82 FR 30010 - Medicare Program; CY 2018 Updates to the Quality Payment Program
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services
Federal Register Volume 82, Issue 125 (June 30, 2017)
Page Range
30010-30500
FR Document
2017-13010
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established the Quality Payment Program for eligible clinicians. Under the Quality Payment Program, eligible clinicians can participate via one of two tracks: Advanced Alternative Payment Models (APMs); or the Merit-based Incentive Payment System (MIPS). We began implementing the Quality Payment Program through rulemaking for calendar year (CY) 2017. This rule provides proposed updates for the second and future years of the Quality Payment Program.
Federal Register, Volume 82 Issue 125 (Friday, June 30, 2017)
[Federal Register Volume 82, Number 125 (Friday, June 30, 2017)]
[Proposed Rules]
[Pages 30010-30500]
From the Federal Register Online [www.thefederalregister.org]
[FR Doc No: 2017-13010]
[[Page 30009]]
Vol. 82
Friday,
No. 125
June 30, 2017
Part II
Book 2 of 3 Books
Pages 30009-30500
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Part 414
Medicare Program; CY 2018 Updates to the Quality Payment Program;
Proposed Rule
Federal Register / Vol. 82 , No. 125 / Friday, June 30, 2017 /
Proposed Rules
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 414
[CMS-5522-P]
RIN 0938-AT13
Medicare Program; CY 2018 Updates to the Quality Payment Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
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SUMMARY: The Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) established the Quality Payment Program for eligible
clinicians. Under the Quality Payment Program, eligible clinicians can
participate via one of two tracks: Advanced Alternative Payment Models
(APMs); or the Merit-based Incentive Payment System (MIPS). We began
implementing the Quality Payment Program through rulemaking for
calendar year (CY) 2017. This rule provides proposed updates for the
second and future years of the Quality Payment Program.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, no later than 5 p.m. on August 21, 2017.
ADDRESSES: In commenting, please refer to file code CMS-5522-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission. You may submit comments in one of four
ways (please choose only one of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-5522-P, P.O. Box 8013,
Baltimore, MD 21244-8013.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-5522-P, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. Alternatively, you may deliver (by hand or
courier) your written comments ONLY to the following addresses prior to
the close of the comment period:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC
20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
call telephone number (410) 786-7195 in advance to schedule your
arrival with one of our staff members. Comments erroneously mailed to
the addresses indicated as appropriate for hand or courier delivery may
be delayed and received after the comment period. For information on
viewing public comments, see the beginning of the SUPPLEMENTARY
INFORMATION section.
FOR FURTHER INFORMATION CONTACT:
Molly MacHarris, (410) 786-4461, for inquiries related to MIPS.
Benjamin Chin, (410) 786-0679, for inquiries related to APMs.
SUPPLEMENTARY INFORMATION:
Table of Contents
I. Executive Summary and Background
II. Provisions of the Proposed Regulations
A. Introduction
B. Definitions
C. MIPS Program Details
D. Overview of Incentives for Participation in Advanced
Alternative Payment Models
III. Collection of Information Requirements
IV. Response to Comments
V. Regulatory Impact Analysis
A. Statement of Need
B. Overall Impact
C. Changes in Medicare Payments
D. Impact on Beneficiaries
E. Regulatory Review Costs
F. Accounting Statement
Acronyms
Because of the many terms to which we refer by acronym in this
rule, we are listing the acronyms used and their corresponding meanings
in alphabetical order below:
ABCTM Achievable Benchmark of Care
ACO Accountable Care Organization
API Application Programming Interface
APM Alternative Payment Model
APRN Advanced Practice Registered Nurse
ASC Ambulatory Surgical Center
ASPE HHS' Office of the Assistant Secretary for Planning and
Evaluation
BPCI Bundled Payments for Care Improvement
CAH Critical Access Hospital
CAHPS Consumer Assessment of Healthcare Providers and Systems
CBSA Core Based Statistical Area
CEHRT Certified EHR technology
CFR Code of Federal Regulations
CHIP Children's Health Insurance Program
CJR Comprehensive Care for Joint Replacement
COI Collection of Information
CPR Customary, Prevailing, and Reasonable
CPS Composite Performance Score
CPT Current Procedural Terminology
CQM Clinical Quality Measure
CY Calendar Year
eCQM Electronic Clinician Quality Measure
ED Emergency Department
EHR Electronic Health Record
EP Eligible Professional
ESRD End-Stage Renal Disease
FFS Fee-for-Service
FR Federal Register
FQHC Federally Qualified Health Center
GAO Government Accountability Office
HIE Health Information Exchange
HIPAA Health Insurance Portability and Accountability Act of 1996
HITECH Health Information Technology for Economic and Clinical
Health
HPSA Health Professional Shortage Area
HHS Department of Health & Human Services
HRSA Health Resources and Services Administration
IHS Indian Health Service
IT Information Technology
LDO Large Dialysis Organization
MACRA Medicare Access and CHIP Reauthorization Act of 2015
MEI Medicare Economic Index
MIPAA Medicare Improvements for Patients and Providers Act of 2008
MIPS Merit-based Incentive Payment System
MLR Minimum Loss Rate
MSPB Medicare Spending per Beneficiary
MSR Minimum Savings Rate
MUA Medically Underserved Area
NPI National Provider Identifier
OCM Oncology Care Model
ONC Office of the National Coordinator for Health Information
Technology
PECOS Medicare Provider Enrollment, Chain, and Ownership System
PFPMs Physician-Focused Payment Models
PFS Physician Fee Schedule
PHI Protected Health Information
PHS Public Health Service
PQRS Physician Quality Reporting System
PTAC Physician-Focused Payment Model Technical Advisory Committee
QCDR Qualified Clinical Data Registry
QP Qualifying APM Participant
QRDA Quality Reporting Document Architecture
QRUR Quality and Resource Use Reports
RBRVS Resource-Based Relative Value Scale
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RFI Request for Information
RHC Rural Health Clinic
RIA Regulatory Impact Analysis
RVU Relative Value Unit
SGR Sustainable Growth Rate
TCPI Transforming Clinical Practice Initiative
TIN Tax Identification Number
VBP Value-Based Purchasing
VM Value-Based Payment Modifier
VPS Volume Performance Standard
I. Executive Summary and Background
A. Overview
This proposed rule would make payment and policy changes to the
Quality Payment Program. The Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 2015) amended
title XVIII of the Social Security Act (the Act) to repeal the Medicare
sustainable growth rate (SGR), to reauthorize the Children's Health
Insurance Program, and to strengthen Medicare access by improving
physician and other clinician payments and making other improvements.
The MACRA advances a forward-looking, coordinated framework for
clinicians to successfully take part in the Quality Payment Program
that rewards value and outcomes in one of two ways:
Advanced Alternative Payment Models (Advanced APMs).
Merit-based Incentive Payment System (MIPS).
These policies are collectively referred to as the Quality Payment
Program. Recognizing that the Quality Payment Program represents a
major milestone in the way that we bring quality measurement and
improvement together with payment, we have taken efforts to review
existing policies to identify how to move the program forward in the
least burdensome manner possible. Our goal is to support patients and
clinicians in making their own decisions about health care using data
driven insights, increasingly aligned and meaningful quality measures,
and technology that allows clinicians to focus on providing high
quality healthcare for their patients. We believe our existing APMs
alongside the proposals in this proposed rule provide opportunities
that support state flexibility, local leadership, regulatory relief and
innovative approaches to improve quality accessibility and
affordability. By driving changes in how care is delivered, we believe
the Quality Payment Program supports eligible clinicians in improving
the health of their patients and increasing care efficiency. To
implement this vision, the Quality Payment Program emphasizes high-
value care and patient outcomes while minimizing burden on eligible
clinicians; the Program is also designed to be flexible, transparent,
and structured to improve over time with input from clinicians,
patients, and other stakeholders. We have sought and continue to seek
feedback from the health care community through various public avenues
such as rulemaking, listening sessions and stakeholder engagement. Last
year, when we engaged in rulemaking to establish policies for effective
implementation of the Quality Payment Program, we did so with the
explicit understanding that technology, infrastructure, physician
support systems, and clinical practices will change over the next few
years. For more information, see the Merit-based Incentive Payment
System (MIPS) and Alternative Payment Model (APM) Incentive under the
Physician Fee Schedule, and Criteria for Physician-Focused Payment
Models final rule with comment period (81 FR 77008, November 4, 2016),
hereinafter referred to as the ``CY 2017 Quality Payment Program final
rule.'' In addition, we are aware of the diversity among clinician
practices in their experience with quality-based payments. As a result
of these factors, we expect the Quality Payment Program to evolve over
multiple years in order to achieve our national goals. To date, we have
laid the groundwork for expansion toward an innovative, outcome-
focused, patient-centered, resource-effective health system that
leverages health information technology to support clinicians and
patients and builds collaboration across care settings. This proposed
rule is the next part of a staged approach to develop policies that are
reflective of system capabilities and grounded in our core strategies
to drive progress and reform efforts. We commit to continue evolving
these policies.
CMS strives to put patients first, ensuring that they can make
decisions about their own healthcare along with their clinicians. We
want to ensure innovative approaches to improve quality, accessibility
and affordability while paying particular attention to improving
clinicians and beneficiaries experience when interacting with CMS
programs. The Quality Payment Program aims to (1) support care
improvement by focusing on better outcomes for patients, decreased
clinician burden, and preservation of independent clinical practice;
(2) promote adoption of APMs that align incentives for high-quality,
low-cost care across healthcare stakeholders; and (3) advance existing
delivery system reform efforts, including ensuring a smooth transition
to a healthcare system that promotes high-value, efficient care through
unification of CMS legacy programs.
We previously finalized the transition year Quality Payment Program
policies in the CY 2017 Quality Payment Program final rule. In that
final rule, we implemented policies to improve physician and other
clinician payments by changing the way Medicare incorporates quality
measurement into payments and by developing new policies to address and
incentivize participation in APMs. The final rule established the
Quality Payment Program and its two interrelated pathways: Advanced
APMs, and the MIPS. The final rule established incentives for
participation in Advanced APMs, supporting the goals of transitioning
from fee-for-service (FFS) payments to payments for quality and value,
including approaches that focus on better care, smarter spending, and
healthier people. The final rule included definitions and processes to
identify Qualifying APM Participants (QPs) in Advanced APMs and
outlined the criteria for use by the Physician-Focused Payment Model
Technical Advisory Committee (PTAC) in making comments and
recommendations to the Secretary on proposals for physician-focused
payment models (PFPMs).
The final rule also established policies to implement MIPS, a
program for certain eligible clinicians that makes Medicare payment
adjustments based on performance on quality, cost and other measures
and activities, and that consolidates components of three precursor
programs--the Physician Quality Reporting System (PQRS), the Physician
Value-based Payment Modifier (VM), and the Medicare Electronic Health
Record (EHR) Incentive Program for eligible professionals (EPs). As
prescribed by MACRA, MIPS focuses on the following: quality--including
a set of evidence-based, specialty-specific standards; cost; practice-
based improvement activities; and use of certified electronic health
record (EHR) technology (CEHRT) to support interoperability and
advanced quality objectives in a single, cohesive program that avoids
redundancies.
In this proposed rule, we are building and improving Quality
Payment Program policies that will be familiar to stakeholders and are
designed to integrate easily across clinical practices during the
second and future years of implementation. We strive to continue our
focus on priorities that can drive improvements toward better patient
outcomes without creating undue
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burden for clinicians. In this proposed rule, we also address elements
of MACRA that were not included in the first year of the program,
including virtual groups, facility-based measurement, and improvement
scoring. We also include proposals to continue implementing elements of
MACRA that do not take effect in the first or second year of the
Quality Payment Program, including policies related to the All-Payer
Combination Option for identifying QPs and assessing eligible
clinicians' participation in Other Payer Advanced APMs. To provide
unity and consistency across the two paths of the Quality Payment
Program, MIPS and APMs, in this proposed rule we have referred to the
second year of the program as ``Quality Payment Program Year 2.''
B. Quality Payment Program Strategic Objectives
As discussed in the CY 2017 Quality Payment Program final rule (81
FR 77010), after extensive outreach with clinicians, patients and other
stakeholders, we created six strategic objectives to drive continued
progress and improvement. These objectives guided our final policies
and will guide our future rulemaking in order to design, implement, and
evolve a Quality Payment Program that aims to improve health outcomes,
promote efficiency, minimize burden of participation, and provide
fairness and transparency in operations. These strategic objectives are
as follows: (1) To improve beneficiary outcomes and engage patients
through patient-centered Advanced APM and MIPS policies; (2) to enhance
clinician experience through flexible and transparent program design
and interactions with easy-to-use program tools; (3) to increase the
availability and adoption of Advanced APMs; (4) to promote program
understanding and maximize participation through customized
communication, education, outreach and support that meet the needs of
the diversity of physician practices and patients, especially the
unique needs of small practices; (5) to improve data and information
sharing to provide accurate, timely, and actionable feedback to
clinicians and other stakeholders; and (6) to promote IT systems
capabilities that meet the needs of users and are seamless, efficient
and valuable on the front and back-end. We also believe it is important
to ensure the Quality Payment Program maintains operational excellence
as the program develops. Therefore we are adding a seventh objective,
specifically to ensure operational excellence in program implementation
and ongoing development. More information on these objectives and the
Quality Payment Program can be found at www.qpp.cms.gov.
With these objectives, we recognize that the Quality Payment
Program provides new opportunities to improve care delivery by
supporting and rewarding clinicians as they find new ways to engage
patients, families, and caregivers and to improve care coordination and
population health management. In addition, we recognize that by
developing a program that is flexible instead of one-size-fits-all,
clinicians will be able to choose to participate in a way that is best
for them, their practice, and their patients. For eligible clinicians
interested in APMs, we believe that by setting ambitious yet achievable
goals, eligible clinicians will move with greater certainty toward
these new approaches of delivering care. APMs are a vital part of
bending the Medicare cost curve by encouraging the delivery of high-
quality, low-cost care. To these ends, and to allow this program to
work for all stakeholders, we further recognize that we must provide
ongoing education, support, and technical assistance so that clinicians
can understand program requirements, use available tools to enhance
their practices, and improve quality and progress toward participation
in APMs if that is the best choice for their practice. Finally, we
understand that we must achieve excellence in program management,
focusing on customer needs, promoting problem-solving, teamwork, and
leadership to provide continuous improvements in the Quality Payment
Program.
C. One Quality Payment Program
Clinicians have told us that they do not separate their patient
care into domains, and that the Quality Payment Program needs to
reflect typical clinical workflows in order to achieve its goal of
better patient care. Advanced APMs, the focus of one pathway of the
Quality Payment Program, contribute to better care and smarter spending
by allowing physicians and other clinicians to deliver coordinated,
customized, high-value care to their patients in a streamlined and
cost-effective manner. Within MIPS, the second pathway of the Quality
Payment Program, we believe that integration into typical clinical
workflows can best be accomplished by making connections across the
four statutory pillars of the MIPS incentive structure--quality,
clinical practice improvement activities (referred to as ``improvement
activities''), meaningful use of CEHRT (referred to as ``advancing care
information''), and resource use (referred to as ``cost'')--and by
emphasizing that the Quality Payment Program is at its core about
improving the quality of patient care.
Although there are two separate pathways within the Quality Payment
Program, the Advanced APM and MIPS tracks both contribute toward the
goal of seamless integration of the Quality Payment Program into
clinical practice workflows. Advanced APMs promote this seamless
integration by way of payment methodology and design that incentivize
care coordination, and the MIPS builds the capacity of eligible
clinicians across the four pillars of MIPS to prepare them for
participation in MIPS APMs and Advanced APMs in later years of the
Quality Payment Program. Indeed, the bedrock of the Quality Payment
Program is high-value, patient-centered care, informed by useful
feedback, in a continuous cycle of improvement. The principal way that
MIPS measures quality of care is through a set of clinical quality
measures (CQMs) from which MIPS eligible clinicians can select. The
CQMs are evidence-based, and the vast majority are created or supported
by clinicians. Over time, the portfolio of quality measures will grow
and develop, driving towards outcomes that are of the greatest
importance to patients and clinicians and away from process, or ``check
the box'' type measures.
Through MIPS, we have the opportunity to measure quality, not only
through evidence-based quality measures, but also by accounting for
activities that clinicians themselves identify: namely, practice-driven
quality improvement. MIPS also requires us to assess whether CEHRT is
used meaningfully. Based on significant feedback, this area was
simplified to support the exchange of patient information, engagement
of patients in their own care through technology, and the way
technology specifically supports the quality goals selected by the
practice. The cost performance category was simplified and weighted at
zero percent of the final score for the transition year of CY 2017 to
allow clinicians an opportunity to ease into the Quality Payment
Program. We further note the cost performance category requires no
separate submissions for participation which minimizes burden on
clinicians. The assessment of cost is a vital part of ensuring that
clinicians are providing Medicare beneficiaries with high-value care.
Given the primary focus on value, we indicated in the CY 2017 Quality
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Payment Program final rule our intention to align cost measures with
quality measures over time in the scoring system (81 FR 77010). That
is, we established special policies for the first year of the Quality
Payment Program, which enabled a ramp-up and gradual transition with
less financial risk for clinicians in the transition year. We called
this approach ``pick your pace'' and allowed clinicians and groups to
participate in MIPS through flexible means while avoiding a negative
payment adjustment. In this proposed rule, we continue the slow ramp-up
of the Quality Payment Program by establishing special policies for
Program Year 2 aimed at encouraging successful participation in the
program while reducing burden, reducing the number of clinicians
required to participate, and preparing clinicians for the CY 2019
performance period (CY 2021 payment year).
D. Summary of the Major Provisions
1. Quality Payment Program Year 2
We believe the second year of the Quality Payment Program should
build upon the foundation that has been established which provides a
trajectory for clinicians to value-based care. This trajectory provides
to clinicians the ability to participate in the program through two
pathways: MIPS and Advanced APMs. As we indicated in the CY 2017
Quality Payment Program final rule (81 FR 77011), we believed that a
second transition period would be necessary to build upon the iterative
learning and development period as we build towards a steady state. We
continue to believe this to be true and have therefore crafted our
policies to extend flexibilities into Quality Payment Program Year 2.
2. Small Practices
The support of small, independent practices remains an important
thematic objective for the implementation of the Quality Payment
Program and is expected to be carried throughout future rulemaking. For
MIPS performance periods occurring in 2017, many small practices are
excluded from new requirements due to the low-volume threshold, which
was set at less than or equal to $30,000 in Medicare Part B allowed
charges or less than or equal to 100 Medicare Part B patients. We have
heard feedback, however, from many small practices that challenges
still exist in their ability to participate in the program. We are
proposing additional flexibilities including: Implementing the virtual
groups provisions; increasing the low-volume threshold to less than or
equal to $90,000 in Medicare Part B allowed charges or less than or
equal to 200 Medicare Part B patients; adding a significant hardship
exception from the advancing care information performance category for
MIPS eligible clinicians in small practices; and providing bonus points
that are added to the final scores of MIPS eligible clinicians who are
in small practices. We believe that these additional flexibilities and
reduction in barriers will further enhance the ability of small
practices to participate successfully in the Quality Payment Program.
In keeping with the objectives to provide education about the
Quality Payment Program and maximize participation, and as mandated by
the statute, during a period of 5 years, $100 million in funding was
provided for technical assistance to be available to provide guidance
and assistance to MIPS eligible clinicians in small practices through
contracts with regional health collaboratives, and others. Guidance and
assistance on the MIPS performance categories or the transition to APM
participation will be available to MIPS eligible clinicians in
practices of 15 or fewer clinicians with priority given to practices
located in rural areas or medically underserved areas (MUAs), and
practices with low MIPS final scores. More information on the technical
assistance support available to small practices can be found at https://qpp.cms.gov/docs/QPP_Support_for_Small_Practices.pdf.
As discussed in section V.C. of this proposed rule, we have also
performed an updated regulatory impact analysis, accounting for
flexibilities, many of which are continuing into the Quality Payment
Program Year 2, that have been created to ease the burden for small and
solo practices. We estimate that at least 80 percent of clinicians in
small practices with 1-15 clinicians will receive a positive or neutral
MIPS payment adjustment. We refer readers to section V.C. of this
proposed rule for details on how this estimate was developed.
3. Summary of Major Provisions for Advanced Alternative Payment Models
(Advanced APMs)
a. Overview
APMs represent an important step forward in our efforts to move our
healthcare system from volume-based to value-based care. APMs that meet
the criteria to be Advanced APMs provide the pathway through which
eligible clinicians, who would otherwise fall under the MIPS, can
become Qualifying APM Participants (QPs), thereby earning incentive
payments for their Advanced APM participation. In the CY 2017 Quality
Payment Program final rule (81 FR 77516), we estimated that 70,000 to
120,000 eligible clinicians would be QPs for payment year 2019 based on
Advanced APM participation in performance year 2017. With new Advanced
APMs expected to be available for participation in 2018, including the
Medicare ACO Track 1 Plus (1+) Model, and the reopening of the
application process to new participants for some current Advanced APMs,
such as the Next Generation ACO Model and Comprehensive Primary Care
Plus Model, we anticipate higher numbers of QPs in subsequent years of
the program. We currently estimate that approximately 180,000 to
245,000 eligible clinicians may become QPs for payment year 2020 based
on Advanced APM participation in performance year 2018.
b. Advanced APMs
In the CY 2017 Quality Payment Program final rule (81 FR 77408), to
be considered an Advanced APM, we finalized that an APM must meet all
three of the following criteria, as required under section
1833(z)(3)(D) of the Act: (1) The APM must require participants to use
CEHRT; (2) The APM must provide for payment for covered professional
services based on quality measures comparable to those in the quality
performance category under MIPS and; (3) The APM must either require
that participating APM Entities bear risk for monetary losses of a more
than nominal amount under the APM, or be a Medical Home Model expanded
under section 1115A(c) of the Act.
We are proposing to maintain the generally applicable revenue-based
nominal amount standard at 8 percent of the estimated average total
Parts A and B revenue of eligible clinicians in participating APM
Entities for QP Performance Periods 2019 and 2020.
c. Qualifying APM Participant (QP) and Partial QP Determination
QPs are eligible clinicians in an Advanced APM who have met a
threshold for a certain percentage of their patients or payments
through an Advanced APM. QPs are excluded from MIPS for the year, and
receive a 5 percent APM Incentive Payment for each year they are QPs
beginning in 2019 through 2024. The statute sets thresholds for the
level of participation in Advanced APMs required for an eligible
clinician to become a QP for a year. For Advanced APMs that start or
end during the Medicare QP Performance Period and operate
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continuously for a minimum of 60 days during the Medicare QP
Performance Period for the year, we are proposing to make QP
determinations using payment or patient data only for the dates that
APM Entities were able to participate in the Advanced APM per the terms
of the Advanced APM, not for the full Medicare QP Performance Period.
