduce the threshold needed to participate in MIPS as a high percentage of eligible Medicare Part B beneficiaries will receive more than one professional service (e.g., E/M services) during a calendar year. CMS has given individual clinicians and groups the option of participating in MIPS if any one or two of the above thresholds are exceeded, but not all three. CMS made this change to allow a subset of clinicians that wanted to participate in the MIPS the opportunity to become MIPS eligible. Clinicians new to Medicare and Qualifying Advanced APM Participants (QPs) are also excluded, as they have been in the past.

MIPS Performance Threshold

The MIPS performance threshold for neutral payment adjustments has been raised to 30 points for 2019 (see Figure 2). Scores above the payment threshold receive positive payment adjustments and scores below the payment threshold receive negative payment adjustments in 2021, the corresponding payment year. The Bipartisan Budget Act of 2018 allows CMS to determine the performance thresholds in performance years 2019-2021. Starting in the 2022 performance year the threshold will be determined by the mean or median scores of all MIPS-eligible practices.

CMS has set the “Additional Performance Threshold” for exceptional performance at 75 points in 2019. Practices that score 75 points or higher will receive a portion of a $500 million exceptional performance fund. There is an additional positive payment adjustment of 0.5 percent for practices that achieve a score of 75 points. From here the adjustment will gradually increase on a linear scale (based on the MIPS score) between 75 and 100 points, as shown in Figure 2.

EHR Certification Requirements in 2019

In 2018 practices could use EHRs certified using 2014 or 2015 Edition criteria. In 2019 all practices must use Certified EHR Technology (CEHRT) that was certified using the 2015 Edition requirements to receive a score in the Promoting Interoperability performance category. A bonus associated with use of 2015 Edition CEHRT in 2018 has been eliminated in 2019. As noted previously, the reporting period for the Promoting Interoperability performance category is a minimum of 90 continuous days, allowing practices time in 2019 to upgrade or install EHRs as needed.

MIPS Promoting Interoperability Performance Category in 2019

CMS made what it described as an “overhaul” of the Promoting Interoperability performance category of MIPS (formerly known as Advancing Care Information) in the 2019 Final Rule. Their stated goal was to emphasize support for interoperability and patient access, while better aligning the ambulatory and hospital Promoting Interoperability requirements.

The weighting of this MIPS category remains at 25 percent. CMS made substantive modifications to the objectives, measures, and scoring methodology for the 2019 performance year. The number of objectives were reduced, some measures were combined, and two new measures were added: “Query of Prescription Drug Monitoring Program” and “Verify Opioid Treatment Agreement”(See Table 3). The two new measures have been made optional in 2019 to reduce the burden on health IT vendors and individuals who manage measure Promoting Interoperability performance at their organizations. Several of the 2019 Promoting Interoperability measures have exclusions. When this occurs the potential points (i.e., denominator value) from an excluded measure are shifted to other measures.

The previous mandatory base measure scoring methodology has been eliminated. In 2018 practices using 2015 Edition CEHRT earned 50 of the maximum 100 points in the Promoting Interoperability category for performing a security risk analysis and meeting minimal volume (e.g., single episode) requirements for four additional measures. Practices were required to meet the minimum requirements for each base measure in order to receive a score greater than 0 points in the Promoting Interoperability performance category (see Table 2).

In 2019 practices all measures except for the registry measures are performance based (see Table 3). The total score in each measure is summated to achieve the Promoting Interoperability score. All practices need to report data with a minimum numerator score of 1 (e.g., one patient that meets the measure requirement) from at least one measure in each of the four objectives to earn a score or greater than zero in the Promoting Interoperability category. In 2019 the Security Risk Analysis is no longer considered a Promoting Interoperability measure, but it must be performed in 2019 or the practice will receive a score of zero points in the Promoting Interoperability category. Practices will need to attest that they are actively engaged with a minimum of two unique registries to earn the 10 points in the Public Health and Clinical Data Registry Reporting objective/measure.

The total number of potential Promoting Interoperability category points has been reduced from 165 points in 2018 (see Table 2) to 110 points in 2019 (see Table 3), although in both years the score is capped at 100 points. The removal of the 50-point base measure score and other changes will make it more challenging for practices to achieve high scores in the Promoting Interoperability category in 2019.

CMS has stated that despite the significant changes to the Promoting Interoperability category for the 2019 performance year EHRs that are certified based on the 2015 Edition Criteria will not be required to undergo recertification.

In summary, changes to the Promoting Interoperability category in 2019 will require updates to CEHRT and other health IT products. It will also require many practices to improve their Promoting Interoperability category performance in 2019 to achieve scores similar to what they received in 2017 and 2018.

MIPS Cost Performance Category in 2019

CMS will continue to measure performance for the Cost category using the Medicare Spending Per Beneficiary (MSPB) and Total Per Capita Cost (TPCC) measures. These measures have retained their case minimums of attributed patients (35 patients for the MSPB measure and 20 patients for the TPCC measure).

CMS approved the use of eight episode-based cost measures for the 2019 performance period, as shown in Table 4. There are two types of episode-based measures approved for 2019: Procedural measures and Acute Inpatient Medical Condition measures.

The case minimums are 20 cases for the acute inpatient episode-based measures and 10 cases for the procedural measures. If the case minimum requirements cannot be met for any of the 10 cost measures (i.e., the MSPB, TPCC and eight episode-based measures) the Cost category is given a weighting of zero percent. The Cost category’s weighting of 15 percent is then reallocated to the Quality category, giving it a weighting of 60 percent.

