Akash Jha

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	CMS’ Quality Payment Program (QPP), launched in 2016 as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), offers clinicians a “pick your pace” approach to help reduce their quality measurement and administrative burden.

	The recently released QPP Year 2 proposed rule targets reporting from 2018 onward and extends to cover certain aspects of the Appropriate Use Criteria (AUC) and the 21

 Century Cures Act. The updates also include measures such as improvement scores, which were proposed in MACRA but were not implemented in Year 1.   

	Here are eight key takeaways from the QPP Year 2 proposed rule, which could be finalized in November 2017, based on CMS’ past release schedules.

	The improvement score, measured at the quality performance category level, will be based on the performance increase from last year, scaling up to 10 percentage points. With the addition of improvement scores, providers can prevent repetitive reporting of the same measures and performances. This will encourage providers to strive for the highest score every year of the Merit-based Incentive Payment System (MIPS), regardless of how well they did the previous year. Providers should take advantage of analytics for real-time score improvements and comparison with peers.

2. Factor cost into performance measurement

	Although cost doesn’t require reporting, it affects the bottom line as far as the composite performance score (CPS) and payment adjustments are concerned. Because CMS is keeping the cost weightage low at zero or 10% initially, providers have a chance to adjust to this new category. However, the cost weightage will jump to 30% starting in 2019, so participants relying on quality scores will need to monitor their costs and start preparing for the huge impact this category will have from 2019. This will require an investment in analytics to leverage Quality and Resource Use Reports (QRUR) and to help optimize costs.

3. Availability of new submission mechanisms

	While the allowance of more than one submission mechanism (such as Qualified Clinical Data Registry (QCDR), Qualified Registry (QR), Certified Electronic Health Record Technology (CEHRT), CMS Web Interface, etc.) within the same performance category is commendable, it will amount to a huge burden for health IT developers to incorporate such flexibility within the system. To minimize confusion and complexity in the submission process, providers should stick with one submission mechanism across all four categories, which would satisfy use cases.

	Immunization reporting has been the mainstay of quality measurement since meaningful use Stage 1; however, many states don’t have an Immunization Registry. CMS has now increased the flexibility for this measurement. If providers cannot report on the Immunization Registry Reporting measure, they can choose to not report it and select from other registries to score the 10% required for the performance score under Public Health Registry Reporting. This will only strengthen the public health objective and the importance of other registries.

	Allowing the ONC 2014 edition and subsequently Advancing Care Information (ACI) transition measures in 2018 relaxes the impact on health IT developers and providers, although CMS does reward bonus points for using ONC 2015 CEHRT in 2018. Considering that only a handful of electronic health records (EHRs) are 2015 edition certified at this point, this change gives all providers a fair chance to upgrade in a timely manner. Providers should consider upgrading to the ONC 2015 edition this year to take advantage of the bonus points.

	For clinicians operating small practices, CMS will add a new category of hardship exceptions to reweight the ACI performance category to 0, add five points to the final score, and also add a bonus of three points for measures in the quality category that don’t meet the data completeness criteria.

	CMS recognized that small practices still faced difficulty participating in MIPS and proposed to increase the low-volume threshold to include small practices so they are exempt from MIPS participation. MIPS exemption thresholds have been enhanced from:

Less than or equal to $30000 Part B billing OR 

Less than or equal to 100 Part B patient 

Less than or equal to $90000 Part B billing OR 

Less than or equal to 200 Part B patients

	If an eligible clinician (EC) meets any of the low-volume threshold criteria, he or she is exempt from MIPS participation.

7. Measures for virtual groups and facility-based scoring

	CMS also implemented elements of MACRA that were not included in the first year, such as “virtual groups” and “facility-based measurement.” Virtual groups would be composed of solo practitioners and groups of 10 or fewer ECs who come together “virtually” with at least one other solo practitioner or group to participate in MIPS for a performance period of a year.  Virtual groups will have the same threshold for non-patient facing criteria as normal groups, which is less than 75% NPIs within a virtual group during a performance period are labeled as non-patient facing.

	The new reporting option of facility-based scoring is available for facility-based clinicians who have at least 75% of their covered professional services supplied in the inpatient hospital setting or emergency department. This applies to both quality and cost categories.

8. A simpler move to advanced payment models (APM)

	The goal of MACRA is to authorize incentives to encourage participation. With the inclusion of the new Medicare ACO Track 1+ program as a qualifying APM, and the reopening of applications for the Next Generation ACO program and Comprehensive Primary Care Plus (CPC+) program, CMS estimates that the number of clinicians in the APM track will increase in 2018 when compared to 2017. Additionally, CMS exempts Round 1 participants in the CPC+ program from the requirement that the medical home standard applies only to APM entities with fewer than 50 clinicians in their parent organization. To further ease the transition, CMS changes the nominal amount standard for Medical Home Models so that the minimum required amount of total risks increases at a slower pace (reduced by 0.5% for the consecutive year).

	The proposed rule also provides details on how the “All-Payer Combination Option” will be implemented in the 2019 performance year. CMS’ aim is to help clinicians become Qualifying APM participants by a combination of Medicare participation in Advanced APMs and participation in other Payer Advanced APMs. 

Akash Jha is a healthcare consultant at CitiusTech and Anvesh Patel is assistant manager, product management, at CitiusTech.

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