Eligible clinicians who participate in Advanced APMs but do not meet
the QP or Partial QP thresholds are subject to MIPS reporting
requirements and payment adjustments.
d. All-Payer Combination Option
The All-Payer Combination Option, which uses a calculation based on
both the Medicare Option and the eligible clinician's participation in
Other Payer Advanced APMs to conduct QP determinations, is applicable
beginning in performance year 2019. To become a QP through the All-
Payer Combination Option, an eligible clinician must participate in an
Advanced APM with CMS, as well as an Other Payer Advanced APM. We
identify Other Payer Advanced APMs based on information submitted to us
by eligible clinicians, APM Entities, and in some cases by payers,
including states and Medicare Advantage Organizations. In addition, the
eligible clinician or the APM Entity must submit information to CMS so
that we can determine whether other payer arrangements are Other Payer
Advanced APMs and whether the eligible clinician meets the requisite QP
threshold of participation. To be an Other Payer Advanced APM, as set
forth in section 1833(z)(2)(B)(ii) and (C)(ii) of the Act and
implemented in the CY 2017 Quality Payment Program final rule, a
payment arrangement with a payer (for example, payment arrangements
authorized under Title XIX, Medicare Health Plan payment arrangements,
and payment arrangements in CMS Multi-Payer Models) must meet all three
of the following criteria: (1) CEHRT is used; (2) the payment
arrangement must require the use of quality measures comparable to
those in the quality performance category under MIPS and; (3) the
payment arrangement must either require the APM Entities to bear more
than nominal financial risk if actual aggregate expenditures exceed
expected aggregate expenditures, or be a Medicaid Medical Home Model
that meets criteria comparable to Medical Home Models expanded under
section 1115A(c) of the Act.
We are proposing modifications pertaining to the third criterion
that the payment arrangement must either require the APM Entities to
bear more than nominal financial risk if actual aggregate expenditures
exceed expected aggregate expenditures; or be a Medicaid Medical Home
Model that meets criteria comparable to Medical Home Models expanded
under section 1115A(c) of the Act. Specifically, we are proposing to
add a revenue-based nominal amount standard in addition to the
benchmark-based nominal amount standard that would be applicable only
to payment arrangements in which risk is expressly defined in terms of
revenue.
We are proposing modifications to our methodologies to determine
whether eligible clinicians will meet the QP thresholds using the All-
Payer Combination Option. Specifically, we are proposing to conduct all
QP determinations under the All-Payer Combination Option at the
individual eligible clinician level and are seeking comment on any
possible exceptions to this proposed policy that would be warranted,
such as a determination based on APM Entity group performance under the
All-Payer Combination Option for eligible clinicians participating in
CMS Multi-Payer Models. We are also proposing to establish an All-Payer
QP Performance Period to assess participation in Other Payer Advanced
APMs under the All-Payer Combination Option, and to rename the QP
Performance Period we established in rulemaking last year as the
Medicare QP Performance Period.
We are proposing to modify the information submission requirements
for the All-Payer Combination Option. Specifically, we are proposing
modifications to the information we require to make APM Entity or
eligible clinician initiated determinations of Other Payer Advanced
APMs after the All-Payer QP Performance Period, as well as the
information we require to perform QP determinations under the All-Payer
Combination Option. We are also proposing policies on the handling of
information submitted for purposes of assessment under the All-Payer
Combination Option.
We are proposing a Payer Initiated Other Payer Advanced APM
Determination Process, which would allow certain other payers,
including payment arrangements authorized under Title XIX, Medicare
Health Plans, and payers with payment arrangements in CMS Multi-Payer
Models, to request that we determine whether their other payer
arrangements are Other Payer Advanced APMs starting prior to the 2019
All-Payer QP Performance Period and each year thereafter.
e. Physician-Focused Payment Models (PFPMs)
The PTAC is an 11-member federal advisory committee that is an
important avenue for the creation of innovative payment models. The
PTAC is charged with reviewing stakeholders' proposed PFPMs, and making
comments and recommendations to the Secretary regarding whether they
meet the PFPM criteria established by the Secretary through rulemaking
in the CY 2017 Quality Payment Program final rule. PTAC comments and
recommendations will be reviewed by the CMS Innovation Center and the
Secretary, and we will post a detailed response to them on the CMS Web
site. We are seeking comments on broadening the definition of PFPM to
include payment arrangements that involve Medicaid or the Children's
Health Insurance Program (CHIP) as a payer even if Medicare is not
included as a payer. This broadened definition might be more inclusive
of potential PFPMs that could focus on areas not generally applicable
to the Medicare population, and could engage more stakeholders in
designing PFPMs. In addition, as we gain experience with public
submission of PFPM proposals to the PTAC, we are seeking comments on
the Secretary's criteria and stakeholders' needs in developing PFPM
proposals aimed at meeting the criteria.
4. Summary of Major Provisions for the Merit-Based Incentive Payment
System (MIPS)
For Quality Payment Program Year 2 which is the second year of the
MIPS and includes the performance periods in 2018 and the 2020 MIPS
payment year, we are proposing the following policies:
a. Quality
We previously finalized that the quality performance category would
comprise 60 percent of the final score for the transition year and 50
percent of the final score for the 2020 MIPS payment year (81 FR
77100). For the 2020 MIPS payment year, now we are proposing to
maintain a 60 percent weight for the quality performance category
contingent upon our proposal to reweight the cost performance category
to zero for the 2020 MIPS payment year as discussed in section
II.C.6.b.(2) in this proposed rule. Quality measures are selected
annually through a call for quality measures, and a final list of
quality measures will be published in the Federal Register by November
1 of each year. Except as discussed in section II.C.6.b.(3)(a)(iii) of
this proposed rule with regard to the
[[Page 30015]]
CAHPS for MIPS survey, we are not proposing any changes to the
submission criteria for quality measures in this proposed rule. We are
proposing for the CAHPS for MIPS survey for the Quality Payment Program
Year 2 and future years that the survey administration period would, at
a minimum, span over 8 weeks and would end no later than February 28th
following the applicable performance period. In addition, we are
proposing for the Quality Payment Program Year 2 and future years to
remove two Summary Survey Modules (SSM), specifically, ``Helping You to
Take Medication as Directed'' and ``Between Visit Communication'' from
the CAHPS for MIPS survey.
For the 2018 MIPS performance period, we previously finalized that
the data completeness threshold would increase to 60 percent for data
submitted on quality measures using QCDRs, qualified registries, via
EHR, or Medicare Part B claims. We noted that these thresholds for data
submitted on quality measures using QCDRs, qualified registries, via
EHR, or Medicare Part B claims would increase for performance periods
occurring in 2019 and future years. However, as discussed in section
II.C.6.b. of this proposed rule, we are proposing for the 2018 MIPS
performance period to maintain the transition year data completeness
threshold of 50 percent for data submitted on quality measures using
QCDRs, qualified registries, EHR, or Medicare Part B claims to provide
an additional year for individual MIPS eligible clinicians and groups
to gain experience with the MIPS before increasing the data
completeness threshold. However, we are proposing to increase the data
completeness threshold for the 2021 MIPS payment year to 60 percent for
data submitted on quality measures using QCDRs, qualified registries,
EHR, or Medicare Part B claims. We anticipate that for performance
periods going forward, as MIPS eligible clinicians gain experience with
the MIPS, we would further increase these thresholds over time.
b. Improvement Activities
Improvement activities are those that support broad aims within
healthcare delivery, including care coordination, beneficiary
engagement, population management, and health equity. In response to
comments from experts and stakeholders across the healthcare system,
improvement activities were given relative weights of high and medium.
For the 2020 MIPS payment year, we previously finalized that the
improvement activities performance category would comprise 15 percent
of the final score (81 FR 77179). For performance periods occurring in
2018, we are not proposing any changes in improvement activities
scoring as discussed in the CY 2017 Quality Payment Program final rule
(81 FR 77312).
As discussed in the appendices of this proposed rule, we are
proposing new improvement activities (Table F) and improvement
activities with changes (Table G) for the 2018 MIPS performance period
and future years for inclusion in the Improvement Activities Inventory.
Activities proposed in this section would apply for the 2018 MIPS
performance period and future performance periods unless further
modified via notice and comment rulemaking. We refer readers to Table H
of the CY 2017 Quality Payment Program final rule for a list of all the
previously finalized improvement activities (81 FR 77817 through
77831).
As discussed in section II.C.6.e.3.(c) of this proposed rule, we
are proposing to expand our definition of how we will recognize an
individual MIPS eligible clinician or group as being a certified
patient-centered medical home or comparable specialty practice. We
finalized at Sec. 414.1380(b)(3)(iv) in the CY 2017 Quality Payment
Program final rule that a certified patient-centered medical home
includes practice sites with current certification from a national
program, regional or state program, private payer or other body that
administers patient-centered medical home accreditation. We are
proposing in section II.C.6.e.(3)(b) of this proposed rule that
eligible clinicians in practices that have been randomized to the
control group in the CPC+ model would also receive full credit as a
Medical Home Model. In addition, for group reporters, for the 2018 MIPS
performance period and future performance periods, we are proposing to
require that at least 50 percent of the practice sites within a TIN
must be recognized as a certified or recognized patient-centered
medical home or comparable specialty practice to receive full credit in
the improvement activities performance category.
As discussed in section II.C.6.f.(2)(d) of this proposed rule, in
recognition of improvement activities as supporting the central mission
of a unified Quality Payment Program, we propose to continue to
designate activities in the Improvement Activities Inventory that will
also qualify for the advancing care information bonus score. This is
consistent with our desire to recognize that CEHRT is often deployed to
improve care in ways that our programs should recognize.
c. Advancing Care Information
For the Quality Payment Program Year 2, the advancing care
information performance category comprises 25 percent of the final
score. However, if a MIPS eligible clinician is participating in a MIPS
APM the advancing care information performance category may comprise 30
percent or 75 percent of the final score depending on the availability
of APM quality data for reporting. Objectives and measures in the
advancing care information performance category focus on the secure
exchange of health information and the use CEHRT to support patient
engagement and improved healthcare quality. While we continue to
recommend that physicians and clinicians migrate to the implementation
and use of EHR technology certified to the 2015 Edition so they may
take advantage of improved functionalities, including care coordination
and technical advancements such as application programming interfaces,
or APIs, we recognize that some practices may have challenges in
adopting new certified health IT. Therefore we are proposing that MIPS
eligible clinicians may continue to use EHR technology certified to the
2014 Edition for the performance period in CY 2018. We are proposing
minor modifications to the advancing care information objectives and
measures and the 2017 advancing care information transition objectives
and measures. We are also proposing to add an exclusion for the e-
Prescribing and Health Information Exchange Objectives. We are
proposing to modify our scoring policy for the Public Health and
Clinical Data Registry Reporting Objectives and Measures for the
performance score and the bonus score.
We are also proposing to implement several provisions of the 21st
Century Cures Act (Pub. L. 114-255, enacted on December 13, 2016)
pertaining to hospital-based MIPS eligible clinicians, ambulatory
surgical center-based MIPS eligible clinicians, MIPS eligible
clinicians using decertified EHR technology, and significant hardship
exceptions under the MIPS. We are also proposing to add a significant
hardship exception for MIPS eligible clinicians in small practices.
d. Cost
In this proposed rule, we are proposing to weight the cost
performance category at zero percent of the final score for the 2020
MIPS payment year in order to improve clinician understanding of the
measures
[[Page 30016]]
and continue development of episode-based measures that will be used in
this performance category.
For the 2018 MIPS performance period, we are proposing to adopt for
the cost performance category the total per capita costs for all
attributed beneficiaries measure and the Medicare Spending per
Beneficiary (MSPB) measure that were adopted for the 2017 MIPS
performance period. For the 2018 MIPS performance period, we are not
proposing to use the 10 episode-based measures that were adopted for
the 2017 MIPS performance period. Although data on the episode-based
measures has been made available to clinicians in the past, we are in
the process of developing new episode-based measures with significant
clinician input and believe it would be more prudent to introduce these
new measures over time. We will continue to offer performance feedback
on episode-based measures prior to potential inclusion of these
measures in MIPS to increase clinician familiarity with the concept as
well as specific episode-based measures.
Specifically, we intend to provide feedback on these new episode-
based cost measures in the fall of this year for informational purposes
only. We intend to provide performance feedback on the MSPB and total
per capita cost measures by July 1, 2018, consistent with section
1848(q)(12) of the Act. In addition, we intend to offer feedback on
another set of newly developed episode-based cost measures in 2018 as
well. Therefore, clinicians would have received feedback on cost
measures at several points prior to the cost performance category
counting as part of the final score.
e. Submission Mechanisms
As discussed in section II.6.a. of this proposed rule, we are
proposing additional flexibility for submitting data. Individual MIPS
eligible clinicians or groups would be able to submit measures and
activities, as available and applicable, via as many mechanisms as
necessary to meet the requirements of the quality, improvement
activities, or advancing care information performance categories. We
expect that this option will provide clinicians the ability to select
the measures most meaningful to them, regardless of the submission
mechanism.
f. Virtual Groups
There are generally three ways to participate in MIPS: (1) As an
individual; (2) as a group; and (3) as a virtual group. In this
proposed rule, we are proposing to establish requirements for MIPS
participation at the virtual group level. We propose to define a
virtual group as a combination of two or more TINs composed of a solo
practitioner (a MIPS eligible clinician (as defined at Sec. 414.1305)
who bills under a TIN with no other NPIs billing under such TIN) or a
group (as defined at Sec. 414.1305) with 10 or fewer eligible
clinicians under the TIN that elects to form a virtual group with at
least one other such solo practitioner or group for a performance
period for a year.
To provide support and reduce burden, we intend to make technical
assistance (TA) available, to the extent feasible and appropriate, to
support clinicians who choose to come together as a virtual group for
the first 2 years of virtual group implementation applicable to the
2018 and 2019 performance years. Clinicians can access the TA
infrastructure that they may be already utilizing. For Quality Payment
Program Year 3, we intend to provide an electronic election process if
technically feasible. Clinicians who do not elect to contact their
designated TA representative would still have the option of contacting
the Quality Payment Program Service Center. We believe that our
proposal will create an election process that is simple and
straightforward.
g. MIPS APMs
In the CY 2017 Quality Payment Program final rule (81 FR 77246), we
finalized that MIPS eligible clinicians who participate in MIPS APMs
will be scored using the APM scoring standard instead of the generally
applicable MIPS scoring standard. For the 2018 performance period, we
are proposing modifications to the quality performance category
reporting requirements and scoring for MIPS eligible clinicians in most
MIPS APMs, and other modifications to the APM scoring standard. For
purposes of the APM scoring standard, we are proposing to add a fourth
snapshot date that would be used only to identify APM Entity groups
participating in those MIPS APMs that require full TIN participation.
Along with the other APM Entity groups, these APM Entity groups would
be used for the purposes of reporting and scoring under the APM scoring
standard described the CY 2017 Quality Payment Program final rule (81
FR 77246).
h. Facility-Based Measurement
For the transition year of MIPS, we considered an option for
facility-based MIPS eligible clinicians to elect to use their
institution's performance rates as a proxy for the MIPS eligible
clinician's performance in the quality and cost performance categories.
However, we did not propose an option for the transition year of MIPS
because there were several operational considerations that needed to be
addressed before this option could be implemented. After consideration
of comments received on the CY 2017 Quality Payment Program proposed
rule (81 FR 28192) and other comments received, we have decided to
implement facility-based measures for the 2018 MIPS performance period
and future performance periods to add more flexibility for clinicians
to be assessed in the context of the facilities at which they work. As
discussed in section II.C.7.b. of this proposed rule, we are proposing
facility-based measures policies related to applicable measures,
applicability to facility-based measurement, group participation, and
facility attribution.
For clinicians whose primary professional responsibilities are in a
healthcare facility we present a method to assess performance in the
quality and cost performance categories of MIPS based on the
performance of that facility in another value-based purchasing program.
While we propose to limit that opportunity to clinicians who practice
primarily in the hospital, we seek to expand the program to other
value-based payment programs as appropriate in the future. We discuss
that new method of scoring in section II.C.7.b.(4) of this proposed
rule.
i. Scoring
In the CY 2017 Quality Payment Program final rule, we finalized a
unified scoring system to determine a final score across the 4
performance categories (81 FR 77273 through 77276). For the 2018 MIPS
performance period, we propose to build on the scoring methodology we
finalized for the transition year, focusing on encouraging MIPS
eligible clinicians to meet data completeness requirements.
For quality performance category scoring, we are proposing to
extend some of the transition year policies to the 2018 MIPS
performance period and are also proposing several modifications to
existing policy. For the 2018 MIPS performance period, we are proposing
to maintain the 3 point floor for measures that can be reliably scored
against a benchmark. We are also proposing, to maintain the policy to
assign 3 points to measures that are submitted but do not have a
benchmark or do not meet the case minimum, which does not apply to the
CMS Web Interface measures and administrative claims based measures.
For the 2018 MIPS performance period, we are also proposing to lower
the number of points available for measures that do not meet the data
completeness
[[Page 30017]]
criteria, except for a measure submitted by a small practice, which we
propose to continue to assign 3 points if the measure does not meet
data completeness. This does not apply to CMS Web Interface measures or
administrative claims based measures.
Beginning with the 2018 MIPS performance period, we are proposing
to add performance standards for scoring improvement for the quality
and cost performance categories. We are also proposing a systematic
approach to address topped out quality measures.
For the 2018 MIPS performance period, we are proposing that 3
performance category scores (quality, improvement activities, and
advancing care information) would be given weight in the final score,
or be reweighted if a performance category score is not available. We
are also proposing to add final score bonuses for small practices and
for MIPS eligible clinicians that care for complex patients.
We are also proposing that the final score will be compared against
a MIPS performance threshold of 15 points, which can be achieved via
multiple pathways and continues the gradual transition into MIPS.
j. Performance Feedback
We are proposing to provide Quality Payment Program performance
feedback to eligible clinicians and groups. Initially, we would provide
performance feedback on an annual basis. In future years, we aim to
provide performance feedback on a more frequent basis, which is in line
with clinician requests for timely, actionable feedback that they can
use to improve care.
k. Targeted Review Process
In the CY 2017 Quality Payment Program final rule (81 FR 77353), we
finalized a targeted review process under MIPS wherein a MIPS eligible
clinician or group may request that we review the calculation of the
MIPS payment adjustment factor and, as applicable, the calculation of
the additional MIPS payment adjustment factor applicable to such MIPS
eligible clinician or group for a year. We are not proposing any
changes to this process for the second year of the MIPS.
l. Third Party Intermediaries
We believe that third party intermediaries that collect or submit
data on behalf of individual eligible clinicians and groups
participating in MIPS and allowing for flexible reporting options, will
provide individual MIPS eligible clinicians and groups with options to
accommodate different practices and make measurement meaningful. In the
CY 2017 Quality Payment Program final rule (81 FR 77362), we finalized
that qualified registries, QCDRs, health IT vendors, and CMS-approved
survey vendors will have the ability to act as intermediaries on behalf
of individual MIPS eligible clinicians and groups for submission of
data to CMS across the quality, improvement activities, and advancing
care information performance categories. As discussed in section
II.C.10.a.(3) of this proposed rule, we propose to eliminate the self-
nomination submission method of email and require that QCDRs and
qualified registries submit their self-nomination applications via a
web-based tool for future program years beginning with performance
periods occurring in 2018. We are proposing, beginning with the 2019
performance period, a simplified process in which existing QCDRs or
qualified registries in good standing may continue their participation
in MIPS by attesting that their approved data validation plan, cost,
approved QCDR measures (applicable to QCDRs only), MIPS quality
measures, activities, services, and performance categories offered in
the previous year's performance period of MIPS have no changes. QCDRs
and qualified registries in good standing, may also make substantive or
minimal changes to their approved self-nomination application from the
previous year of MIPS that would be submitted during the self-
nomination period for CMS review and approval. By attesting that
certain aspects of their application will remain the same, as approved
from the previous year, existing QCDRs in good standing and qualified
registries will be spending less time completing the self-nomination
application, as was previously required. This process will be conducted
on an annual basis.
In addition, we are proposing that the term ``QCDR measures''
replace the term ``non-MIPS measures,'' without proposing any changes
to the definition, criteria, or requirements that were finalized in the
CY 2017 Quality Payment Program final rule (81 FR 77375). We are not
proposing any changes to the health IT vendors that obtain data from
CEHRT requirements.
Lastly, we are proposing for future program years, beginning with
performance periods occurring in 2018 that we remove the April 30th
survey vendor application deadline. We are proposing for the Quality
Payment Program Year 2 and future years that the vendor application
deadline be January 31st of the applicable performance year or a later
date specified by CMS. We will notify vendors of the application
deadline, to become a CMS-approved survey vendor through additional
communications and postings.
m. Public Reporting
As discussed in section II.C.11. of this proposed rule, we are
proposing public reporting of certain eligible clinician and group
Quality Payment Program information, including MIPS and APM data in an
easily understandable format as required under the MACRA.
n. Eligibility and Exclusion Provisions of the MIPS Program
In section II.C.1.f. of this proposed rule, we are proposing to
modify the definition of a non-patient facing MIPS eligible clinician
to apply to virtual groups. We are also proposing to specify that
groups considered to be non-patient facing (more than 75 percent of the
NPIs billing under the group's TIN meet the definition of a non-patient
facing individual MIPS eligible clinician) during the non-patient
facing determination period would automatically have their advancing
care information performance category reweighted to zero. Additionally,
in section II.C.3.c. of this proposed rule, we are proposing to modify
the low-volume threshold policy established in the CY 2017 Quality
Payment Program final rule. As discussed in section II.C.3.c of this
proposed rule, we believe that increasing the low-volume threshold to
less than or equal to $90,000 in Medicare Part B charges or 200 or
fewer Part-B enrolled Medicare beneficiaries would further decrease
burden on MIPS eligible clinicians that practice in rural areas or are
part of a small practice or are solo practitioners.