CMS will use claims data to determine cost measure performance. Practices do not need to report data for this performance category. Cost measures are risk adjusted, placing additional emphasis on accurate HCC-related documentation and coding.

MIPS Quality Performance Category in 2019

CMS is continuing with its “Meaningful Measures” initiative through work with seven awarded cooperative agreement partnerships. CMS is in the process of developing additional outcome-based quality measures that better demonstrate improvements in patient care. CMS elected to create new terms for quality and other category reporting activities (see Figure 3).

Starting with the 2019 performance year, groups may submit and be scored on quality measures using more than one “collection type.” This is significant as the same measure may have two or more collection types with differing benchmarks. For example, if a practice submits quality data on the same quality measure via both the CQM and eCQM collection types, they may receive different scores depending on unique benchmarks tied to the measures collection type. CMS will choose the higher score for this measure when determining the quality performance score.

Small group practices may report via the claims reporting mechanism in 2019. Formerly this was limited to clinicians reporting as individuals. CMS is also maturing the process whereby quality measures that traditionally have very high performance (i.e., “topped-out” measures) are being removed. CMS added 10 new quality measures and removed a total of 26 topped-out and otherwise “non-clinically useful” measures in 2019.

MIPS Improvement Activities Performance Category in 2019

There were minimal changes made to the Improvement Activities category for 2019. Six new improvement activities were added, five were modified, and one was removed. As noted previously, the five percent Promoting Interoperability bonus associated with the use of certain improvement activities has been removed.

MIPS Reporting Options for Facility-based Clinicians

Clinicians that are facility-based can use their hospital’s performance under the Hospital Value-Based Purchasing (VBP) Program for the MIPS quality and cost performance categories. Facility-based clinicians are defined as clinicians that furnish 75 percent or more of their covered professional services in inpatient hospitals, on-campus outpatient hospitals, or emergency rooms. For groups, 75 percent or more of the clinicians in the group need to meet this same individual clinician facility-based requirement.

Facility-based practices retain the option of submitting quality category performance data based on the MIPS quality category performance. If the practice submits MIPS quality data, CMS will use the higher of the two performance scores for the quality and cost categories (i.e., VBP vs. MIPS) as the performance score for the Quality and Cost categories. The practice may still need to submit Promoting Interoperability performance data and attest to meeting improvement activity requirements.

MIPS Bonuses in 2019

CMS had discontinued the five percent small practice bonus that is applied to the total MIPS score in 2019. Small practices (15 and fewer clinicians) will instead receive a six point bonus added to their quality scores. As noted above, CMS also removed bonuses in the Promoting Interoperability category for specified improvement activities that involved the use of certified EHR technology.

Bonuses that CMS retained include the complex patient care bonus (up to five points added to the total MIPS score) and bonuses associated with reporting additional outcome, high priority, and end-to-end electronic quality measures.

Advanced Alternative Payment Models (APMs) in 2019

There were relatively few changes to Advanced APM requirements for 2019. A brief overview of selected changes is provided below.

Qualified Participant (QP) Thresholds in 2019

As per statute the percent of payments and patient volume thresholds to achieve QP and Partial QP status increased for the 2019 performance year (see Table 4 and Table 5). This has been partially offset by the approval of the All-Payer Combination and Other Payer Advanced APMs in 2019. These initiatives will allow clinicians participating in non-QPP Advanced APMs that meet CMS approval to have their payment and volume thresholds summated with QPP Advanced APMs. This will allow larger numbers of clinicians to meet the increased thresholds in 2019 and future years. Other APMs may be Medicaid, Medicare Advantage, and CMS multi-payer models or commercial/private payer Advanced APMs.

A significant number of MIPS eligible clinicians that met the thresholds for partial QP status in 2017 and 2018 may find themselves not meeting the new threshold requirements in 2019. When this occurs clinicians will receive a MIPS score that is not determined by the MIPS APM scoring standard—it will be based on their or their group’s performance in the four MIPS categories. MIPS eligible clinicians with historical APM payment percentages in the range of 20 percent and 40 percent and APM patient volumes in the range of 10 percent and 25 percent may wish to consider having a MIPS strategy in place for 2019 and future years.

Certified Electronic Health Records Technology (CEHRT) Usage in 2019

Advanced APMs must require that at least 75 percent of eligible clinicians in each APM entity are using CEHRT in 2019.

More Information Available in the Final Rule

This article provides an overview of changes to the Quality Payment Program in 2019. Please see the QPP section of the 2019 Physician Fee Schedule Final Rule and emerging guidance from CMS for additional information. Addition information from this author pertaining to the 2018 QPP performance year is also available.4

Notes
  1. Centers for Medicare and Medicaid Services. “83 FR 59452 (2019 Medicare Physician Fee Schedule Final Rule).” Federal Register. November 23, 2018. federalregister.gov/documents/2018/11/23/2018-24170/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions.
  2. Ibid.
  3. Ibid.
  4. Marron-Stearns, Michael. “MACRA Strategies for 2018 and 2019 (Update)” Journal of AHIMA 89, no.2 (February 2018): 22-27. http://bok.ahima.org/doc?oid=302408.

Michael Marron-Stearns (Michael@apollohit.com) is CEO and founder of Apollo HIT, LLC.

Source: journal.ahima.org