E. Payment Adjustments
As discussed in section V.C. of this proposed rule, for the 2020
payment year based on Advanced APM participation in 2018 performance
period, we estimate that approximately 180,000 to 245,000 clinicians
will become QPs, and therefore be exempt from MIPS and qualify for lump
sum incentive payments based on 5 percent of their Part B allowable
charges for covered professional services. We estimate that the total
lump sum incentive payments will be between approximately $590 and $800
million for the 2020 Quality Payment Program payment year. This
expected growth in QPs between the first and second year of the program
is due in part to reopening of CPC+ and Next Generation ACO for 2018,
and the ACO Track 1+ which is projected to have a large number of
participants, with a large majority reaching QP status.
[[Page 30018]]
Under the policies in this proposed rule, we estimate that
approximately 572,000 eligible clinicians would be required to
participate in MIPS in the 2018 MIPS performance period, although this
number may vary depending on the number of eligible clinicians excluded
from MIPS based on their status as QPs or Partial QPs. After
restricting the population to eligible clinician types who are not
newly enrolled, the proposed increase in the low-volume threshold is
expected to exclude 585,560 clinicians who do not exceed the low-volume
threshold. In the 2020 MIPS payment year, MIPS payment adjustments will
be applied based on MIPS eligible clinicians' performance on specified
measures and activities within three integrated performance categories;
the fourth category of cost, as previously outlined, would be weighted
to zero in the 2020 MIPS payment year. Assuming that 90 percent of
eligible clinicians of all practice sizes participate in MIPS, we
estimate that MIPS payment adjustments will be approximately equally
distributed between negative MIPS payment adjustments ($173 million)
and positive MIPS payment adjustments ($173 million) to MIPS eligible
clinicians, as required by the statute to ensure budget neutrality.
Positive MIPS payment adjustments will also include up to an additional
$500 million for exceptional performance to MIPS eligible clinicians
whose final score meets or exceeds the additional performance threshold
of 70 points. These MIPS payment adjustments are expected to drive
quality improvement in the provision of MIPS eligible clinicians' care
to Medicare beneficiaries and to all patients in the health care
system. However, the distribution will change based on the final
population of MIPS eligible clinicians for CY 2020 and the distribution
of scores under the program. We believe that starting with these modest
initial MIPS payment adjustments is in the long-term best interest of
maximizing participation and starting the Quality Payment Program off
on the right foot, even if it limits the magnitude of MIPS positive
adjustments during the 2018 MIPS performance period. The increased
availability of Advanced APM opportunities, including through Medical
Home models, also provides earlier avenues to earn APM incentive
payments for those eligible clinicians who choose to participate.
F. Benefits and Costs of Proposed Rule
The Quality Payment Program may result in quality improvements and
improvements to the patients' experience of care as MIPS eligible
clinicians respond to the incentives for high-quality care provided by
MIPS and implement care quality improvements in their clinical
practices.
We also quantify several costs associated with this rule. We
estimate that this proposed rule will result in approximately $857
million in collection of information-related burden. We estimate that
the incremental collection of information-related burden associated
with this proposed rule is approximately $12.4 million relative to the
estimated burden of continuing the policies the CY 2017 Quality Payment
Program final rule, which is $869 million. We also estimate regulatory
review costs of $4.8 million for this proposed rule, comparable to the
regulatory review costs of the CY 2017 Quality Payment Program proposed
rule. We estimate that federal expenditures will include $173 million
in revenue neutral payment adjustments and $500 million for exceptional
performance payments. Additional federal expenditures include
approximately $590-$800 million in APM incentive payments to QPs.
G. Stakeholder Input
In developing this proposed rule, we sought feedback from
stakeholders and the public throughout the process, including in the CY
2017 Quality Payment Program final rule with comment period, listening
sessions, webinars, and other listening venues. We received a high
degree of interest from a broad spectrum of stakeholders. We thank our
many commenters and acknowledge their valued input throughout the
rulemaking process. We discuss the substance of relevant comments in
the appropriate sections of this proposed rule, though we were not able
to address all comments or all issues that all commenters brought forth
due to the volume of comments and feedback. In general, commenters
continue to support establishment of the Quality Payment Program and
maintain optimism as we move from pure FFS Medicare payment towards an
enhanced focus on the quality and value of care. Public support for our
proposed approach and policies in the proposed rule focused on the
potential for improving the quality of care delivered to beneficiaries
and increasing value to the public--while rewarding eligible clinicians
for their efforts.
We thank stakeholders again for their considered responses
throughout our process, in various venues, including comments on the
Request for Information Regarding Implementation of the Merit-based
Incentive Payment System, Promotion of Alternative Payment Models, and
Incentive Payments for Participation in Eligible Alternative Payment
Models (herein referred to as the MIPS and APMs RFI) (80 FR 59102
through 59113) and the CY 2017 Quality Payment Program final rule (81
FR 77008 through 77831). We intend to continue open communication with
stakeholders, including consultation with tribes and tribal officials,
on an ongoing basis as we develop the Quality Payment Program in future
years.
II. Provisions of the Proposed Regulations and Analysis of and
Responses to Comments
A. Introduction
The Quality Payment Program, authorized by the Medicare Access and
CHIP Reauthorization Act of 2015 (MACRA) is a new approach for
reforming care across the health care delivery system for eligible
clinicians. Under the Quality Payment Program, eligible clinicians can
participate via one of two pathways: Advanced Alternative Payment
Models (APMs); or the Merit-based Incentive Payment System (MIPS). We
began implementing the Quality Payment Program through rulemaking for
calendar year (CY) 2017. This rule provides proposed updates for the
second and future years of the Quality Payment Program.
B. Definitions
At Sec. 414.1305, subpart O, we propose to define the following
terms:
All-Payer QP Performance Period.
Ambulatory Surgical Center (ASC)-based MIPS eligible
clinician.
CMS Multi-Payer Model.
Full TIN APM.
Improvement Scoring.
Medicare QP Performance Period.
Other MIPS APM.
Virtual group.
We propose to revise the definitions of the following terms:
Affiliated practitioner.
APM Entity.
Attributed beneficiary.
Certified Electronic Health Record Technology (CEHRT).
Final Score.
Hospital-based MIPS eligible clinician.
Low-volume threshold.
Medicaid APM.
Non-patient facing MIPS eligible clinician.
Other Payer Advanced APM.
Rural areas.
We propose to remove the following terms:
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Advanced APM Entity.
QP Performance Period.
These terms and definitions are discussed in detail in relevant
sections of this proposed rule.
C. MIPS Program Details
1. MIPS Eligible Clinicians
a. Definition of a MIPS Eligible Clinician
In the CY 2017 Quality Payment Program final rule (81 FR77040
through 77041), we defined at Sec. 414.1305 a MIPS eligible clinician,
as identified by a unique billing TIN and NPI combination used to
assess performance, as any of the following (excluding those identified
at Sec. 414.1310(b)): A physician (as defined in section 1861(r) of
the Act), a physician assistant, nurse practitioner, and clinical nurse
specialist (as such terms are defined in section 1861(aa)(5) of the
Act), a certified registered nurse anesthetist (as defined in section
1861(bb)(2) of the Act), and a group that includes such clinicians. We
established at Sec. 414.1310(b) and (c) that the following are
excluded from this definition per the statutory exclusions defined in
section 1848(q)(1)(C)(ii) and (v) of the Act: (1) QPs; (2) Partial QPs
who choose not to report on applicable measures and activities that are
required to be reported under MIPS for any given performance period in
a year; (3) low-volume threshold eligible clinicians; and (4) new
Medicare-enrolled eligible clinicians. In accordance with sections
1848(q)(1)(A) and (q)(1)(C)(vi) of the Act, we established at Sec.
414.1310(b)(2) that eligible clinicians (as defined at Sec. 414.1305)
who are not MIPS eligible clinicians have the option to voluntarily
report measures and activities for MIPS. Additionally, we established
at Sec. 414.1310(d) that in no case will a MIPS payment adjustment
apply to the items and services furnished during a year by eligible
clinicians who are not MIPS eligible clinicians, as described in Sec.
414.1310(b) and (c), including those who voluntarily report on
applicable measures and activities specified under MIPS.
In the CY 2017 Quality Payment Program final rule (81 FR 77340), we
noted that the MIPS payment adjustment applies only to the amount
otherwise paid under Part B with respect to items and services
furnished by a MIPS eligible clinician during a year, in which we will
apply the MIPS payment adjustment at the TIN/NPI level. We have
received requests for additional clarifications on which specific Part
B services are subject to the MIPS payment adjustment, as well as which
Part B services are included for eligibility determinations. We note
that when Part B items or services are rendered by suppliers that are
also MIPS eligible clinicians, there may be circumstances in which it
is not operationally feasible for us to attribute those items or
services to a MIPS eligible clinician at an NPI level in order to
include them for purposes of applying the MIPS payment adjustment or
making eligibility determinations.
To further clarify, there are circumstances that involve Part B
prescription drugs and durable medical equipment where the supplier may
also be a MIPS eligible clinician. In circumstances in which a MIPS
eligible clinician furnishes a Part B covered item or service such as
prescribing Part B drugs that are dispensed, administered, and billed
by a supplier that is a MIPS eligible clinician, or ordering durable
medical equipment that is administered and billed by a supplier that is
a MIPS eligible clinician, it is not operationally feasible for us at
this time to associate those billed allowable charges with a MIPS
eligible clinician at an NPI level in order to include them for
purposes of applying the MIPS payment adjustment or making eligibility
determinations. For Part B items and services furnished by a MIPS
eligible clinician such as purchasing and administering Part B drugs
that are billed by the MIPS eligible clinician, such items and services
may be subject to MIPS adjustment based on the MIPS eligible
clinician's performance during the applicable performance period or
included for eligibility determinations. For those billed Medicare Part
B allowable charges relating to the purchasing and administration of
Part B drugs that we are able to associate with a MIPS eligible
clinician at an NPI level, such items and services furnished by the
MIPS eligible clinician would be included for purposes of applying the
MIPS payment adjustment or making eligibility determinations.
b. Group Practice (Group)
As discussed in the CY 2017 Quality Payment Program final rule (81
FR 77088 through 77831), we indicated that we will assess performance
either for individual MIPS eligible clinicians or for groups. We
defined a group at Sec. 414.1305 as a single Taxpayer Identification
Number (TIN) with two or more eligible clinicians (including at least
one MIPS eligible clinician), as identified by their individual NPI,
who have reassigned their Medicare billing rights to the TIN. We
recognize that MIPS eligible clinicians participating in MIPS may be
part of a TIN that has one portion of its NPIs participating in MIPS
according to the generally applicable scoring criteria while the
remaining portion of its NPIs is participating in a MIPS APM or an
Advanced APM according to the MIPS APM scoring standard. In the CY 2017
Quality Payment Program final rule (81 FR 77058), we noted that except
for groups containing APM participants, we are not permitting groups to
``split'' TINs if they choose to participate in MIPS as a group. Thus,
we would like to clarify that we consider a group to be either an
entire single TIN or portion of a TIN that: (1) Is participating in
MIPS according to the generally applicable scoring criteria while the
remaining portion of the TIN is participating in a MIPS APM or an
Advanced APM according to the MIPS APM scoring standard; and (2)
chooses to participate in MIPS at the group level. Also, we defined an
APM Entity group at Sec. 414.1305 as a group of eligible clinicians
participating in an APM Entity, as identified by a combination of the
APM identifier, APM Entity identifier, TIN, and NPI for each
participating eligible clinician.
c. Small Practices
In the CY 2017 Quality Payment Program final rule (81 FR 77188), we
defined the term small practices at Sec. 414.1305 as practices
consisting of 15 or fewer clinicians and solo practitioners. In section
II.C.4.d. of this proposed rule, we discuss how small practice status
would apply to virtual groups. Also, in the final rule, we noted that
we would not make an eligibility determination regarding the size of
small practices, but indicated that small practices would attest to the
size of their group practice (81 FR 77057). However, we have since
realized that our system needs to account for small practice size in
advance of a performance period for operational purposes relating to
assessing and scoring the improvement activities performance category,
determining hardship exceptions for small practices as proposed in this
proposed rule, calculating the small practice bonus for the final score
as proposed in this proposed rule, and identifying small practices
eligible for technical assistance. As a result, we believe it is
critical to modify the way in which small practice size would be
determined. To make eligibility determinations regarding the size of
small practices for performance periods occurring in 2018 and future
years, we propose that CMS would determine the size of small practices
as described in this section of the proposed rule. As noted in the CY
2017 Quality Payment
[[Page 30020]]
Program final rule, the size of a group (including a small practice)
would be determined before exclusions are applied (81 FR 77057). We
note that group size determinations are based on the number of NPIs
associated with a TIN, which would include clinicians (NPIs) who may be
excluded from MIPS participation and do not meet the definition of a
MIPS eligible clinician.
To make eligibility determinations regarding the size of small
practices for performance periods occurring in 2018 and future years,
we propose that CMS would determine the size of small practices by
utilizing claims data. For purposes of this section, we are coining the
term ``small practice size determination period'' to mean a 12-month
assessment period, which consists of an analysis of claims data that
spans from the last 4 months of a calendar year 2 years prior to the
performance period followed by the first 8 months of the next calendar
year and includes a 30-day claims run out. This would allow us to
inform small practices of their status near the beginning of the
performance period as it pertains to eligibility relating to technical
assistance, applicable improvement activities criteria, the proposed
hardship exception for small practices under the advancing care
information performance category, and the proposed small practice bonus
for the final score.
Thus, for purposes of performance periods occurring in 2018 and the
2020 MIPS payment year, we would identify small practices based on 12
months of data starting from September 1, 2016 to August 31, 2017. We
would not change an eligibility determination regarding the size of a
small practice once the determination is made for a given performance
period and MIPS payment year. We recognize that there may be
circumstances in which the small practice size determinations made by
CMS do not reflect the real-time size of such practices. We considered
two options that could address such potential discrepancies. One option
would include an expansion of the proposed small practice size
determination period to 24 months with two 12-month segments of data
analysis (before and during the performance period), in which CMS would
conduct a second analysis of claims data during the performance period.
Such an expanded determination period may better capture the real-time
size of small practices, but determinations made during the performance
period prevent our system from being able to account for the assessment
and scoring of the improvement activities performance category and
identification of small practices eligible for technical assistance
prior to the performance period. Specifically, our system needs to
capture small practice determinations in advance of the performance
period in order for the system to reflect the applicable requirements
for the improvement activities performance category and when a small
practice bonus would be applied. A second option would include an
attestation component, in which a small practice that was not
identified as a small practice during the proposed small practice size
determination period would be able to attest to the size of their group
practice prior to the performance period. However, this second option
would require us to develop several operational improvements, such as a
manual process or system that would provide an attestation mechanism
for small practices, and a verification process to ensure that only
small practices are identified as eligible for technical assistance.
Since individual MIPS eligible clinicians and groups are not required
to register to participate in MIPS (except for groups utilizing the CMS
Web Interface for the Quality Payment Program or administering the
CAHPS for MIPS survey), requiring small practices to attest to the size
of their group practice prior to the performance period could increase
burden on individual MIPS eligible clinicians and groups that are not
already utilizing the CMS Web Interface for the Quality Payment Program
or administering the CAHPS for MIPS survey. We solicit public comment
on the proposal regarding how CMS would determine small practice size.
d. Rural Area and Health Professional Shortage Area Practices
In the CY 2017 Quality Payment Program final rule (81 FR 77188), we
finalized at Sec. 414.1380 that for individual MIPS eligible
clinicians and groups that are located in rural areas or geographic
HPSAs, to achieve full credit under the improvement activities
performance category, one high-weighted or two medium-weighted
improvement activities are required. In addition, we defined rural
areas at Sec. 414.1305 as clinicians in ZIP codes designated as rural,
using the most recent Health Resources and Services Administration
(HRSA) Area Health Resource File data set available; and Health
Professional Shortage Areas (HPSAs) at Sec. 414.1305 as areas
designated under section 332(a)(1)(A) of the Public Health Service Act.
For technical accuracy purposes, we are proposing to modify the
definition of a rural areas at Sec. 414.1305 as ZIP codes designated
as rural, using the most recent Health Resources and Services
Administration (HRSA) Area Health Resource File data set available. We
recognize that there are cases in which an individual MIPS eligible
clinician (including a solo practitioner) or a group may have multiple
practice sites associated with its TIN and as a result, it is critical
for us to outline the application of rural area and HPSA practice
designations to such practices. For performance periods occurring in
2017, we consider an individual MIPS eligible clinician or a group with
at least one practice site under its TIN in a ZIP code designated as a
rural area or HPSA to be a rural area or HPSA practice. For performance
periods occurring in 2018 and future years, we believe that a higher
threshold than one practice within a TIN is necessary to designate an
individual MIPS eligible clinician, a group, or a virtual group as a
rural or HPSA practice. We recognize that the establishment of a higher
threshold starting in 2018 would more appropriately identify groups and
virtual groups with multiple practices under a group's TIN or TINs that
are part of a virtual group as rural or HPSA practices and ensure that
groups and virtual groups are assessed and scored according to
requirements that are applicable and appropriate. We note that in the
CY 2017 Quality Payment Program final rule (81 FR 77048 through 77049),
we defined a non-patient facing MIPS eligible clinician at Sec.
414.1305 as including a group provided that more than 75 percent of the
NPIs billing under the group's TIN meet the definition of a non-patient
facing individual MIPS eligible clinician during the non-patient facing
determination period. We refer readers to section II.C.1.e. of this
proposed rule for our proposal to modify the definition of a non-
patient facing MIPS eligible clinician. We believe that using a similar
threshold for applying the rural and HPSA designation to an individual
MIPS eligible clinician, a group, or virtual group with multiple
practices under its TIN or TINs within a virtual group will add
consistency for such practices across the MIPS as it pertains to groups
and virtual groups obtaining such statuses. Also, we believe that
establishing a 75 percent threshold renders an adequate representation
of a group or virtual group where a significant portion of a group or a
virtual group is identified as having such status. Therefore, for
performance periods occurring in 2018 and future
[[Page 30021]]
years, we propose that an individual MIPS eligible clinician, a group,
or a virtual with multiple practices under its TIN or TINs within a
virtual group would be designated as a rural or HPSA practice if more
than 75 percent of NPIs billing under the individual MIPS eligible
clinician or group's TIN or within a virtual group, as applicable, are
designated in a ZIP code as a rural area or HPSA. We solicit public
comment on these proposals.
e. Non-Patient Facing MIPS Eligible Clinicians
Section 1848(q)(2)(C)(iv) of the Act requires the Secretary, in
specifying measures and activities for a performance category, to give
consideration to the circumstances of professional types (or
subcategories of those types determined by practice characteristics)
who typically furnish services that do not involve face-to-face
interaction with a patient. To the extent feasible and appropriate, the
Secretary may take those circumstances into account and apply
alternative measures or activities that fulfill the goals of the
applicable performance category to such non-patient facing MIPS
eligible clinicians. In carrying out these provisions, we are required
to consult with non-patient facing MIPS eligible clinicians.
In addition, section 1848(q)(5)(F) of the Act allows the Secretary
to re-weight MIPS performance categories if there are not sufficient
measures and activities applicable and available to each type of MIPS
eligible clinician. We assume many non-patient facing MIPS eligible
clinicians will not have sufficient measures and activities applicable
and available to report under the performance categories under MIPS. We
refer readers to section II.C.6.f.(7) of this proposed rule for the
discussion regarding how we address performance category weighting for
MIPS eligible clinicians for whom no measures or activities are
applicable and available in a given category.
In the CY 2017 Quality Payment Program final rule (81 FR 77048
through 77049), we defined a non-patient facing MIPS eligible clinician
for MIPS at Sec. 414.1305 as an individual MIPS eligible clinician
that bills 100 or fewer patient-facing encounters (including Medicare
telehealth services defined in section 1834(m) of the Act) during the
non-patient facing determination period, and a group provided that more
than 75 percent of the NPIs billing under the group's TIN meet the
definition of a non-patient facing individual MIPS eligible clinician
during the non-patient facing determination period. In order to account
for the formation of virtual groups starting in the 2018 performance
year and how non-patient facing determinations would apply to virtual
groups, we need to modify the definition of a non-patient facing MIPS
eligible clinician. Therefore, for performance periods occurring in
2018 and future years, we propose to modify the definition of a non-
patient facing MIPS eligible clinician at Sec. 414.1305 to mean an
individual MIPS eligible clinician that bills 100 or fewer patient-
facing encounters (including Medicare telehealth services defined in
section 1834(m) of the Act) during the non-patient facing determination
period, and a group or virtual group provided that more than 75 percent
of the NPIs billing under the group's TIN or within a virtual group, as
applicable, meet the definition of a non-patient facing individual MIPS
eligible clinician during the non-patient facing determination period.
We considered a patient-facing encounter to be an instance in which
the individual MIPS eligible clinician or group billed for items and
services furnished such as general office visits, outpatient visits,
and procedure codes under the PFS. We published the list of patient-
facing encounter codes for performance periods occurring in 2017 at
qpp.cms.gov/resources/education. We intend to publish the list of
patient-facing encounter codes for performance periods occurring in
2018 at qpp.cms.gov by the end of 2017. The list of patient-facing
encounter codes is used to determine the non-patient facing status of
MIPS eligible clinicians.
The list of patient-facing encounter codes include two general
categories of codes: Evaluation and Management (E&M) codes; and
Surgical and Procedural codes. E&M codes capture clinician-patient
encounters that occur in a variety of care settings, including office
or other outpatient settings, hospital inpatient settings, emergency
departments, and nursing facilities, in which clinicians utilize
information provided by patients regarding history, present illness,
and symptoms to determine the type of assessments to conduct.
Assessments are conducted on the affected body area(s) or organ
system(s) for clinicians to make medical decisions that establish a
diagnosis or select a management option(s).
Surgical and Procedural codes capture clinician-patient encounters
that involve procedures, surgeries, and other medical services
conducted by clinicians to treat medical conditions. In the case of
many of these services, evaluation and management work is included in
the payment for the single code instead of separately reported.
Patient-facing encounter codes from both of these categories describe
direct services furnished by eligible clinicians with impact on patient
safety, quality of care, and health outcomes.
For purposes of the non-patient facing policies under MIPS, the
utilization of E&M codes and Surgical and Procedural codes allows for
accurate identification of patient-facing encounters, and thus accurate
eligibility determinations regarding non-patient facing status. As a
result, MIPS eligible clinicians considered non-patient facing are able
to prepare to meet requirements applicable to non-patient facing MIPS
eligible clinicians. We propose to continue applying these policies for
purposes of the 2020 MIPS payment year and future years.
As described in the CY 2017 Quality Payment Program final rule, we
established the non-patient facing determination period for purposes of
identifying non-patient facing MIPS eligible clinicians in advance of
the performance period and during the performance period using
historical and performance period claims data. This eligibility
determination process allows us to begin identifying non-patient facing
MIPS eligible clinicians prior to or shortly after the start of the
performance period. The non-patient facing determination period is a
24-month assessment period, which includes a two-segment analysis of
claims data regarding patient-facing encounters during an initial 12-
month period prior to the performance period followed by another 12-
month period during the performance period. The initial 12-month
segment of the non-patient facing determination period spans from the
last 4 months of a calendar year 2 years prior to the performance
period followed by the first 8 months of the next calendar year and
includes a 60-day claims run out, which allows us to inform individual
MIPS eligible clinicians and groups of their non-patient facing status
during the month (December) prior to the start of the performance
period. The second 12-month segment of the non-patient facing
determination period spans from the last 4 months of a calendar year 1
year prior to the performance period followed by the first 8 months of
the performance period in the next calendar year and includes a 60-day
claims run out, which will allow us to inform additional individual
MIPS eligible clinicians and groups of their non-patient status during
the performance period.
[[Page 30022]]
However, based on our analysis of data from the initial segment of
the non-patient facing determination period for performance periods
occurring in 2017 (that is, data spanning from September 1, 2015 to
August 31, 2016), we found that it may not be necessary to include a
60-day claims run out since we could achieve a similar outcome for such
eligibility determinations by utilizing a 30-day claims run out. In our
comparison of data analysis results utilizing a 60-day claims run out
versus a 30-day claims run out, there was a 1 percent decrease in data
completeness (see Table 1 for data completeness regarding comparative
analysis of a 60-day and 30-day claims run out). The small decrease in
data completeness would not negatively impact individual MIPS eligible
clinicians or groups regarding non-patient facing determinations. We
believe that a 30-day claims run out would allow us to complete the
analysis and provide such determinations in a more timely manner.
Table 1--Percentages of Data Completeness for 60-Day and 30-Day Claims
Run Out
------------------------------------------------------------------------
30-day claims 60-day claims
Incurred year run out * run out *
------------------------------------------------------------------------
2015.................................. 97.1% 98.4%
------------------------------------------------------------------------
* Note: Completion rates are estimated and averaged at aggregated
service categories and may not be applicable to subsets of these
totals. For example, completion rates can vary by provider due to
claim processing practices, service mix, and post payment review
activity. Completion rates vary from subsections of a calendar year;
later portions of a given calendar year will be less complete than
earlier ones. Completion rates vary due to variance in loading
patterns due to technical, seasonal, policy, and legislative factors.
Completion rates are a function of the incurred date used to process
claims, and these factors will need to be updated if claims are
processed on a claim from date or other methodology.
For performance periods occurring in 2018 and future years, we
propose a modification to the non-patient facing determination period,
in which the initial 12-month segment of the non-patient facing
determination period would span from the last 4 months of a calendar
year 2 years prior to the performance period followed by the first 8
months of the next calendar year and include a 30-day claims run out;
and the second 12-month segment of the non-patient facing determination
period would span from the last 4 months of a calendar year 1 year
prior to the performance period followed by the first 8 months of the
performance period in the next calendar year and include a 30-day
claims run out. This proposal would only change the duration of the
claims run out, not the 12-month timeframes used for the first and
second segments of data analysis.
For purposes of the 2020 MIPS payment year, we would initially
identify individual MIPS eligible clinicians and groups who are
considered non-patient facing MIPS eligible clinicians based on 12
months of data starting from September 1, 2016, to August 31, 2017. To
account for the identification of additional individual MIPS eligible
clinicians and groups that may qualify as non-patient facing during
performance periods occurring in 2018, we would conduct another
eligibility determination analysis based on 12 months of data starting
from September 1, 2017, to August 31, 2018.
Similarly, for future years, we would conduct an initial
eligibility determination analysis based on 12 months of data
(consisting of the last 4 months of the calendar year 2 years prior to
the performance period and the first 8 months of the calendar year
prior to the performance period) to determine the non-patient facing
status of individual MIPS eligible clinicians and groups, and conduct
another eligibility determination analysis based on 12 months of data
(consisting of the last 4 months of the calendar year prior to the
performance period and the first 8 months of the performance period) to
determine the non-patient facing status of additional individual MIPS
eligible clinicians and groups. We would not change the non-patient
facing status of any individual MIPS eligible clinician or group
identified as non-patient facing during the first eligibility
determination analysis based on the second eligibility determination
analysis. Thus, an individual MIPS eligible clinician or group that is
identified as non-patient facing during the first eligibility
determination analysis would continue to be considered non-patient
facing for the duration of the performance period and MIPS payment year
regardless of the results of the second eligibility determination
analysis. We would conduct the second eligibility determination
analysis to account for the identification of additional, previously
unidentified individual MIPS eligible clinicians and groups that are
considered non-patient facing.
Additionally, in the CY 2017 Quality Payment Program final rule (81
FR 77241), we established a policy regarding the re-weighting of the
advancing care information performance category for non-patient facing
MIPS eligible clinicians. Specifically, MIPS eligible clinicians who
are considered to be non-patient facing will have their advancing care
information performance category automatically reweighted to zero (81
FR 77241). For groups that are considered to be non-patient facing
(that is, more than 75 percent of the NPIs billing under the group's
TIN meet the definition of a non-patient facing individual MIPS
eligible clinician) during the non-patient facing determination period,
we are proposing in section II.C.7.b.(3) of this proposed rule to
automatically reweight their advancing care information performance
category to zero.
We propose to continue applying these policies for purposes of the
2020 MIPS payment year and future years. We solicit public comment on
these proposals.
f. MIPS Eligible Clinicians Who Practice in Critical Access Hospitals
Billing Under Method II (Method II CAHs)
In the CY 2017 Quality Payment Program final rule (81 FR 77049), we
noted that MIPS eligible clinicians who practice in CAHs that bill
under Method I (Method I CAHs), the MIPS payment adjustment would apply
to payments made for items and services billed by MIPS eligible
clinicians, but it would not apply to the facility payment to the CAH
itself. For MIPS eligible clinicians who practice in Method II CAHs and
have not assigned their billing rights to the CAH, the MIPS payment
adjustment would apply in the same manner as for MIPS eligible
clinicians who bill for items and services in Method I CAHs. As
established in the CY 2017 Quality Payment Program final rule (81 FR
77051), the MIPS payment adjustment will apply to Method II CAH
payments under section 1834(g)(2)(B) of the Act when MIPS eligible
clinicians who practice in Method II CAHs have assigned their billing
rights to the CAH.
We refer readers to the CY 2017 Quality Payment Program final rule
(81 FR 77049 through 77051) for our discussion of MIPS eligible
clinicians who practice in Method II CAHs.
g. MIPS Eligible Clinicians Who Practice in Rural Health Clinics (RHCs)
or Federally Qualified Health Centers (FQHCs)
As established in the CY 2017 Quality Payment Program final rule
(81 FR 77051 through 77053), services rendered by an eligible clinician
under the RHC or FQHC methodology, will not be subject to the MIPS
payments adjustments. As noted, these eligible clinicians have the
option to voluntarily report on applicable measures and activities for
MIPS, in which the data received will not be used to assess their
[[Page 30023]]
performance for the purpose of the MIPS payment adjustment.
We refer readers to the CY 2017 Quality Payment Program final rule
(81 FR 77051 through 77053) for our discussion of MIPS eligible
clinicians who practice in RHCs or FQHCs.
h. MIPS Eligible Clinicians Who Practice in Ambulatory Surgical Centers
(ASCs), Home Health Agencies (HHAs), Hospice, and Hospital Outpatient
Departments (HOPDs)
Section 1848(q)(6)(E) of the Act provides that the MIPS payment
adjustment is applied to the amount otherwise paid under Part B with
respect to the items and services furnished by a MIPS eligible
clinician during a year. Some eligible clinicians may not receive MIPS
payment adjustments due to their billing methodologies. If a MIPS
eligible clinician furnishes items and services in an ASC, HHA,
Hospice, and/or HOPD and the facility bills for those items and
services (including prescription drugs) under the facility's all-
inclusive payment methodology or prospective payment system
methodology, the MIPS adjustment would not apply to the facility
payment itself. However, if a MIPS eligible clinician furnishes other
items and services in an ASC, HHA, Hospice, and/or HOPD and bills for
those items and services separately, such as under the PFS, the MIPS
adjustment would apply to payments made for such items and services.
Such items and services would also be considered for purposes of
applying the low-volume threshold. Therefore, we propose that services
rendered by an eligible clinician that are payable under the ASC, HHA,
Hospice, or HOPD methodology would not be subject to the MIPS payments
adjustments. However, these eligible clinicians have the option to
voluntarily report on applicable measures and activities for MIPS, in
which the data received would not be used to assess their performance
for the purpose of the MIPS payment adjustment. We note that eligible
clinicians who bill under both the PFS and one of these other billing
methodologies (ASC, HHA, Hospice, and/or HOPD) may be required to
participate in MIPS if they exceed the low-volume threshold and are
otherwise eligible clinicians; in such case, data reported would be
used to determine their MIPS payment adjustment. We solicit public
comments on this proposal.
i. MIPS Eligible Clinician Identifier
As described in the CY 2017 Quality Payment Program final rule (81
FR 77057), we established that the use of multiple identifiers that
allow MIPS eligible clinicians to be measured as an individual or
collectively through a group's performance and that the same identifier
be used for all four performance categories. While we have multiple
identifiers for participation and performance, we established the use
of a single identifier, TIN/NPI, for applying the MIPS payment
adjustment, regardless of how the MIPS eligible clinician is assessed.
(1) Individual Identifiers
As established in the CY 2017 Quality Payment Program final rule
(81 FR 77058), we define a MIPS eligible clinician at Sec. 414.1305 to
mean the use of a combination of unique billing TIN and NPI combination
as the identifier to assess performance of an individual MIPS eligible
clinician. Each unique TIN/NPI combination is considered a different
MIPS eligible clinician, and MIPS performance is assessed separately
for each TIN under which an individual bills.
(2) Group Identifiers for Performance
As established in the CY 2017 Quality Payment Program final rule
(81 FR 77059), we codified the definition of a group at Sec. 414.1305
to mean a group that consists of a single TIN with two or more eligible
clinicians (including at least one MIPS eligible clinician), as
identified by their individual NPI, who have reassigned their billing
rights to the TIN.
(3) APM Entity Group Identifier for Performance
As described in the CY 2017 Quality Payment Program final rule (81
FR 77060), we established that each eligible clinician who is a
participant of an APM Entity is identified by a unique APM participant
identifier. The unique APM participant identifier is a combination of
four identifiers: (1) APM Identifier (established by CMS; for example,
XXXXXX); (2) APM Entity identifier (established under the APM by CMS;
for example, AA00001111); (3) TIN(s) (9 numeric characters; for
example, XXXXXXXXX); (4) EP NPI (10 numeric characters; for example,
1111111111). We codified the definition of an APM Entity group at Sec.
414.1305 to mean a group of eligible clinicians participating in an APM
Entity, as identified by a combination of the APM identifier, APM
Entity identifier, TIN, and NPI for each participating eligible
clinician.
2. Exclusions
a. New Medicare-Enrolled Eligible Clinician
As established in the CY 2017 Quality Payment Program final rule
(81 FR 77061 through 77062), we defined a new Medicare-enrolled
eligible clinician at Sec. 414.1305 as a professional who first
becomes a Medicare-enrolled eligible clinician within the PECOS during
the performance period for a year and had not previously submitted
claims under Medicare such as an individual, an entity, or a part of a
physician group or under a different billing number or tax identifier.
Additionally, we established at Sec. 414.1310(c) that these eligible
clinicians will not be treated as a MIPS eligible clinician until the
subsequent year and the performance period for such subsequent year. We
established at Sec. 414.1310(d) that in no case would a MIPS payment
adjustment apply to the items and services furnished during a year by
new Medicare-enrolled eligible clinicians for the applicable
performance period.
We used the term ``new Medicare-enrolled eligible clinician
determination period'' to refer to the 12 months of a calendar year
applicable to the performance period. During the new Medicare-enrolled
eligible clinician determination period, we conduct eligibility
determinations on a quarterly basis to the extent that is technically
feasible to identify new Medicare-enrolled eligible clinicians that
would be excluded from the requirement to participate in MIPS for the
applicable performance period.
b. Qualifying APM Participant (QP) and Partial Qualifying APM
Participant (Partial QP)
In the CY 2017 Quality Payment Program final rule (81 FR 77062), we
established at Sec. 414.1305 that a QP (as defined at Sec. 414.1305)
is not a MIPS eligible clinician, and is therefore excluded from MIPS.
Also, we established that a Partial QP (as defined, at Sec. 414.1305)
who does not report on applicable measures and activities that are
required to be reported under MIPS for any given performance period in
a year is not a MIPS eligible clinician.
c. Low-Volume Threshold
Section 1848(q)(1)(C)(ii)(III) of the Act provides that the
definition of a MIPS eligible clinician does not include MIPS eligible
clinicians who are below the low-volume threshold selected by the
Secretary under section 1848(q)(1)(C)(iv) of the Act for a given year.
Section 1848(q)(1)(C)(iv) of the Act requires the Secretary to select a
low-volume
[[Page 30024]]
threshold to apply for the purposes of this exclusion which may include
one or more of the following: (1) The minimum number, as determined by
the Secretary, of Part B-enrolled individuals who are treated by the
MIPS eligible clinician for a particular performance period; (2) the
minimum number, as determined by the Secretary, of items and services
furnished to Part B-enrolled individuals by the MIPS eligible clinician
for a particular performance period; and (3) the minimum amount, as
determined by the Secretary, of allowed charges billed by the MIPS
eligible clinician for a particular performance period.
In the CY 2017 Quality Payment Program final rule (81 FR 77069
through 77070), we defined individual MIPS eligible clinicians or
groups who do not exceed the low-volume threshold at Sec. 414.1305 as
an individual MIPS eligible clinician or group who, during the low-
volume threshold determination period, has Medicare Part B allowed
charges less than or equal to $30,000 or provides care for 100 or fewer
Part B-enrolled Medicare beneficiaries. We established at Sec.
414.1310(b) that for a year, MIPS eligible clinicians who do not exceed
the low-volume threshold (as defined at Sec. 414.1305) are excluded
from MIPS for the performance period for a given calendar year.
In the CY 2017 Quality Payment Program final rule (81 FR 77069
through 77070), we defined the low-volume threshold determination
period to mean a 24-month assessment period, which includes a two-
segment analysis of claims data during an initial 12-month period prior
to the performance period followed by another 12-month period during
the performance period. The initial 12-month segment of the low-volume
threshold determination period spans from the last 4 months of a
calendar year 2 years prior to the performance period followed by the
first 8 months of the next calendar year and includes a 60-day claims
run out, which allows us to inform eligible clinicians and groups of
their low-volume status during the month (December) prior to the start
of the performance period. The second 12-month segment of the low-
volume threshold determination period spans from the last 4 months of a
calendar year 1 year prior to the performance period followed by the
first 8 months of the performance period in the next calendar year and
includes a 60-day claims run out, which allows us to inform additional
eligible clinicians and groups of their low-volume status during the
performance period.
We recognize that individual MIPS eligible clinicians and groups
that are small practices or practicing in designated rural areas face
unique dynamics and challenges such as fiscal limitations and workforce
shortages, but serve as a critical access point for care and provide a
safety net for vulnerable populations. Claims data shows that
approximately 15 percent of individual MIPS eligible clinicians (TIN/
NPIs) are considered to be practicing in rural areas after applying all
exclusions. Also, we have heard from stakeholders that MIPS eligible
clinicians practicing in small practices and designated rural areas
tend to have a patient population with a higher proportion of older
adults, as well as higher rates of poor health outcomes, co-
morbidities, chronic conditions, and other social risk factors, which
can result in the costs of providing care and services being
significantly higher compared to non-rural areas. We also have heard
from many solo practitioners and small practices who still face
challenges and additional resource burden in participating in the MIPS.
In the CY 2017 Quality Payment Program final rule, we did not
establish an adjustment for social risk factors in assessing and
scoring performance. In response to the CY 2017 Quality Payment Program
final rule, we received public comments indicating that individual MIPS
eligible clinicians and groups practicing in designated rural areas
would be negatively impacted and at a disadvantage if assessment and
scoring methodology did not adjust for social risk factors.
Additionally, commenters expressed concern that such individual MIPS
eligible clinicians and groups may be disproportionately more
susceptible to lower performance scores across all performance
categories and negative MIPS payments adjustments, and as a result,
such outcomes may further strain already limited fiscal resources and
workforce shortages, and negatively impact access to care (reduction
and/or elimination of available services).
After the consideration of stakeholder feedback provided during
informal listening sessions since the publication of the CY 2017
Quality Payment Program final rule, we are proposing to modify the low-
volume threshold policy established in the CY 2017 Quality Payment
Program final rule. We believe that increasing the dollar amount and
beneficiary count of the low-volume threshold would further reduce the
number of eligible clinicians that are required to participate in the
MIPS, which would reduce the burden on individual MIPS eligible
clinicians and groups practicing in small practices and designated
rural areas. Based on our analysis of claims data, we found that
increasing the low-volume threshold to to exclude individual eligible
clinicians or groups that have Medicare Part B allowed charges less
than or equal to $90,000 or that provide care for 200 or fewer Part B-
enrolled Medicare beneficiaries will exclude approximately 134,000
additional clinicians from MIPS from the approximately 700,000
clinicians that would have been eligible based on the low-volume
threshold that was finalized in the CY 2017 Quality Payment Program
final rule. Almost half of the additionally excluded clinicians are in
small practices and approximately 17 percent are clinicians from
practices in designated rural areas. Applying this criterion decreases
the percent of the MIPS eligible clinicians that come from small
practices. For example, prior to any exclusions, clinicians in small
practices represent 35 percent of all clinicians billing Part B
services. After applying the eligibility criteria for the CY 2017
Quality Payment Program final rule, MIPS eligible clinicians in small
practices represent approximately 27 percent of the clinicians eligible
for MIPS; however, with the increased low-volume threshold,
approximately 22 percent of the clinicians eligible for MIPS are from
small practices. In our analysis, the proposed changes to the low-
volume threshold showed little impact on MIPS eligible clinicians from
practices in designated rural areas. MIPS eligible clinicians from
practices in designated rural areas account for 15 to 16 percent of the
total MIPS eligible population. We note that, due to data limitations,
we assessed rural status based on the status of individual TIN/NPI and
did not model any group definition for practices in designated rural
areas.
We believe that increasing the number of such individual eligible
clinicians and groups excluded from MIPS participation would reduce
burden and mitigate, to the extent feasible, the issue surrounding
confounding variables impacting performance under the MIPS. Therefore,
beginning with the 2018 MIPS performance period, we are proposing to
increase the low-volume threshold. Specifically, at Sec. 414.1305, we
are proposing to define an individual MIPS eligible clinician or group
who does not exceed the low-volume threshold as an individual MIPS
eligible clinician or group who, during the low-volume threshold
determination period, has Medicare Part B allowed charges less than or
equal to $90,000 or provides care for 200 or fewer Part B-enrolled
Medicare beneficiaries. This
[[Page 30025]]
would mean that 37 percent of individual MIPS eligible clinicians and
groups would be in MIPS based on the low-volume threshold exclusion
(and the other exclusions). However, 65 percent of Medicare payments
would still be captured under MIPS compared to 72.2 percent of Medicare
payments under the CY 2017 Quality Payment Program final rule.
We recognize that increasing the dollar amount and beneficiary
count of the low-volume threshold would increase the number of
individual MIPS eligible clinicians and groups excluded from MIPS. We
assessed various levels of increases and found that $90,000 as the
dollar amount and 200 as the beneficiary count balances the need to
account for individual MIPS eligible clinicians and groups who face
additional participation burden while not excluding a significant
portion of the clinician population.
MIPS eligible clinicians who do not exceed the low-volume threshold
(as defined at Sec. 414.1305) are excluded from MIPS for the
performance period with respect to a year. The low-volume threshold
also applies to MIPS eligible clinicians who practice in APMs under the
APM scoring standard at the APM Entity level, in which APM Entities do
not exceed the low-volume threshold. In such cases, the MIPS eligible
clinicians participating in the MIPS APM Entity would be excluded from
the MIPS requirements for the applicable performance period and not
subject to a MIPS payment adjustment for the applicable year. Such an
exclusion would not affect an APM Entity's QP determination if the APM
Entity is an Advanced APM.
In the CY 2017 Quality Payment Program final rule, we established
the low-volume threshold determination period to refer to the timeframe
used to assess claims data for making eligibility determinations for
the low-volume threshold exclusion (81 FR 77069 through 77070). We
defined the low-volume threshold determination period to mean a 24-
month assessment period, which includes a two-segment analysis of
claims data during an initial 12-month period prior to the performance
period followed by another 12-month period during the performance
period. Based on our analysis of data from the initial segment of the
low-volume threshold determination period for performance periods
occurring in 2017 (that is, data spanning from September 1, 2015 to
August 31, 2016), we found that it may not be necessary to include a
60-day claims run out since we could achieve a similar outcome for such
eligibility determinations by utilizing a 30-day claims run out.
In our comparison of data analysis results utilizing a 60-day
claims run out versus a 30-day claims run out, there was a 1 percent
decrease in data completeness. The small decrease in data completeness
would not substantially impact individual MIPS eligible clinicians or
groups regarding low-volume threshold determinations. We believe that a
30-day claims run out would allow us to complete the analysis and
provide such determinations in a more timely manner. For performance
periods occurring in 2018 and future years, we propose a modification
to the low-volume threshold determination period, in which the initial
12-month segment of the low-volume threshold determination period would
span from the last 4 months of a calendar year 2 years prior to the
performance period followed by the first 8 months of the next calendar
year and include a 30-day claims run out; and the second 12-month
segment of the low-volume threshold determination period would span
from the last 4 months of a calendar year 1 year prior to the
performance period followed by the first 8 months of the performance
period in the next calendar year and include a 30-day claims run out.
This proposal would only change the duration of the claims run out, not
the 12-month timeframes used for the first and second segments of data
analysis.
For purposes of the 2020 MIPS payment year, we would initially
identify individual eligible clinicians and groups that do not exceed
the low-volume threshold based on 12 months of data starting from
September 1, 2016 to August 31, 2017. To account for the identification
of additional individual eligible clinicians and groups that do not
exceed the low-volume threshold during performance periods occurring in
2018, we would conduct another eligibility determination analysis based
on 12 months of data starting from September 1, 2017 to August 31,
2018. We would not change the low-volume status of any individual
eligible clinician or group identified as not exceeding the low-volume
threshold during the first eligibility determination analysis based on
the second eligibility determination analysis. Thus, an individual
eligible clinician or group that is identified as not exceeding the
low-volume threshold during the first eligibility determination
analysis would continue to be excluded from MIPS for the duration of
the performance period regardless of the results of the second
eligibility determination analysis. We established our policy to
include two eligibility determination analyses in order to prevent any
potential confusion for an individual eligible clinician or group to
know whether or not participate in MIPS; also, such policy makes it
clear from the onset as to which individual eligible clinicians and
groups would be required to participate in MIPS. We would conduct the
second eligibility determination analysis to account for the
identification of additional, previously unidentified individual
eligible clinicians and groups who do not exceed the low-volume
threshold. We note that low-volume threshold determinations are made at
the individual and group level, and not at the virtual group level.
We note that section 1848(q)(1)(C)(iv) of the Act requires the
Secretary to select a low-volume threshold to apply for the purposes of
this exclusion which may include one or more of the following: (1) The
minimum number, as determined by the Secretary, of Part B-enrolled
individuals who are treated by the MIPS eligible clinician for a
particular performance period; (2) the minimum number, as determined by
the Secretary, of items and services furnished to Part B-enrolled
individuals by the MIPS eligible clinician for a particular performance
period; and (3) the minimum amount, as determined by the Secretary, of
allowed charges billed by the MIPS eligible clinician for a particular
performance period. We have established a low-volume threshold that
accounts for the minimum number of Part-B enrolled individuals who are
treated by a MIPS eligible clinician and that accounts for the minimum
amount of allowed charges billed by a MIPS eligible clinician. We have
not made proposals specific to a minimum number of items and service
furnished to Part-B enrolled individuals by a MIPS eligible clinician.
In order to expand the ways in which claims data could be analyzed
for purposes of determining a more comprehensive assessment of the low-
volume threshold, we have assessed the option of establishing a low-
volume threshold for items and services furnished to Part-B enrolled
individuals by a MIPS eligible clinician. We have considered defining
items and services by using the number of patient encounters or
procedures associated with a clinician. Defining items and services by
patient encounters would assess each patient per visit or encounter
with the MIPS eligible clinician. We believe that defining items and
services by using the number of patient encounters or procedures is a
simple and straightforward approach for stakeholders to understand.
However,
[[Page 30026]]
we are concerned that using this unit of analysis could incentivize
clinicians to focus on volume of services rather than the value of
services provided to patients. Defining items and services by procedure
would tie a specific clinical procedure rendered to a patient to a
clinician. We solicit public comment on the methods of defining items
and services furnished by clinicians described above and alternate
methods of defining items and services.
For the individual MIPS eligible clinicians and groups that would
be excluded from MIPS participation as a result of an increased low-
volume threshold, we believe that in future years it would be
beneficial to provide, to the extent feasible, such individual MIPS
eligible clinicians and groups with the option to opt-in to MIPS
participation if they might otherwise be excluded under the low-volume
threshold such as where they only meet one of the threshold
determinations (including a third determination based on Part B items
and services, if established). For example, if a clinician meets the
low-volume threshold of $90,000 in allowed charges, but does not meet
the threshold of 200 patients or, if established, the threshold
pertaining to Part B items and services, we believe the clinician
should, to the extent feasible, have the opportunity to choose whether
or not to participate in the MIPS and be subject to MIPS payment
adjustments. We recognize that this choice would present additional
complexity to clinicians in understanding all of their available
options and may impose additional burden on clinicians by requiring
them to notify CMS of their decision. Because of these concerns and our
desire to establish options in a way that is a low-burden and user-
focused experience for all MIPS eligible clinicians, we would not be
able to offer this additional flexibility until performance periods
occurring in 2019. Therefore, as a means of expanding options for
clinicians and offering them the ability to participate in MIPS if they
otherwise would not be included, for the purposes of the 2021 MIPS
payment year, we propose to provide clinicians the ability to opt-in to
the MIPS if they meet or exceed one, but not all, of the low-volume
threshold determinations, including as defined by dollar amount,
beneficiary count or, if established, items and services. We request
public comment on this proposal.
We note that there may be additional considerations we should
address for scenarios in which an individual eligible clinician or a
group does not exceed the low-volume threshold and opts-in to
participate in MIPS. We therefore seek comment on any additional
considerations we should address when establishing this opt-in policy.
Such as, should we establish parameters for individual clinicians or
groups who elect to opt-in to participate in MIPS such as required
length of participation? Additionally, we note that there is the
potential with this opt-in policy for there to be an impact on our
ability to create quality benchmarks that meet our sample size
requirements. For example, if particularly small practices or solo
practitioners with low Part B beneficiary volumes opt-in, such
clinician's may lack sufficient sample size to be scored on many
quality measures, especially measures that do not apply to all of a
MIPS eligible clinician's patients. We therefore seek comment on how to
address any potential impact on our ability to create quality
benchmarks that meet our sample size requirements.
We solicit public comments on these proposals.
3. Group Reporting
a. Background
As described in the CY 2017 Quality Payment Program final rule, we
established the following requirements for groups (81 FR 77072):
Individual eligible clinicians and individual MIPS
eligible clinicians will have their performance assessed as a group as
part of a single TIN associated with two or more eligible clinicians
(including at least one MIPS eligible clinician), as identified by a
NPI, who have reassigned their Medicare billing rights to the TIN (at
Sec. 414.1310(e)(1)).
A group must meet the definition of a group at all times
during the performance period for the MIPS payment year in order to
have its performance assessed as a group (at Sec. 414.1310(e)(2)).
Individual eligible clinicians and individual MIPS
eligible clinicians within a group must aggregate their performance
data across the TIN to have their performance assessed as a group (at
Sec. 414.1310(e)(3)).
A group that elects to have its performance assessed as a
group will be assessed as a group across all four MIPS performance
categories (at Sec. 414.1310(e)(4)).
As noted in the CY 2017 Quality Payment Program final rule, we
would not make an eligibility determination regarding group size, but
indicated that groups would attest to their group size for purpose of
using the CMS Web Interface or a group identifying as a small practice
(81 FR 77057). In section II.C.1.d. of this proposed rule, we are
proposing to modify the way in which size would be determined for small
practices by establishing a process under which CMS would utilize
claims data to make small practice size determinations. Also, in
section II.C.4.e. of this proposed rule, we are proposing to establish
a policy under which CMS would utilize claims data to determine group
size for groups of 10 or fewer eligible clinicians seeking to form or
join a virtual group.
As noted in the CY 2017 Quality Payment Program final rule, a group
size would be determined before exclusions are applied (81 FR 77057).
We note that group size determinations are based on the number of NPIs
associated with a TIN, which would include clinicians (NPIs) who may be
excluded from MIPS participation and do not meet the definition of a
MIPS eligible clinician.
b. Registration
As described in the CY 2017 Quality Payment Program final rule (81
FR 77072 through 77073), we established, the following policies:
A group must adhere to an election process established and
required by CMS (Sec. 414.1310(e)(5)), which includes:
++ Groups will not be required to register to have their
performance assessed as a group except for groups submitting data on
performance measures via participation in the CMS Web Interface or
groups electing to report the CAHPS for MIPS survey for the quality
performance category. For all other data submission mechanisms, groups
must work with appropriate third party intermediaries as necessary to
ensure the data submitted clearly indicates that the data represent a
group submission rather than an individual submission.
++ In order for groups to elect participation via the CMS Web
Interface or administration of the CAHPS for MIPS survey, such groups
must register by June 30 of the applicable performance period (that is,
June 30, 2018, for performance periods occurring in 2018). We note that
groups participating in APMs that require APM Entities to report using
the CMS Web Interface are not required to register for the CMS Web
Interface or administer the CAHPS for MIPS survey separate from the
APM.
When groups submit data utilizing third party intermediaries, such
as a qualified registry, QCDR, or EHR, we are able to obtain group
information from the third party intermediary and discern whether the
data submitted represents group submission or individual submission
once the data are submitted.
[[Page 30027]]
In the CY 2017 Quality Payment Program final rule (81 FR 77072
through 77073), we discussed the implementation of a voluntary
registration process if technically feasible. Since the publication of
the CY 2017 Quality Payment Program final rule, we have determined that
it is not technically feasible to develop and build a voluntary
registration process. Until further notice, we are not implementing a
voluntary registration process.
Also, in the CY 2017 Quality Payment Program final rule (81 FR
77075), we expressed our commitment to pursue the active engagement of
stakeholders throughout the process of establishing and implementing
virtual groups. We received public comments in response to the CY 2017
Quality Payment Program final rule and additional stakeholder feedback
by hosting several virtual group listening sessions and convening user
groups. Many stakeholders requested that CMS provide an option that
would permit a portion of a group to participate in MIPS outside the
group by reporting as a separate subgroup or forming a virtual group.
Stakeholders indicated that the option would measure performance more
effectively, enable groups to identify areas for improvement at a
granular level that would further improve quality of care and health
outcomes, and increase coordination of care.
We recognize that groups, including multi-specialty groups, have
requested over the years that we make an option available to them that
would allow a portion of a group to report as a separate subgroup on
measures and activities that are more applicable to the subgroup and be
assessed and scored accordingly based on the performance of the
subgroup. In future rulemaking, we intend to explore the feasibility of
establishing group-related policies that would permit participation in
MIPS at a subgroup level and create such functionality through a new
identifier. We solicit public comment on the ways in which
participation in MIPS at the subgroup level could be established.
4. Virtual Groups
a. Background
There are generally three ways to participate in MIPS: (1)
Individual-level reporting; (2) group-level reporting; and (3) virtual
group-level reporting. We refer readers to sections II.C.1., II.C.3.,
and II.C.5. of this proposed rule for a discussion of the previously
established requirements for individual- and group-level participation
and our proposed policies for performance periods occurring in 2018 and
future years. In this rule, we are proposing to establish requirements
for MIPS participation at the virtual group level.
Section 1848(q)(5)(I) of the Act provides for the use of voluntary
virtual groups for certain assessment purposes, including the election
of practices to be a virtual group and the requirements for the
election process. Section 1848(q)(5)(I)(i) of the Act provides that
MIPS eligible clinicians electing to be a virtual group must: (1) Have
their performance assessed for the quality and cost performance
categories in a manner that applies the combined performance of all the
MIPS eligible clinicians in the virtual group to each MIPS eligible
clinician in the virtual group for the applicable performance period;
and (2) be scored for the quality and cost performance categories based
on such assessment. Section 1848(q)(5)(I)(ii) of the Act requires, in
accordance with section 1848(q)(5)(I)(iii) of the Act, the
establishment and implementation of a process that allows an individual
MIPS eligible clinician or a group consisting of not more than 10 MIPS
eligible clinicians to elect, for a given performance period, to be a
virtual group with at least one other such individual MIPS eligible
clinician or group. The virtual group may be based on appropriate
classifications of providers, such as by geographic areas or by
provider specialties defined by nationally recognized specialty boards
of certification or equivalent certification boards.
Section 1848(q)(5)(I)(iii) of the Act provides that the virtual
group election process must include the following requirements: (1) An
individual MIPS eligible clinician or group electing to be in a virtual
group must make their election prior to the start of the applicable
performance period and cannot change their election during the
performance period; (2) an individual MIPS eligible clinician or group
may elect to be in no more than one virtual group for a performance
period, and, in the case of a group, the election applies to all MIPS
eligible clinicians in the group; (3) a virtual group is a combination
of TINs; (4) the requirements must provide for formal written
agreements among individual MIPS eligible clinicians and groups
electing to be a virtual group; and (5) such other requirements as the
Secretary determines appropriate.
b. Definition of a Virtual Group
As noted above, section 1848(q)(5)(I)(ii) of the Act requires, in
accordance with section 1848(q)(5)(I)(iii) of the Act, the
establishment and implementation of a process that allows an individual
MIPS eligible clinician or group consisting of not more than 10 MIPS
eligible clinicians to elect, for a given performance period, to be a
virtual group with at least one other such individual MIPS eligible
clinician or group. Given that section 1848(q)(5)(I)(iii)(V) of the Act
provides that a virtual group is a combination of TINs, we interpret
the references to an ``individual'' MIPS eligible clinician in section
1848(q)(5)(I)(ii) of the Act to mean a solo practitioner, which, for
purposes of section 1848(q)(5)(I) of the Act, we propose to define as a
MIPS eligible clinician (as defined at Sec. 414.1305) who bills under
a TIN with no other NPIs billing under such TIN.
Also, we recognize that a group (TIN) may include not only NPIs who
meet the definition of a MIPS eligible clinician, but also NPIs who do
not meet the definition of a MIPS eligible clinician at Sec. 414.1305
and who are excluded from MIPS under Sec. 414.1310(b) or (c) based on
one of four exclusions (new Medicare-enrolled eligible clinician; QP;
Partial QP who chooses not to report on measures and activities under
MIPS; and eligible clinicians that do not exceed the low-volume
threshold). Thus, we interpret the references to a group ``consisting
of not more than 10'' MIPS eligible clinicians in section
1848(q)(5)(I)(ii) of the Act to mean that a group with 10 or fewer
eligible clinicians (as defined at Sec. 414.1305) would be eligible to
form or join a virtual group. For purposes of the MIPS payment
adjustment, the adjustment would apply only to NPIs in the virtual
group who meet the definition of a MIPS eligible clinician at Sec.
414.1305 and who are not excluded from MIPS under Sec. 414.1310(b) or
(c). We note that such groups, as defined at Sec. 414.1305, would need
to include at least one MIPS eligible clinician in order to be eligible
to join or form a virtual group. We refer readers to section II.C.4.g.
of this proposed rule for discussion regarding the assessment and
scoring of groups participating in MIPS as a virtual group.
We propose to define a virtual group at Sec. 414.1305 as a
combination of two or more TINs composed of a solo practitioner (a MIPS
eligible clinician (as defined at Sec. 414.1305) who bills under a TIN
with no other NPIs billing under such TIN), or a group (as defined at
Sec. 414.1305) with 10 or fewer eligible clinicians under the TIN that
elects to form a virtual group with at least one
[[Page 30028]]
other such solo practitioner or group for a performance period for a
year.
Lastly, we note that qualifications as a virtual group for purposes
of MIPS do not change the application of the physician self-referral
law to a financial relationship between a physician and an entity
furnishing designated health services, nor does it change the need for
such a financial relationship to comply with the physician self-
referral law.
We note that while entire TINs participate in a virtual group,
including each NPI under a TIN, and are assessed and scored
collectively as a virtual group, only NPIs that meet the definition of
a MIPS eligible clinician would be subject to a MIPS payment
adjustment. However, we note that, as discussed in section II.C.4.h. of
this proposed rule, any MIPS eligible clinician who is part of a TIN
participating in a virtual group and participating in a MIPS APM or
Advanced APM under the MIPS APM scoring standard would not receive a
MIPS payment adjustment based on the virtual group's final score, but
would receive a payment adjustment based on the MIPS APM scoring
standard.
Additionally, we recognize that there are circumstances in which a
TIN may have one portion of its NPIs participating under the generally
applicable MIPS scoring criteria while the remaining portion of NPIs
under the TIN is participating in a MIPS APM or an Advanced APM under
the MIPS APM scoring standard. In the CY 2017 Quality Payment Program
final rule (81 FR 77058), we noted that except for groups containing
APM participants, we are not permitting groups to ``split'' TINs if
they choose to participate in MIPS as a group (81 FR 77058). Thus, we
consider a group to mean an entire single TIN that elects to
participate in MIPS at the group or virtual group level, including
groups that have a portion of its NPIs participating in a MIPS APM or
an Advanced APM. We note that such groups would participate in MIPS
similar to other groups.
To clarify, for all groups, including groups containing
participants in a MIPS APM or an Advanced APM, the group's performance
assessment consists of the entire TIN regardless of whether the group
participates in MIPS as part of a virtual group. Generally, for groups
other than groups containing participants in a MIPS APM or an Advanced
APM, each MIPS eligible clinician under the TIN (TIN/NPI) receives a
MIPS adjustment based on the entire group's performance assessment
(entire TIN). For groups containing participants in a MIPS APM or an
Advanced APM, only the portion of the TIN that is being scored for MIPS
according to the generally applicable scoring criteria (TIN/NPI)
receives a MIPS adjustment based on the entire group's performance
assessment (entire TIN). The remaining portion of the TIN that is being
scored according to the APM scoring standard (TIN/NPI) receives a MIPS
adjustment based on that standard, or may be exempt from MIPS if they
achieve QP or Partial QP status.
We propose to apply a similar policy to groups, including groups
containing participants in a MIPS APM or an Advanced APM, that are
participating in MIPS as part of a virtual group. Specifically, for
groups other than groups containing participants in a MIPS APM or an
Advanced APM, each MIPS eligible clinician (TIN/NPI) would receive a
MIPS adjustment based on the virtual group's combined performance
assessment (combination of TINs). For groups containing participants in
a MIPS APM or an Advanced APM, only the portion of the TIN that is
being scored for MIPS according to the generally applicable scoring
criteria (TIN/NPI) would receive a MIPS adjustment based on the virtual
group's combined performance assessment (combination of TINs). As
discussed in section II.C.4.h. of this proposed rule, we are proposing
to use waiver authority to ensure that any participants in the group
who are participating in a MIPS APM receive their payment adjustment
based on their score under the APM scoring standard (TIN/NPI). Such
participants may be exempt from MIPS if they achieve QP or Partial QP
status.
We refer readers to section II.C.4.e. of this proposed rule for a
discussion of the proposed virtual group election process and section
II.C.4.g. of this proposed rule for discussion of our proposals
regarding the assessment and scoring of virtual groups.
We recognize that virtual groups would each have unique
characteristics and varying patient populations. As noted in section
II.C.4.a. of this proposed rule, the statute provides the Secretary
with discretion to establish appropriate classifications regarding the
composition of virtual groups such as by geographic area or specialty.
However, we believe it is important for virtual groups to have the
flexibility to determine their own composition at this time, and, as a
result, we are not proposing to establish any such classifications
regarding virtual group composition. We further note that the statute
does not limit the number of TINs that may form a virtual group, and we
are not proposing to establish such a limit at this time. We did
consider however proposing to establish such a limit, such as 50 or 100
participants. In particular, we are concerned that virtual groups of
too substantial a size (for example, 10 percent of all MIPS eligible
clinicians in a given specialty or sub-specialty) may make it difficult
to compare performance between and among clinicians. We believe that
limiting the number of virtual group participants could eventually
assist virtual groups as they aggregate their performance data across
the virtual group. However, we believe that as we initially implement
virtual groups, it is important for virtual groups to have the
flexibility to determine their own size, and thus, a better approach is
to not place such a limit on virtual group size. We will, however,
monitor the ways in which solo practitioners and groups with 10 or
fewer eligible clinicians form virtual groups and may propose to
establish appropriate classifications regarding virtual group
composition or a limit on the number of TINs that may form a virtual
group in future rulemaking as necessary. We solicit public comment on
these proposals, as well as our approach of not establishing
appropriate classifications (such as classification by geographic area
or specialty) regarding virtual group composition or a limit on the
number of TINs that may form a virtual group at this time.
In the CY 2017 Quality Payment Program final rule (81 FR 77073
through 77077), we expressed our commitment to pursue the active
engagement of stakeholders throughout the process of establishing and
implementing virtual groups. We received public comments in response to
the CY 2017 Quality Payment Program final rule and additional
stakeholder feedback by hosting several virtual group listening
sessions and convening user groups. Many stakeholders requested that
CMS provide an option that would permit a portion of a group to
participate in MIPS outside the group by reporting separately or
forming a virtual group. We refer readers to section II.C.b.3. of this
proposed rule for discussion regarding a potential option for
addressing such issue.
c. MIPS Virtual Group Identifier for Performance
To ensure that we have accurately captured all of the MIPS eligible
clinicians participating in a virtual group, we propose that each MIPS
eligible clinician who is part of a virtual group would be identified
by a unique virtual group participant identifier. The unique virtual
group participant
[[Page 30029]]
identifier would be a combination of three identifiers: (1) Virtual
group identifier (established by CMS; for example, XXXXXX); (2) TIN (9
numeric characters; for example, XXXXXXXXX); and (3) NPI (10 numeric
characters; for example, 1111111111). For example, a virtual
participant identifier could be VG-XXXXXX, TIN-XXXXXXXXX, NPI-
11111111111. We solicit public comment on this proposal.
d. Application of MIPS Group Policies to Virtual Groups
In the CY 2017 Quality Payment Program final rule (81 FR 77070
through 77072), we finalized various requirements for groups under MIPS
at Sec. 414.1310(e), under which groups electing to report at the
group level are assessed and scored across the TIN for all four
performance categories. We propose to apply our previously finalized
and proposed group policies to virtual groups, unless otherwise
specified. We recognize that there are instances in which we may need
to clarify or modify the application of certain previously finalized or
proposed group-related policies to virtual groups, such as the
definition of a non-patient facing MIPS eligible clinician; small
practice, rural area and HPSA designations; and groups that have a
portion of its NPIs participating in a MIPS APM or an Advanced APM (see
section II.C.4.b. of this proposed rule). More generally, such policies
may include those that require a calculation of the number of NPIs
across a TIN (given that a virtual group is a combination of TINs), the
application of any virtual group participant's status or designation to
the entire virtual group, and the applicability and availability of
certain measures and activities to any virtual group participant and to
the entire virtual group.
With regard to the applicability of the non-patient facing policies
to virtual groups, in the CY 2017 Quality Payment Program final rule
(81 FR 77048 through 77049), we defined the term non-patient facing
MIPS eligible clinician at Sec. 414.1305 as an individual MIPS
eligible clinician that bills 100 or fewer patient facing encounters
(including Medicare telehealth services defined in section 1834(m) of
the Act) during the non-patient facing determination period, and a
group provided that more than 75 percent of the NPIs billing under the
group's TIN meet the definition of a non-patient facing individual MIPS
eligible clinician during the non-patient facing determination period.
We are proposing to modify the definition of a non-patient facing MIPS
eligible clinician to include clinicians in a virtual group provided
that more than 75 percent of the NPIs billing under the virtual group's
TINs meet the definition of a non-patient facing individual MIPS
eligible clinician during the non-patient facing determination period.
We refer readers to section II.C.4.f. of this rule for the proposed
modification. We note that other policies previously established and
proposed in this proposed rule for non-patient facing groups would
apply to virtual groups. For example, as discussed in section II.C.1.e.
of this proposed rule, virtual groups determined to be non-patient
facing would have their advancing care information performance category
automatically reweighted to zero.
In regard to the application of small practice status to virtual
groups, we are proposing that a virtual group would be identified as
having a small practice status if the virtual group does not have 16 or
more members of a virtual group (NPIs). We refer readers to section
II.C.4.d. of this proposed rule for discussion regarding how small
practice status would apply to virtual groups for scoring under MIPS.
In the CY 2017 Quality Payment Program final rule (81 FR 77188), we
defined the term small practices at Sec. 414.1305 as practices
consisting of 15 or fewer clinicians and solo practitioners. In section
II.C.1.c. of this proposed rule, we are proposing for performance
periods occurring in 2018 and future years to identify small practices
by utilizing claims data. For performance periods occurring in 2018, we
would identify small practices based on 12 months of data starting from
September 1, 2016 to August 31, 2017.
In section II.C.1.e. of this rule, we propose to determine rural
area and HPSA practice designations for groups participating in MIPS at
the group level. We note that in section II.C.7.b we describe our
scoring proposals for practices that are in a rural area or HPSA
practice. For performance periods occurring in 2018 and future years,
we are proposing that a group with 75 percent or more of the TIN's
practice sites designated as rural areas or HPSA practices would be
designated as a rural area or HPSA at the group level. We are proposing
that a virtual group with 75 percent or more of the virtual group's
TINs designated as rural areas or HPSA practices would be designated as
a rural area or HPSA practice at the virtual group level. We note that
other policies previously established and proposed in this proposed
rule for rural area and HPSA groups would apply to virtual groups.
We recognize that the measures and activities available to groups
would also be available to virtual groups. Virtual groups would be
required to meet the reporting requirements for each measure and
activity, and the virtual group would be responsible for ensuring that
their measures and activities are aggregated across the virtual group
(for example, across their TINs). We note that other previously
established group-related policies and proposed policies in this
proposed rule pertaining to the four performance categories would apply
to virtual groups.
Therefore, we propose to apply MIPS group policies to virtual
groups except as otherwise specified. We solicit public comment on this
proposal. We are also interested on receiving feedback on how such
group-related policies previously established and proposed in this
proposed rule either would or would not apply to virtual groups. In
addition, we request public comment on any other policies that may need
to be clarified or modified with respect to virtual groups, such as
those that require a calculation of the number of NPIs across a TIN
(given that a virtual group is a combination of TINs), the application
of any virtual group participant's status or designation to the entire
virtual group, the application of the group reporting requirements for
the individual performance categories to virtual groups, and the
applicability and availability of certain measures and activities to
any virtual group participant and to the entire virtual group.
e. Election Process
As noted above, section 1848(q)(5)(I)(iii)(I) and (II) of the Act
provides that the virtual group election process must include certain
requirements, including that: (1) An individual MIPS eligible clinician
or group electing to be in a virtual group must make their election
prior to the start of the applicable performance period and cannot
change their election during the performance period; and (2) an
individual MIPS eligible clinician or group may elect to be in no more
than one virtual group for a performance period, and, in the case of a
group, the election applies to all MIPS eligible clinicians in the
group. We propose to codify at Sec. 414.1315(a) that a solo
practitioner or a group of 10 or fewer eligible clinicians must make
their election prior to the start of the applicable performance period
and cannot change their election during the performance period. Virtual
group participants may elect to be in no more than one virtual group
for a performance period and, in the case of a group, the election
applies to all MIPS eligible
[[Page 30030]]
clinicians in the group. For the 2018 performance year and future
years, we are proposing to establish an election period.
We propose to codify at Sec. 414.1315(b) that, beginning with
performance periods occurring in 2018, a solo practitioner, or group of
10 or fewer eligible clinicians electing to be in a virtual group must
make their election by December 1 of the calendar year preceding the
applicable performance period. For example, a solo practitioner or
group would need to make their election by December 1, 2017 to
participate in MIPS as a virtual group during the 2018 performance
period. Prior to the election deadline, a virtual group representative
would have the opportunity to make an election, on behalf of the
members of a virtual group, regarding the formation of a virtual group
for an applicable performance period. We intend to publish the
beginning date of the virtual group election period applicable to the
2018 performance period and future years in subregulatory guidance.
In order to provide support and reduce burden, we intend to make
technical assistance (TA) available, to the extent feasible and
appropriate, to support clinicians who choose to come together as a
virtual group. Clinicians can access TA infrastructure and resources
that they may already be utilizing). For Quality Payment Program year
3, we intend to provide an electronic election process if technically
feasible. We propose that clinicians who do not elect to contact their
designated TA representative would still have the option of contacting
the Quality Payment Program Service Center.
We propose to codify at Sec. 414.1315(c) a two-stage virtual group
election process, stage 1 of which is optional, for the applicable 2018
and 2019 performance periods. Stage 1 pertains to virtual group
eligibility determinations. In stage 1, solo practitioners and groups
with 10 or fewer eligible clinicians interested in forming or joining a
virtual group would have the option to contact their designated TA
representative or the Quality Payment Program Service Center in order
to obtain information pertaining to virtual groups and/or determine
whether or not they are eligible, as it relates to the practice size
requirement of a solo practitioner or a group of 10 or fewer eligible
clinicians, to participate in MIPS as a virtual group (Sec.
414.1315(a)(1)(i)). We note that activity involved in stage 1 is not
required, but a resource available to solo practitioners and groups
with 10 or fewer eligible clinicians; otherwise, solo practitioners or
groups with 10 or fewer eligible clinicians that do not engage in any
activity during stage 1, they would begin the election process at stage
2. For solo practitioners and groups who engage in stage 1 and were
determined eligible for virtual group participation, they would proceed
to stage 2. Engaging in stage 1 would provide solo practitioners and
groups with the option to confirm whether or not they are eligible to
join or form a virtual group before going to the lengths of executing
formal written agreements, submitting a formal election registration,
allocating resources for virtual group implementation, and other
related activities; whereas, engaging directly in stage 2 as an initial
step, solo practitioners and groups may have conducted all such efforts
to only have their election registration be rejected with no recourse
or remaining time to amend and resubmit.
During stage 1 of the virtual group election process, we would
determine whether or not a TIN is eligible to form or join a virtual
group. In order for a solo practitioner to be eligible to form or join
a virtual group, the solo practitioner would need to be considered a
MIPS eligible clinician (defined at Sec. 414.1305) who bills under a
TIN with no other NPIs billing under such TIN, and not excluded from
MIPS under Sec. 414.1310(b) and (c). In order for a group to be
eligible to form or join a virtual group, a group would need to have a
TIN size that does not exceed 10 eligible clinicians and not excluded
from MIPS based on the low-volume threshold exclusion at the group
level. For purposes of determining TIN size for virtual group
participation eligibility, we coin the term ``virtual group eligibility
determination period'' and define it to mean an analysis of claims data
during an assessment period of up to five months that would begin on
July 1 and end as late as November 30 of a calendar year prior to the
performance year and includes a 30-day claims run out.
To capture a real-time representation of TIN size, we propose to
analyze up to five months of claims data on a rolling basis, in which
virtual group eligibility determinations for each TIN would be updated
and made available monthly. We note that an eligibility determination
regarding TIN size is based on a relative point in time within the
five-month virtual group eligibility determination period, and not an
eligibility determination made at the end of such five-month
determination period. If at any time a TIN is determined to be eligible
to participate in MIPS as part of a virtual group, the TIN would retain
that status for the duration of the election period and the applicable
performance period. TINs could determine their status by contacting
their designated TA representative or the Quality Payment Program
Service Center; otherwise, the TIN's status would be determined at the
time that the TIN's virtual group election is submitted. For example,
if a group contacted their designated TA representative or the Quality
Payment Program Service Center on October 20, 2017, the claims data
analysis would include the months of July through September of 2017,
and if determined not to exceed 10 eligible clinicians, such TIN's size
status would be identified at such time and would be retained for the
duration of the election period and the 2018 performance period. If
another group contacted their designated TA representative or the
Quality Payment Program Service Center on November 20, 2017, the claims
data analysis would include the months of July through October of 2017,
and if determined not to exceed 10 eligible clinicians, such TIN's size
status would be identified at such time and would be retained for the
duration of the election period and the 2018 performance period.
We believe such a virtual group determination period process
provides a relative representation of real-time group size for purposes
of virtual group eligibility and allows groups to know their real-time
size status immediately and plan accordingly for virtual group
implementation. It is anticipated that starting in September of each
calendar year prior to the applicable performance year beginning in
2018, groups would be able to contact their designated TA
representative or the Quality Payment Program Service Center and
inquire about virtual group participation eligibility. We note that TIN
size determinations are based on the number of NPIs associated with a
TIN, which would include clinicians (NPIs) excluded from MIPS
participation and who do not meet the definition of a MIPS eligible
clinician.
For groups that do not choose to participate in stage 1 of the
election process (that is, the group does not request an eligibility
determination), we will make an eligibility determination during stage
2 of the election process. If a group began the election process at
stage 2 and if its TIN size is determined not to exceed 10 eligible
clinicians and not excluded based on the low-volume threshold exclusion
at the group level, the group is determined eligible to participate in
MIPS as part of a virtual group, and such virtual group eligibility
determination status would be retained
[[Page 30031]]
for the duration of the election period and applicable performance
period.
Stage 2 pertains to virtual group formation. For stage two, we
propose the following:
TINs comprising a virtual group must establish a written
formal agreement between each member of a virtual group prior to an
election (Sec. 414.1315(c)(2)(i)).
On behalf of a virtual group, the official designated
virtual group representative must submit an election by December 1 of
the calendar year prior to the start of the applicable performance
period. (Sec. 414.1315(c)(2)(ii)). We anticipate this election will
occur via email to the Quality Payment Program Service Center using the
following email address: [email protected].
The submission of a virtual group election must include,
at a minimum, information pertaining to each TIN and NPI associated
with the virtual group and contact information for the virtual group
representative (Sec. 414.1315(c)(2)(iii). A virtual group
representative would submit the following type of information: each TIN
associated with the virtual group; each NPI associated with a TIN that
is part of the virtual group; name of the virtual group representative;
affiliation of the virtual group representative to the virtual group;
contact information for the virtual group representative; and confirm
through acknowledgment that a written formal agreement has been
established between each member of the virtual group prior to election
and each member of the virtual group is aware of participating in MIPS
as a virtual group for an applicable performance period. Each member of
the virtual group must retain a copy of the virtual group's written
agreement. We note that the virtual group agreement is subject to the
MIPS data validation and auditing requirements as described in section
II.C.9.c. of this rule.
Once an election is made, the virtual group representative
must contact their designated CMS contact to update any election
information that changed during an applicable performance period one
time prior to the start of an applicable submission period (Sec.
414.1315(c)(2)(iv)). We anticipate that virtual groups will use the
Quality Payment Program Service Center as their designated CMS contact;
however, we will define this further in subregulatory guidance.
For stage 2 of the election process, we would review all submitted
election information; confirm whether or not each TIN within a virtual
group is eligible to participate in MIPS as part of a virtual group;
identify the NPIs within each TIN participating in a virtual group that
are excluded from MIPS in order to ensure that such NPIs would not
receive a MIPS payment adjustment or, when applicable and when
information is available, would receive a payment adjustment based on a
MIPS APM scoring standard; calculate the low-volume threshold at the
individual and group levels in order to determine whether or not a solo
practitioner or group is eligible to participate in MIPS as part of a
virtual group; and notify virtual groups as to whether or not they are
considered official virtual groups for the applicable performance
period. For virtual groups that are determined to have met the virtual
group formation criteria and identified as an official virtual group
participating in MIPS for an applicable performance period, we would
contact the official designated virtual group representative via email
notifying the virtual group of its official virtual group status and
issuing a virtual group identifier for performance (as described in
section II.C.4.c. of this proposed rule) that would accompany the
virtual group's submission of performance data during the submission
period.
In regard to virtual group determinations pertaining to the low-
volume threshold, we recognize that such determinations are made at the
individual and group level, but not at the virtual group level. The
low-volume threshold determinations are applicable to the way in which
individual eligible clinicians and groups participate in MIPS as
individual MIPS eligible clinicians (solo practitioners) or groups. For
example, if an individual MIPS eligible clinician is part of a practice
that is participating in MIPS at the individual level (reporting at the
individual level), then the low-volume threshold determination is made
at the individual level. Whereas, if an individual MIPS eligible
clinician is part of a practice that is participating in MIPS at the
group level (reporting at the group level), then the low-volume
threshold determination at the group level would be applicable to such
MIPS eligible clinician regardless of the low-volume threshold
determination made at the individual level because such individual MIPS
eligible clinician is part of a group reporting at the group level and
the low-volume threshold determinations for groups applies to the group
as a whole. Similarly, if a solo practitioner or a group with 10 or
fewer eligible clinicians seeks to participate in MIPS at the virtual
group level (reporting at the virtual group level), then the low-volume
threshold determination at the individual or group level would be
applicable to such solo practitioner or group with 10 or fewer eligible
clinicians. Thus, solo practitioners (individual MIPS eligible
clinicians) or groups with 10 or fewer eligible clinicians that are
determined not to exceed the low-volume threshold at the individual or
group level would not be eligible to participate in MIPS as an
individual, group, or virtual group.
As we engaged in various discussions with stakeholders during the
rulemaking process through listening sessions and user groups,
stakeholders indicated that many solo practitioners and small groups
have limited resources and technical capacities, which may make it
difficult for the entities to form virtual groups without sufficient
time and technical assistance. Depending on the resources and technical
capacities of the entities, stakeholders conveyed that it may take
entities 3 to 18 months to prepare to participate in MIPS as a virtual
group. The majority of stakeholders indicated that virtual groups would
need at least 6 to 12 months prior to the start of the 2018 performance
period to form virtual groups, prepare health IT systems, and train
staff to be ready for the implementation of virtual group related
activities by January 1, 2018.
We recognize that for the first year of virtual group formation and
implementation prior to the start of the 2018 performance period, the
timeframe for virtual groups to make an election by registering would
be relatively short, particularly from the date we issue the
publication of a final rule toward the end of the 2017 calendar year.
To provide solo practitioners and groups with 10 or fewer eligible
clinicians with additional time to assemble and coordinate resources,
and form a virtual group prior to the start of the 2018 performance
period, we are providing virtual groups with an opportunity to make an
election prior to the publication of our final rule. We intend for the
virtual group election process to be available as early as mid-
September of 2017; we will publicize the specific opening date via
subregulatory guidance. Virtual groups would have from mid-September to
December 1, 2017 to make an election for the 2018 performance year. In
regard to our proposed policies pertaining to virtual group
implementation (for example, definition of a virtual group and election
process requirements), we intend to closely align with the statutory
requirements in order to establish clear expectations for solo
practitioners and
[[Page 30032]]
small groups, and have an opportunity to begin the preparation of
forming virtual groups in advance of the publication of our final rule.
However, any MIPS eligible clinicians applying to be a virtual group
that does not meet all finalized virtual group requirements would not
be permitted to participate in MIPS as a virtual group.
As previously noted, groups participating in a virtual group would
have the size of their TIN determined for eligibility purposes. The
virtual group size would be determined one time for each performance
period. We recognize that the size of a group may fluctuate during a
performance period with eligible clinicians and/or MIPS eligible
clinicians joining or leaving a group. For groups within a virtual
group that are determined to have a group size of 10 eligible
clinicians or less based on the one time determination per applicable
performance year, any new eligible clinicians or MIPS eligible
clinicians that join the group during the performance period would
participate in MIPS as part of the virtual group. In such cases, we
recognize that a group may exceed 10 eligible clinicians associated
with its TIN during an applicable performance period, but at the time
of election, such group would have been determined eligible to form or
join a virtual group given that the TIN did not have more than 10
eligible clinicians associated with its TIN. As previously noted, the
virtual group representative would need to contact the Quality Payment
Program Service Center to update the virtual group's information that
was provided during the election period if any information changed
during an applicable performance period one time prior to the start of
an applicable submission period (for example, include new NPIs who
joined a TIN that is part of a virtual group). Virtual groups must re-
register before each performance period.
The statute provides that a solo practitioner (TIN/NPI) and a group
with 10 or fewer eligible clinicians may elect to be in no more than
one virtual group for a performance period. We note that such a solo
practitioner or a group that is part of a virtual group may not elect
to be in more than one virtual group for a performance period. Also,
the statute determines that a virtual group election by the group for
an applicable performance period applies to all MIPS eligible
clinicians in the group. In the case of a TIN within a virtual group
being acquired or merged with another TIN, or no longer operating as a
TIN (for example, a group practice closes) during a performance period,
such solo practitioner or group's performance data would continue to be
attributed to the virtual group. The remaining members of a virtual
group would continue to be part of the virtual group even if only one
solo practitioner or group remains. We consider a TIN that is acquired
or merged with another TIN, or no longer operating as a TIN (e.g., a
group practice closes) to mean a TIN that no longer exists or operates
under the auspices of such TIN during a performance year.
As outlined in section 1848(q)(5)(I)(iii) of the Act and previously
noted, a virtual group is a combination of TINs, which would include at
least two separate TINs associated with a solo practitioner (TIN/NPI),
or a group with 10 or fewer eligible clinicians and another such solo
practitioner, or group. However, given that a virtual group must be a
combination of TINs, we recognize that the composition of a virtual
group could include, for example, one solo practitioner (NPI) who is
practicing under multiple TINs, in which the solo practitioner would be
able to form a virtual group with his or her own self based on each TIN
assigned to the solo practitioner. For the number of TINs able to form
a virtual group, we note that there is not a limit to the number of
TINs able to comprise a virtual group.
f. Virtual Group Agreements
The statute provides for formal written agreements among the MIPS
eligible clinicians electing to form a virtual group. We propose that
each virtual group member would be required to execute formal written
agreements with each other virtual group member to ensure that
requirements and expectations of participation in MIPS are clearly
articulated, understood, and agreed upon. We note that a virtual group
may not include a solo practitioner or group as part of the virtual
group unless an authorized person of the TIN has executed a formal
written agreement. During the election process and submission of a
virtual group election, a designated virtual group representative would
be required to confirm through acknowledgement that an agreement is in
place between each member of the virtual group. An agreement would be
executed for at least one performance period. If a NPI joins or leaves
a TIN, or a change is made to a TIN that impacts the agreement itself,
such as a legal business name change, during the applicable performance
year, a virtual group would be required to update the agreement to
reflect such changes and submit changes to CMS via the Quality Payment
Program Service Center.
We propose, at Sec. 414.1315(c)(3), that a formal written
agreement between each member of a virtual group must include the
following elements:
Expressly state the only parties to the agreement are the
TINs and NPIs of the virtual group (at Sec. 414.1315(c)(3)(i)). For
example, the agreement may not be between a virtual group and another
entity, such as an independent practice association (IPA) or management
company that in turn has an agreement with one or more TINs within the
virtual group. Similarly, virtual groups should not use existing
contracts between TINs that include third parties.
Be executed on behalf of the TINs and the NPIs by
individuals who are authorized to bind the TINs and the NPIs,
respectively at Sec. 414.1315(c)(3)(ii)).
Expressly require each member of the virtual group
(including each NPI under each TIN) to agree to participate in MIPS as
a virtual group and comply with the requirements of the MIPS and all
other applicable laws and regulations (including, but not limited to,
federal criminal law, False Claims Act, anti-kickback statute, civil
monetary penalties law, Health Insurance Portability and Accountability
Act, and physician self-referral law) at Sec. 414.1315(c)(3)(iii)).
Require each TIN within a virtual group to notify all NPIs
associated with the TIN of their participation in the MIPS as a virtual
group at Sec. 414.1315(c)(3)(iv)).
Set forth the NPI's rights and obligations in, and
representation by, the virtual group, including without limitation, the
reporting requirements and how participation in MIPS as a virtual group
affects the ability of the NPI to participate in the MIPS outside of
the virtual group at Sec. 414.1315(c)(3)(v)).
Describe how the opportunity to receive payment
adjustments will encourage each member of the virtual group (including
each NPI under each TIN) to adhere to quality assurance and improvement
at Sec. 414.1315(c)(3)(vi)).
Require each member of the virtual group to update its
Medicare enrollment information, including the addition and deletion of
NPIs billing through a TIN that is part of a virtual group, on a timely
basis in accordance with Medicare program requirements and to notify
the virtual group of any such changes within 30 days after the change
at Sec. 414.1315(c)(3)(vii)).
Be for a term of at least one performance period as
specified in the formal written agreement at Sec.
414.1315(c)(3)(viii)).
[[Page 30033]]
Require completion of a close-out process upon termination
or expiration of the agreement that requires the TIN (group part of the
virtual group) or NPI (solo practitioner part of the virtual group) to
furnish all data necessary in order for the virtual group to aggregate
its data across the virtual group at Sec. 414.1315(c)(3)(ix)).
As part of the virtual group election ICR, we filed a 60-day notice
on June 14, 2017 (82 FR 27257), which includes an agreement template
that could be used by virtual groups and will be made available via
subregulatory guidance. The agreement template is not required, but
serves as a model agreement that could be utilized by virtual groups.
The agreement template includes all necessary elements required for
such an agreement.
We solicit public comment on these proposals.
Through the formal written agreements, we want to ensure that all
members of a virtual group are aware of their participation in a
virtual group. As noted above, formal written agreements must include a
provision that requires each TIN within a virtual group to notify all
NPIs associated with the TIN regarding their participation in the MIPS
as a virtual group in order to ensure that each member of a virtual
group is aware of their participation in the MIPS as a virtual group.
We want to implement an approach that considers a balance between the
need to ensure that all members of a virtual group are aware of their
participation in a virtual group and the minimization of administration
burden. We solicit public comment on approaches for virtual groups to
ensure that all members of a virtual group are aware of their
participation in the virtual group.
g. Reporting Requirements
As we noted in this proposed rule, we believe virtual groups should
generally be treated under the MIPS as groups. Therefore, for MIPS
eligible clinicians participating at the virtual group level, we
propose the following requirements:
Individual eligible clinicians and individual MIPS
eligible clinicians who are part of a TIN participating in MIPS at the
virtual group level would have their performance assessed as a virtual
group at Sec. 414.1315(d)(1).
Individual eligible clinicians and individual MIPS
eligible clinicians who are part of a TIN participating in MIPS at the
virtual group level would need to meet the definition of a virtual
group at all times during the performance period for the MIPS payment
year (at Sec. 414. 1315(d)(2)).
Individual eligible clinicians and individual MIPS
eligible clinicians who are part of a TIN participating in MIPS at the
virtual group level must aggregate their performance data across
multiple TINs in order for their performance to be assessed as a
virtual group (at Sec. 414.1315(d)(3)).
MIPS eligible clinicians that elect to participate in MIPS
at the virtual group level would have their performance assessed at the
virtual group level across all four MIPS performance categories (at
Sec. 414.1315(d)(4)).
Virtual groups would need to adhere to an election process
established and required by CMS (at Sec. 414.1315(d)(5)).
We solicit public comment on these proposals.
h. Assessment and Scoring for the MIPS Performance Categories
As noted above, section 1848(q)(5)(I)(i) of the Act provides that
eligible clinicians electing to be a virtual group will: (1) Have their
performance assessed for the quality and cost performance categories in
a manner that applies the combined performance of all eligible
clinicians in the virtual group to each MIPS eligible clinician (except
for those participating in a MIPS APM or an Advanced APM under the MIPS
APM scoring standard) in the virtual group for a performance period of
a year; and (2) be scored based on the assessment of the combined
performance described above regarding the quality and cost performance
categories for a performance period. We believe it is critical for
virtual groups to be assessed and scored at the virtual group level for
all performance categories; it eliminates the burden of virtual group
members having to report as a virtual group and separately outside of a
virtual group. Additionally, we believe that the assessment and scoring
at the virtual group level provides for a comprehensive measurement of
performance, shared responsibility, and an opportunity to effectively
and efficiently coordinate resources to also achieve performance under
the improvement activities and the advancing care information
performance categories. We propose at Sec. 414.1315 that virtual
groups would be assessed and scored across all four MIPS performance
categories at the virtual group level for a performance period of a
year.
In the CY 2017 Quality Payment Program final rule (81 FR 77319
through 77329), we established the MIPS final score methodology, which
will apply to virtual groups. We refer readers to sections II.C.7.b.
and II.C.8. of this proposed rule for scoring policies that would apply
to virtual groups.
As previously noted, we propose to allow solo practitioners and
groups with 10 or fewer eligible clinicians that have elected to be
part of a virtual group to have their performance measured and
aggregated at the virtual group level across all four performance
categories; however, we would apply payment adjustments at the
individual TIN/NPI level. Each TIN/NPI would receive a final score
based on the virtual group performance, but the payment adjustment
would still be applied at the TIN/NPI level. We would assign the
virtual group score to all TIN/NPIs billing under a TIN in the virtual
group during the performance period.
During the performance year, we recognize that NPIs in a TIN that
has joined a virtual group may also be participants in an APM. The TIN,
as part of the virtual group, must submit performance data for all
eligible clinicians associated with the TIN, including those
participating in APMs, to ensure that all eligible clinicians
associated with the TIN are being measured under MIPS.
For participants in MIPS APMs, we propose to use our authority
under section 1115A(d)(1) for MIPS APM authorized under section 1115A
of the Act, and under section 1899(f) for the Shared Savings Program,
to waive the requirement under section 1848 (q)(2)(5)(I)(i)(II) of the
Act that requires performance category scores from virtual group
reporting must be used to generate the composite score upon which the
MIPS payment adjustment is based for all TIN/NPIs in the virtual group.
Instead, we would use the score assigned to the MIPS eligible clinician
based on the applicable APM Entity score to determine MIPS payment
adjustments for all MIPS eligible clinicians that are part of an APM
Entity participating in a MIPS APM, in accordance with Sec. 414.1370,
instead of determining MIPS payment adjustments for these MIPS eligible
clinicians using the composite score of their virtual group.
APMs seek to deliver better care at lower cost and to test new ways
of paying for care and measuring and assessing performance. In the CY
2017 Quality Payment Program final rule, we established policies to the
address concerns we have expressed in regard to the application of
certain MIPS policies to MIPS eligible clinicians in MIPS APMs (81 FR
77246 through 77269). In section II.C.6.g. of this proposed rule, we
reiterate those concerns and propose additional policies for the APM
scoring standard. We believe it is important to
[[Page 30034]]
consistently apply the APM scoring standard under MIPS for eligible
clinicians participating in MIPS APMs in order to avoid potential
misalignments between the evaluation of performance under the terms of
the MIPS APM and evaluation of performance on measures and activities
under MIPS, and to preserve the integrity of the initiatives we are
testing. Therefore, we believe it is necessary to waive the requirement
to only use the virtual group scores under section 1848(q)(5)(I)(i)(II)
of the Act, and instead to apply the score under the APM scoring
standard for eligible clinicians in virtual groups who are also in an
APM Entity participating in an APM.
We note that MIPS eligible clinicians who are participants in both
a virtual group and a MIPS APM would be assessed under MIPS as part of
the virtual group and under the APM scoring standard as part of an APM
Entity group, but would receive their payment adjustment based only on
the APM Entity score. In the case of an eligible clinician
participating in both a virtual group and an Advanced APM who has
achieved QP status, the clinician would be assessed under MIPS as part
of the virtual group, but would still be excluded from the MIPS payment
adjustment as a result of his or her QP status. We refer readers to
section II.C.6.g.(2) of this proposed rule for further discussion
regarding the waiver and the CY 2017 Quality Payment Program final rule
(81 FR 77013) for discussion regarding the timeframe used for
determining QP status.
5. MIPS Performance Period
In the CY 2017 Quality Payment Program final rule (81 FR 77085), we
finalized at Sec. 414.1320(b)(1) that for purposes of the MIPS payment
year 2020, the performance period for the quality and cost performance
categories is CY 2018 (January 1, 2018 through December 31, 2018). For
the improvement activities and advancing care information performance
categories, we finalized at Sec. 414.1320(b)(2) that for purposes of
the MIPS payment year 2020, the performance period for the improvement
activities and advancing care information performance categories is a
minimum of a continuous 90-day period within CY 2018, up to and
including the full CY 2018 (January 1, 2018, through December 31,
2018). We are not proposing any changes to these policies.
We also finalized at Sec. 414.1325(f)(2) to use claims with dates
of service during the performance period that must be processed no
later than 60 days following the close of the performance period for
purposes of assessing performance and computing the MIPS payment
adjustment. Lastly, we finalized that individual MIPS eligible
clinicians or groups who report less than 12 months of data (due to
family leave, etc.) would be required to report all performance data
available from the applicable performance period (for example, CY 2018
or a minimum of a continuous 90-day period within CY 2018).
We are proposing at Sec. 414.1320(c) and (c)(1) that for purposes
of the MIPS payment year 2021 and future years, for the quality and
cost performance categories, the performance period under MIPS would be
the full calendar year (January 1 through December 31) that occurs 2
years prior to the applicable payment year. For example, for the MIPS
payment year 2021, the performance period would be CY 2019 (January 1,
2019 through December 31, 2019), and for the MIPS payment year 2022 the
performance period would be CY 2020 (January 1, 2020 through December
31, 2020).
We are proposing at Sec. 414.1320(d) and (d)(1) that for purposes
of the MIPS payment year 2021, the performance period for the
improvement activities and advancing care information performance
categories would be a minimum of a continuous 90-day period within the
calendar year that occurs 2 years prior to the applicable payment year,
up to and including the full CY 2019 (January 1, 2019 through December
31, 2019).
We request comments on our proposals for the performance period for
MIPS payment year 2021 and future years.
6. MIPS Performance Category Measures and Activities
a. Performance Category Measures and Reporting
(1) Submission Mechanisms
We finalized in the CY 2017 Quality Payment Program final rule (81
FR 77094) at Sec. 414.1325(a) that individual MIPS eligible clinicians
and groups must submit measures and activities, as applicable, for the
quality, improvement activities, and advancing care information
performance categories. For the cost performance category, we finalized
that each individual MIPS eligible clinician's and group's cost
performance would be calculated using administrative claims data. As a
result, individual MIPS eligible clinicians and groups are not required
to submit any additional information for the cost performance category.
For individual eligible clinicians and groups that are not MIPS
eligible clinicians, such as physical therapists, but elect to report
to MIPS, we will calculate administrative claims-based cost measures
and quality measures, if data are available. We finalized in the CY
2017 Quality Payment Program final rule (81 FR 77094 through 77095)
multiple data submission mechanisms for MIPS, which provide individual
MIPS eligible clinicians and groups with the flexibility to submit
their MIPS measures and activities in a manner that best accommodates
the characteristics of their practice, as indicated in Tables 2 and 3.
Table 2 summarizes the data submission mechanisms for individual MIPS
eligible clinicians that we finalized at Sec. 414.1325(b) and (e).
Table 3 summarizes the data submission mechanisms for groups that are
not reporting through an APM that we finalized at Sec. 414.1325(c) and
(e).
Table 2--Data Submission Mechanisms for MIPS Eligible Clinicians
Reporting Individually
[TIN/NPI]
------------------------------------------------------------------------
Performance category/submission Individual reporting data submission
combinations accepted mechanisms
------------------------------------------------------------------------
Quality........................... Claims.
QCDR.
Qualified registry.
EHR.
Cost.............................. Administrative claims.\1\
[[Page 30035]]
Advancing Care Information........ Attestation.
QCDR.
Qualified registry.
EHR.
Improvement Activities............ Attestation.
QCDR.
Qualified registry.
EHR.
------------------------------------------------------------------------
Table 3--Data Submission Mechanisms for MIPS Eligible Clinicians
Reporting as Groups (TIN)
------------------------------------------------------------------------
Performance category/submission Group reporting data submission
combinations accepted mechanisms
------------------------------------------------------------------------
Quality........................... QCDR.
Qualified registry.
EHR.
CMS Web Interface (groups of 25 or
more).
CMS-approved survey vendor for CAHPS
for MIPS (must be reported in
conjunction with another data
submission mechanism).
and
Administrative claims (for all-cause
hospital readmission measure; no
submission required).
Cost.............................. Administrative claims.\1\
Advancing Care Information........ Attestation.
QCDR.
Qualified registry.
EHR.
CMS Web Interface (groups of 25 or
more).
Improvement Activities............ Attestation.
QCDR.
Qualified registry.
EHR.
CMS Web Interface (groups of 25 or
more).
------------------------------------------------------------------------
We finalized at Sec. 414.1325(d) that individual MIPS eligible
clinicians and groups may elect to submit information via multiple
mechanisms; however, they must use the same identifier for all
performance categories, and they may only use one submission mechanism
per performance category. In response to the CY 2017 Quality Payment
Program final rule (81 FR 77089), we received comments supportive of
the use of multiple submission mechanisms for a single performance
category due to the flexibility it would provide clinicians. Another
commenter supported such an approach because they believed that the
scoring of only one submission mechanism per performance category may
influence which quality measures a MIPS eligible clinician chooses to
report given that the commenter believed only a limited number of
measures relevant to one's practice might be available through a
particular submission mechanism. The commenter also believed that such
flexibility would encourage continued participation in MIPS.
---------------------------------------------------------------------------
\1\ Requires no separate data submission to CMS: Measures are
calculated based on data available from MIPS eligible clinicians'
billings on Medicare Part B claims. Note: Claims differ from
administrative claims as they require MIPS eligible clinicians to
append certain billing codes to denominator eligible claims to
indicate the required quality action or exclusion occurred.
---------------------------------------------------------------------------
We are proposing to revise Sec. 414.1325(d) for purposes of the
2020 MIPS payment year and future years, beginning with performance
periods occurring in 2018, to allow individual MIPS eligible clinicians
and groups to submit data on measures and activities, as applicable,
via multiple data submission mechanisms for a single performance
category (specifically, the quality, improvement activities, or
advancing care information performance category). Under this proposal,
individual MIPS eligible clinicians and groups that have fewer than the
required number of measures and activities applicable and available
under one submission mechanism could be required to submit data on
additional measures and activities via one or more additional
submission mechanisms, as necessary, provided that such measures and
activities are applicable and available to them to receive the maximum
number of points under a performance category. We considered an
approach that would require MIPS eligible clinicians to first submit
data on as many required measures and activities as possible via one
submission mechanism before submitting data via an additional
submission mechanism, but we believe that such an approach would limit
flexibility.
If an individual MIPS eligible clinician or group submits the same
measure through two different mechanisms, each submission would be
calculated and scored separately. We do not have the ability to
aggregate data on the same measure across submission mechanisms. We
would only count the submission that gives the clinician the higher
score, thereby avoiding the double count. We refer readers to section
II.C.7. of this proposed rule, which further outlines how we propose to
score measures and activities regardless of submission mechanism.
We believe that this flexible approach would help individual MIPS
eligible clinicians and groups with reporting, as it provides more
options for the submission of data for the applicable
[[Page 30036]]
performance categories. For example, an individual MIPS eligible
clinician or group submitting data on four applicable and available
quality measures via EHR may not be able to receive the maximum number
of points available under the quality performance category. However,
with this proposed modification, the MIPS eligible clinician could meet
the requirement to report six quality measures by submitting data on
two additional quality measure via another submission mechanism, such
as claims or qualified registry. This would enable the MIPS eligible
clinician to receive the maximum number of points available under the
quality performance category. We believe that by providing this
flexibility, we would be allowing MIPS eligible clinicians the
flexibility to choose the measures and activities that are most
meaningful to them, regardless of the submission mechanism. We are
aware that this proposal for increased flexibility in data submission
mechanisms may increase complexity and in some instances additional
costs for clinicians, as they may need to establish relationships with
additional data submission mechanism vendors in order to report
additional measures and/or activities for any given performance
category. We would like to clarify that the requirements for the
performance categories remain the same, regardless of the number of
submission mechanisms used. It is also important to note for the
improvement activities and advancing care information performance
categories, that using multiple data submission mechanisms (for
example, attestation and the qualified registry) may limit our ability
to provide real-time feedback. While we strive to provide flexibility
to individual MIPS eligible clinicians and groups, we would like to
note that our goal within the MIPS program is to minimize complexity
and administrative burden to individual MIPS eligible clinicians and
groups. We request comments on this proposal.
As discussed in section II.C.4. of this proposed rule, we are
proposing to generally apply our previously finalized and proposed
group policies to virtual groups. With respect to data submission
mechanisms, we are proposing that virtual groups would be able to use a
different submission mechanism for each performance category, and would
be able to utilize multiple submission mechanisms for the quality
performance category, beginning with performance periods occurring in
2018. However, virtual groups would be required to utilize the same
submission mechanism for the improvement activities and the advancing
care information performance categories.
For those MIPS eligible clinicians participating in a MIPS APM, who
are on an APM Participant List on at least one of the three snapshot
dates as finalized in the CY 2017 Quality Payment Program Final Rule
(81 FR 77444 through 77445), or for MIPS eligible clinicians
participating in a full TIN MIPS APM, who are on an APM Participant
List on at least one of the four snapshot dates as discussed in section
II.C.6.g.(2) of this proposed rule, the APM scoring standard applies.
We refer readers to Sec. 414.1370 and the CY 2017 Quality Payment
Program final rule (81 FR 77246), which describes how MIPS eligible
clinicians participating in APM entities submit data to MIPS in the
form and manner required, including separate approaches to the quality
and cost performance categories applicable to MIPS APMs. We are not
proposing any changes to how APM entities in MIPS APMs and their
participating MIPS eligible clinicians submit data to MIPS.
(2) Submission Deadlines
In the CY 2017 Quality Payment Program final rule (81 FR 77097), we
finalized submission deadlines by which all associated data for all
performance categories must be submitted for the submission mechanisms
described in this rule.
As specified at Sec. 414.1325(f)(1), the data submission deadline
for the qualified registry, QCDR, EHR, and attestation submission
mechanisms is March 31 following the close of the performance period.
The submission period will begin prior to January 2 following the close
of the performance period, if technically feasible. For example, for
performance periods occurring in 2018, the data submission period will
occur prior to January 2, 2019, if technically feasible, through March
31, 2019. If it is not technically feasible to allow the submission
period to begin prior to January 2 following the close of the
performance period, the submission period will occur from January 2
through March 31 following the close of the performance period. In any
case, the final deadline will remain March 31, 2019.
At Sec. 414.1325(f)(2), we specified that for the Medicare Part B
claims submission mechanism, data must be submitted on claims with
dates of service during the performance period that must be processed
no later than 60 days following the close of the performance period.
Lastly, for the CMS Web Interface submission mechanism, at Sec.
414.1325(f)(3), we specified that the data must be submitted during an
8-week period following the close of the performance period that will
begin no earlier than January 2, and end no later than March 31. For
example, the CMS Web Interface submission period could span an 8-week
timeframe beginning January 16 and ending March 13. The specific
deadline during this timeframe will be published on the CMS Web site.
We are not proposing any changes to the submission deadlines in this
proposed rule.
b. Quality Performance Criteria
(1) Background
Sections 1848(q)(1)(A)(i) and (ii) of the Act require the Secretary
to develop a methodology for assessing the total performance of each
MIPS eligible clinician according to performance standards and, using
that methodology, to provide for a final score for each MIPS eligible
clinician. Section 1848(q)(2)(A)(i) of the Act requires us to use the
quality performance category in determining each MIPS eligible
clinician's final score, and section 1848(q)(2)(B)(i) of the Act
describes the measures and activities that must be specified under the
quality performance category.
The statute does not specify the number of quality measures on
which a MIPS eligible clinician must report, nor does it specify the
amount or type of information that a MIPS eligible clinician must
report on each quality measure. However, section 1848(q)(2)(C)(i) of
the Act requires the Secretary, as feasible, to emphasize the
application of outcomes-based measures.
Sections 1848(q)(1)(E) of the Act requires the Secretary to
encourage the use of QCDRs, and section 1848(q)(5)(B)(ii)(I) of the Act
requires the Secretary to encourage the use of CEHRT and QCDRs for
reporting measures under the quality performance category under the
final score methodology, but the statute does not limit the Secretary's
discretion to establish other reporting mechanisms.
Section 1848(q)(2)(C)(iv) of the Act generally requires the
Secretary to give consideration to the circumstances of non-patient
facing MIPS eligible clinicians and allows the Secretary, to the extent
feasible and appropriate, to apply alternative measures or activities
to such clinicians.
As discussed in the CY 2017 Quality Payment Program final rule (81
FR 77098 through 77099), we finalized MIPS quality criteria that focus
on measures that are important to beneficiaries and maintain some of
the
[[Page 30037]]
flexibility from PQRS, while addressing several of the comments we
received in response to the CY 2017 Quality Payment Program proposed
rule and the MIPS and APMs RFI.
To encourage meaningful measurement, we finalized allowing
individual MIPS eligible clinicians and groups the flexibility to
determine the most meaningful measures and data submission mechanisms
for their practice.
To simplify the reporting criteria, we aligned the
submission criteria for several of the data submission mechanisms.
To reduce administrative burden and focus on measures that
matter, we lowered the required number of the measures for several of
the data submission mechanisms, yet still required that certain types
of measures, particularly outcome measures, be reported.
To create alignment with other payers and reduce burden on
MIPS eligible clinicians, we incorporated measures that align with
other national payers.
To create a more comprehensive picture of a practice's
performance, we also finalized the use of all-payer data where
possible.
As beneficiary health is always our top priority, we finalized
criteria to continue encouraging the reporting of certain measures such
as outcome, appropriate use, patient safety, efficiency, care
coordination, or patient experience measures. However, as discussed in
the CY 2017 Quality Payment Program final rule (81 FR 77098), we
removed the requirement for measures to span across multiple domains of
the NQS. We continue to believe the NQS domains are extremely
important, and we encourage MIPS eligible clinicians to continue to
strive to provide care that focuses on: Effective clinical care,
communication and care coordination, efficiency and cost reduction,
person and caregiver-centered experience and outcomes, community and
population health, and patient safety. While we do not require that
MIPS eligible clinicians select measures across multiple domains, we
encourage them to do so. In addition, we believe the MIPS program
overall, with the focus on the quality, cost, improvement activities,
and advancing care information performance categories, will naturally
cover many elements in the NQS.
(2) Contribution to Final Score
For MIPS payment year 2019, the quality performance category will
account for 60 percent of the final score, subject to the Secretary's
authority to assign different scoring weights under section
1848(q)(5)(F) of the Act. Section 1848(q)(2)(E)(i)(I)(aa) of the Act
states that the quality performance category will account for 30
percent of the final score for MIPS. However, section
1848(q)(2)(E)(i)(I)(bb) of the Act stipulates that for the first and
second years for which MIPS applies to payments, the percentage of the
final score applicable for the quality performance category will be
increased so that the total percentage points of the increase equals
the total number of percentage points by which the percentage applied
for the cost performance category is less than 30 percent. Section
1848(q)(2)(E)(i)(II)(bb) of the Act requires that, for the transition
year for which MIPS applies to payments, not more than 10 percent of
the final score shall be based on the cost performance category.
Furthermore, section 1848(q)(2)(E)(i)(II)(bb) of the Act states that,
for the second year for which MIPS applies to payments, not more than
15 percent of the final score shall be based on the cost performance
category.
In the CY 2017 Quality Payment Program final rule (81 FR 77100), we
finalized at Sec. 414.1330(b) that, for MIPS payment years 2019 and
2020, 60 percent and 50 percent, respectively, of the MIPS final score
will be based on the quality performance category. For the third and
future years, 30 percent of the MIPS final score will be based on the
quality performance category.
As discussed in section II.C.6.d. of this proposed rule, we are
proposing to weight the cost performance category at zero percent for
the second MIPS payment year (2020). In accordance with section
1848(q)(5)(E)(i)(I)(bb) of the Act, for the first 2 years, the
percentage of the MIPS final score that would otherwise be based on the
quality performance category (that is, 30 percent) must be increased by
the same number of percentage points by which the percentage based on
the cost performance category is less than 30 percent. Therefore, if
our proposal to reweight the cost performance category for MIPS payment
year 2020 is finalized, we would need to inversely reweight the quality
performance category for the same year. Accordingly, we are proposing
to modify Sec. 414.1330(b)(2) to reweight the percentage of the MIPS
final score based on the quality performance category for MIPS payment
year 2020 as may be necessary to account for any reweighting of the
cost performance category, if finalized. For example, if our proposal
to reweight the cost performance category to zero percent for MIPS
payment year 2020 is finalized, then we would modify Sec.
414.1330(b)(2) to provide that performance in the quality performance
category will comprise 60 percent of a MIPS eligible clinician's final
score for MIPS payment year 2020. We refer readers to section II.C.6.d.
for more information on the cost performance category.
As also discussed in section II.C.6.d. of this proposed rule, we
note that by reweighting the cost performance category to zero percent
in performance period 2018, there will be a sharp increase in the cost
performance category to a 30 percent weight in performance period 2019.
In order to assist MIPS eligible clinicians and groups in obtaining
additional comfort with measurement based on the cost performance
category, we considered maintaining our previously-finalized cost
performance category weight of 10 percent for the 2018 performance
period. However, in our discussions with some MIPS eligible clinicians
and clinician societies, eligible clinicians expressed their desire to
down-weight the cost performance category to zero percent for an
additional year with full knowledge that the cost performance category
weight is set at 30 percent under the statute for the 2021 MIPS payment
year. The clinicians we spoke with preferred our proposed approach and
noted that they are actively preparing for full cost performance
category implementation and would be prepared for the 30 percent
statutory weight for the cost performance category for the 2021 MIPS
payment year.
We intend to provide an initial opportunity for clinicians to
review their performance based on the new episode-based measures at
some point in the fall of 2017, as the measures are developed and as
the information is available. We note that this feedback will be
specific to the new episode-based measures that are developed under the
process described above and may be presented in a different format than
MIPS eligible clinicians' performance feedback as described in section
II.C.9.a. of this proposed rule. However, our intention is to align the
feedback as much as possible to ensure clinicians receive opportunities
to review their performance on potential new episode-based measures for
the cost performance category prior to the proposed 2019 MIPS
performance period. We are unable to offer a list of new episode-based
measures on which we will provide feedback because that will be
determined in our ongoing development work described above. We are
concerned that continuing to
[[Page 30038]]
provide feedback on the older episode-based measures along with
feedback on new episode-based measures will be confusing and a poor use
of resources. Because we are focusing on development of new episode-
based measures, our feedback on episode-based measures that were
previously developed will discontinue after 2017 as these measures
would no longer be maintained or reflect changes in diagnostic and
procedural coding. As described in section II.C.9.a. of this proposed
rule, we intend to provide feedback on these new measures as they
become available in a new format around summer 2018, in addition to the
fall 2017 feedback discussed previously. We note that the feedback
provided in the summer of 2018 will go to those MIPS eligible
clinicians for whom we are able to calculate the episode-based
measures, which means it would be possible that a clinical may not
receive feedback on episode-based measures in both the fall of 2017 and
the summer of 2018. We believe that receiving feedback on the new
episode-based measures, along with the previously-finalized total per
capita cost and MSPB measures, will support clinicians in their
readiness for the proposed 2019 MIPS performance period.
Section 1848(q)(5)(B)(i) of the Act requires the Secretary to treat
any MIPS eligible clinician who fails to report on a required measure
or activity as achieving the lowest potential score applicable to the
measure or activity. Specifically, under our finalized scoring
policies, an individual MIPS eligible clinician or group that reports
on all required measures and activities could potentially obtain the
highest score possible within the performance category, assuming they
perform well on the measures and activities they report. An individual
MIPS eligible clinician or group who does not submit data on a required
measure or activity would receive a zero score for the unreported items
in the performance category (in accordance with section
1848(q)(5)(B)(i) of the Act). The individual MIPS eligible clinician or
group could still obtain a relatively good score by performing very
well on the remaining items, but a zero score would prevent the
individual MIPS eligible clinician or group from obtaining the highest
possible score within the performance category.
(3) Quality Data Submission Criteria
(a) Submission Criteria
(i) Submission Criteria for Quality Measures Excluding Groups Reporting
via the CMS Web Interface and the CAHPS for MIPS Survey
In the CY 2017 Quality Payment Program final rule (81 FR 77114), we
finalized at Sec. 414.1335(a)(1) that individual MIPS eligible
clinicians submitting data via claims and individual MIPS eligible
clinicians and groups submitting data via all mechanisms (excluding the
CMS Web Interface and the CAHPS for MIPS survey) are required to meet
the following submission criteria. For the applicable period during the
performance period, the individual MIPS eligible clinician or group
will report at least six measures, including at least one outcome
measure. If an applicable outcome measure is not available, the
individual MIPS eligible clinician or group will be required to report
one other high priority measure (appropriate use, patient safety,
efficiency, patient experience, and care coordination measures) in lieu
of an outcome measure. If fewer than six measures apply to the
individual MIPS eligible clinician or group, then the individual MIPS
eligible clinician or group would be required to report on each measure
that is applicable. We defined ``applicable'' to mean measures relevant
to a particular MIPS eligible clinician's services or care rendered. As
discussed in section II.C.7.a.(2)(e)., we will only make determinations
as to whether a sufficient number of measures are applicable for
claims-based and registry submission mechanisms; we will not make this
determination for EHR and QCDR submission mechanisms, for example.
Alternatively, the individual MIPS eligible clinician or group will
report one specialty measure set, or the measure set defined at the
subspecialty level, if applicable. If the measure set contains fewer
than six measures, MIPS eligible clinicians will be required to report
all available measures within the set. If the measure set contains six
or more measures, MIPS eligible clinicians will be required to report
at least six measures within the set. Regardless of the number of
measures that are contained in the measure set, MIPS eligible
clinicians reporting on a measure set will be required to report at
least one outcome measure or, if no outcome measures are available in
the measure set, the MIPS eligible clinician will report another high
priority measure (appropriate use, patient safety, efficiency, patient
experience, and care coordination measures) within the measure set in
lieu of an outcome measure. MIPS eligible clinicians may choose to
report measures in addition to those contained in the specialty measure
set and will not be penalized for doing so, provided that such MIPS
eligible clinicians follow all requirements discussed here.
In accordance with Sec. 414.1335(a)(1)(ii), individual MIPS
eligible clinicians and groups will select their measures from either
the set of all MIPS measures listed or referenced in Table A of the
Appendix in this proposed rule or one of the specialty measure sets
listed in Table B of the Appendix in this proposed rule. We note that
some specialty measure sets include measures grouped by subspecialty;
in these cases, the measure set is defined at the subspecialty level.
Previously finalized quality measures may be found in the CY 2017
Quality Payment Program final rule (81 FR 77558 through 77816).
We also finalized the definition of a high priority measure at
Sec. 414.1305 to mean an outcome, appropriate use, patient safety,
efficiency, patient experience, or care coordination quality measure.
Except as discussed in section II.C.6.b.(3)(a) of this proposed rule
with regard to the CMS Web Interface and the CAHPS for MIPS survey, we
are not proposing any changes to the submission criteria or definitions
established for measures in this proposed rule.
In the CY 2017 Quality Payment Program final rule (81 FR 77114), we
solicited comments regarding adding a requirement to our finalized
policy that patient-facing MIPS eligible clinicians would be required
to report at least one cross-cutting measure in addition to the high
priority measure requirement for further consideration for the Quality
Payment Program Year 2 and future years. For clarification, we consider
a cross-cutting measure to be any measure that is broadly applicable
across multiple clinical settings and individual MIPS eligible
clinicians or groups within a variety of specialties. We specifically
requested feedback on how we could construct a cross-cutting measure
requirement that would be most meaningful to MIPS eligible clinicians
from different specialties and that would have the greatest impact on
improving the health of populations. We received conflicting feedback
on adding a future requirement for MIPS eligible clinicians to report
at least one cross-cutting measure in the Quality Payment Program Year
2 and future years.
[[Page 30039]]
Many commenters agreed that cross-cutting measures are applicable
across multiple clinical settings and that MIPS eligible clinicians
within a variety of specialties should report at least one cross-
cutting measure. Some stated that cross-cutting measures promote shared
accountability and improve the health of populations. Others
recommended we continue to work with stakeholders and specialists,
including solo and small practices, to develop cross-cutting measures
for all settings, whether they be patient-facing or non-patient facing
practices that are patient-centric (that is, following the patient and
not the site of care) and recommended the term ``patient-centered
measures'' rather than ``cross-cutting measures.'' In addition, some
commenters stated we should consider measures that are
multidisciplinary, foster cross-collaboration within virtual groups,
improve patient outcomes, target high-cost areas, target areas with
gaps in care, and include individual patient preferences in shared
decision-making. A few commenters provided specific measures that they
recommended utilizing as cross-cutting measures, such as: Screening for
Hepatitis C; Controlling High Blood Pressure; Tobacco Use Cessation
Counseling and Treatment; Advance Care Planning; or Medication
Reconciliation. One commenter recommended we utilize shared
accountability measures around surgical goals of care, shared decision
making relying on some form of risk estimation such as a risk
calculator, medication reconciliation, and a shared plan of care across
clinicians. Another commenter suggested that instead of having a cross-
cutting measure requirement, we could use health IT as a cross-cutting
requirement. Specifically, the commenter noted we could require that at
least one measure using end-to-end electronic reporting, or that at
least one measure be tied to an improvement activity the clinician is
performing. Other commenters suggested that we provide bonus points to
practices that elect to submit data on cross-cutting measures and hold
harmless from any future cross-cutting measure requirements MIPS
eligible clinicians who have less than 15 instances in the measure
denominator during the performance period, allow MIPS eligible
clinicians to use high-priority measures in the place of a cross-
cutting measure if necessary, and apply the guiding principles listed
in NQF's ``Attribution: Principles and Approaches'' final report which
may be found at http://www.qualityforum.org/ProjectDescription.aspx?projectID=80808.
Other commenters appreciated our decision not to finalize the
requirement to report a cross-cutting measure in the transition year
and requested that we not require cross-cutting measures in the future,
as they believed it is administratively burdensome for clinicians and
QCDRs and removes focus and resources from quality measures that are
more relevant to MIPS eligible clinicians' scope of practice and
important to their patients' treatment and outcomes. They stated that
PQRS demonstrated the challenge of identifying cross-cutting measures
that are truly meaningful across different specialties and that truly
have an impact on improving the health of populations. Some stated we
should focus on high-priority measures over cross-cutting measures. A
few commenters did not agree that cross-cutting measures were relevant
and stated they should not be a requirement in MIPS until all MIPS
eligible clinicians can successfully meet the current requirements.
Others did not agree that QCDRs should be required to submit cross-
cutting measures because they believed that Congress did not intend for
QCDRs to submit clinical process measures, that implementation may be
complicated by practices that upgrade their health IT, and vendors have
indicated it would take 12 to 18 months to implement system changes to
support capture of cross-cutting measures. They also questioned the
value of investing additional time and resources in this effort,
especially if these cross-cutting measures are ultimately found to be
topped out or removed. Others believed we should delay implementation
until the Quality Payment Program Year 3 in order to allow MIPS
eligible clinicians to focus on implementing new CEHRT requirements and
modifying their processes to address lessons learned from reporting in
the first 2 years.
Except as discussed in section II.C.6.b.(3)(a)(iii). of this
proposed rule with regard to the CAHPS for MIPS survey, we are not
proposing any changes to the submission criteria for quality measures
in this proposed rule. We thank the commenters for their feedback and
will take the comments into consideration in future rulemaking. We
welcome additional feedback on meaningful ways to incorporate cross-
cutting measurement into MIPS and the Quality Payment Program
generally.
(ii) Submission Criteria for Quality Measures for Groups Reporting via
the CMS Web Interface
In the CY 2017 Quality Payment Program final rule (81 FR 77116), we
finalized at Sec. 414.1335(a)(2) the following criteria for the
submission of data on quality measures by registered groups of 25 or
more eligible clinicians who want to report via the CMS Web Interface.
For the applicable 12-month performance period, the group would be
required to report on all measures included in the CMS Web Interface
completely, accurately, and timely by populating data fields for the
first 248 consecutively ranked and assigned Medicare beneficiaries in
the order in which they appear in the group's sample for each module or
measure. If the sample of eligible assigned beneficiaries is less than
248, then the group would report on 100 percent of assigned
beneficiaries. A group would be required to report on at least one
measure for which there is Medicare patient data. Groups reporting via
the CMS Web Interface are required to report on all of the measures in
the set. Any measures not reported would be considered zero performance
for that measure in our scoring algorithm. In addition, we are
proposing to clarify that these criteria apply to groups of 25 or more
eligible clinicians. Specifically, we propose to revise Sec.
414.1335(a)(2)(i) to provide criteria applicable to groups of 25 or
more eligible clinicians, report on all measures included in the CMS
Web Interface. The group must report on the first 248 consecutively
ranked beneficiaries in the sample for each measure or module.
In the CY 2017 Quality Payment Program final rule (81 FR 77116), we
finalized to continue to align the 2019 CMS Web Interface beneficiary
assignment methodology with the attribution methodology for two of the
measures that were formerly in the VM: The population quality measure
discussed in the CY 2017 Quality Payment Program proposed rule (81 FR
28188) and total per capita cost for all attributed beneficiaries
discussed in the CY 2017 Quality Payment Program proposed rule (81 FR
28196). When establishing MIPS, we also finalized a modified
attribution process to update the definition of primary care services
and to adapt the attribution to different identifiers used in MIPS.
These changes are discussed in the CY 2017 Quality Payment Program
proposed rule (81 FR 28196). We note that groups reporting via the CMS
Web Interface may also report the CAHPS for MIPS survey and receive
bonus points for submitting that
[[Page 30040]]
measure. We are not proposing any changes to the submission criteria
for quality measures for groups reporting via the CMS Web Interface in
this proposed rule.
(iii) Performance Criteria for Quality Measures for Groups Electing To
Report Consumer Assessment of Healthcare Providers and Systems (CAHPS)
for MIPS Survey
In the CY 2017 Quality Payment Program final rule (81 FR 77100), we
finalized at Sec. 414.1335(a)(3) the following criteria for the
submission of data on the CAHPS for MIPS survey by registered groups
via CMS-approved survey vendor: For the applicable 12-month performance
period, a group that wishes to voluntarily elect to participate in the
CAHPS for MIPS survey measure must use a survey vendor that is approved
by CMS for a particular performance period to transmit survey measures
data to CMS. The CAHPS for MIPS survey counts for one measure towards
the MIPS quality performance category and, as a patient experience
measure, also fulfills the requirement to report at least one high
priority measure in the absence of an applicable outcome measure. In
addition, groups that elect this data submission mechanism must select
an additional group data submission mechanism (that is, qualified
registries, QCDRs, EHR, etc.) in order to meet the data submission
criteria for the MIPS quality performance category. The CAHPS for MIPS
survey will count as one patient experience measure, and the group will
be required to submit at least five other measures through one other
data submission mechanism. A group may report any five measures within
MIPS plus the CAHPS for MIPS survey to achieve the six measures
threshold. We are not proposing any changes to the performance criteria
for quality measures for groups electing to report the CAHPS for MIPS
survey in this proposed rule.
In the CY 2017 Quality Payment Program final rule (see 81 FR
77120), we finalized retaining the CAHPS for MIPS survey administration
period that was utilized for PQRS of November to February. However,
this survey administration period has become operationally problematic
for the administration of MIPS. In order to compute scoring, we must
have the CAHPS for MIPS survey data earlier than the current survey
administration period deadline allows. Therefore, we are proposing for
the Quality Payment Program Year 2 and future years that the survey
administration period would, at a minimum, span over 8 weeks and would
end no later than February 28th following the applicable performance
period. In addition, we propose to further specify the start and end
timeframes of the survey administration period through our normal
communication channels.
In addition, as discussed in the CY 2017 Quality Payment Program
final rule (81 FR 77116), we anticipated exploring the possibility of
updating the CAHPS for MIPS survey under MIPS, specifically not
finalizing all of the proposed Summary Survey Measures (SSMs). The
CAHPS for MIPS survey currently consists of the core CAHPS Clinician &
Group (CG-CAHPS) Survey developed by the Agency for Healthcare Research
and Quality (AHRQ), plus additional survey questions to meet CMS's
program needs. We are proposing for the Quality Payment Program Year 2
and future years to remove two SSMs, specifically, ``Helping You to
Take Medication as Directed'' and ``Between Visit Communication'' from
the CAHPS for MIPS survey. We are proposing to remove the SSM entitled
``Helping You to Take Medication as Directed'' due to low reliability.
In 2014 and 2015, the majority of groups had very low reliability on
this SSM. Furthermore, based on analyses conducted of SSMs in an
attempt to improve their reliability, removing questions from this SSM
did not result in any improvements in reliability. The SSM, ``Helping
You to Take Medication as Directed,'' has also never been a scored
measure with the Medicare Shared Savings Program CAHPS for Accountable
Care Organizations (ACOs) Survey. We refer readers to the CY 2014
Physician Fee Schedule final rule for a discussion on the CAHPS for ACO
survey scoring (79 FR 67909 through 67910) and measure tables (79 FR
67916 through 67917). The SSM entitled ``Between Visit Communication''
currently contains only one question. This question could also be
considered related to other SSMs entitled: ``Care Coordination'' or
``Courteous and Helpful Office Staff,'' but does not directly overlap
with any of the questions under that SSM. However, we are proposing to
remove this SSM in order to maintain consistency with the Medicare
Shared Savings Program which, utilizes the CAHPS for Accountable Care
Organizations (ACOs) Survey. The SSM entitled ``Between Visit
Communication'' has never been a scored measure with the Medicare
Shared Savings Program CAHPS for ACOs Survey.
In addition to public comments we receive, we will also take into
consideration analysis we will be conducting before finalizing this
proposal. Specifically, we will review the findings of the CAHPS for
ACO survey pilot, which was administered from November 2016 through
February 2017. The CAHPS for ACO survey pilot utilized a survey
instrument which did not contain the two SSMs we are proposing for
removal from the CAHPS for MIPS survey. For more information on the
other SSMs within the CAHPS for MIPS survey, please see the explanation
of the CAHPS for PQRS survey in the CY 2016 PFS final rule with comment
period (80 FR 71142 through 71143).
Table 4--Proposed Summary Survey Measures (SSMs) Included in the CAHPS
for MIPS Survey
------------------------------------------------------------------------
Summary survey measures (SSMs)
-------------------------------------------------------------------------
Getting Timely Care, Appointments, and Information.
How Well Providers Communicate.
Patient's Rating of Provider.
Access to Specialists.
Health Promotion and Education.
Shared Decision-Making.
Health Status and Functional Status.
Courteous and Helpful Office Staff.
Care Coordination.
Stewardship of Patient Resources.
------------------------------------------------------------------------
We are seeking comment on expanding the patient experience data
available for the CAHPS for MIPS survey. Currently, the CAHPS for MIPS
survey is available for groups to report under the MIPS. The patient
experience survey data that is available on Physician Compare is highly
valued by patients and their caregivers as they evaluate their health
care options. However, in user testing with patients and caregivers in
regard to the Physician Compare Web site, the users regularly ask for
more information from patients like them in their own words. Patients
regularly request that we include narrative reviews of individual
clinicians and groups on the Web site. AHRQ is fielding a beta version
of the CAHPS Patient Narrative Elicitation Protocol (https://www.ahrq.gov/cahps/surveys-guidance/item-sets/elicitation/index.html).
This includes five open-ended questions designed to be added to the CG
CAHPS survey, after which the CAHPS for MIPS survey is modeled. These
five questions have been developed and tested in order to capture
patient narratives in a scientifically grounded and rigorous way,
setting it apart from other patient narratives collected by various
health systems and patient rating sites. More scientifically rigorous
patient narrative data would not only greatly benefit patients in their
[[Page 30041]]
decision for healthcare, but it would also greatly aid individual MIPS
eligible clinicians and groups as they assess how their patients
experience care. We are seeking comment on adding these five open-ended
questions to the CAHPS for MIPS survey in future rulemaking. Beta
testing is an ongoing process, and we anticipate reviewing the results
of that testing in collaboration with AHRQ before proposing changes to
the CAHPS for MIPS survey.
We are requiring, where possible, all-payer data for all reporting
mechanisms, yet certain reporting mechanisms are limited to Medicare
Part B data. Specifically, the CAHPS for MIPS survey currently relies
on sampling protocols based on Medicare Part B billing; therefore, only
Medicare Part B beneficiaries are sampled through that methodology. In
the CY 2017 Quality Payment Program proposed rule (81 FR 28189), we
requested comments on ways to modify the methodology to assign and
sample patients for these mechanisms using data from other payers. We
received mixed feedback on the use of all-payer data overall. The full
discussion of the comments and the responses can be found in the CY
2017 Quality Payment Program final rule (81 FR 77123 through 77125). We
are requesting additional comments on ways to modify the methodology to
assign and sample patients using data from other payers for reporting
mechanisms that are currently limited to Medicare Part B data. In
particular, we are seeking comment on the ability of groups to provide
information on the patients to whom they provide care during a calendar
year, whether it would be possible to identify a list of patients seen
by individual clinicians in the group, and what type of patient contact
information groups would be able to provide. Further, we would like to
seek comment on the challenges groups may anticipate in trying to
provide this type of information, especially for vulnerable beneficiary
populations, such as those lacking stable housing. We are also seeking
comment on EHR vendors' ability to provide information on the patients
who receive care from their client groups.
(b) Data Completeness Criteria
In the CY 2017 Quality Payment Program final rule (81 FR 77125), we
finalized data completeness criteria for the transition year and MIPS
payment year 2020. We finalized at Sec. 414.1340 the data completeness
criteria below for performance periods occurring in 2017.
Individual MIPS eligible clinicians or groups submitting
data on quality measures using QCDRs, qualified registries, or via EHR
must report on at least 50 percent of the individual MIPS eligible
clinician or group's patients that meet the measure's denominator
criteria, regardless of payer for the performance period. In other
words, for these submission mechanisms, we expect to receive quality
data for both Medicare and non-Medicare patients. For the transition
year, MIPS eligible clinicians whose measures fall below the data
completeness threshold of 50 percent would receive 3 points for
submitting the measure.
Individual MIPS eligible clinicians submitting data on
quality measures data using Medicare Part B claims, would report on at
least 50 percent of the Medicare Part B patients seen during the
performance period to which the measure applies. For the transition
year, MIPS eligible clinicians whose measures fall below the data
completeness threshold of 50 percent would receive 3 points for
submitting the measure.
Groups submitting quality measures data using the CMS Web
Interface or a CMS-approved survey vendor to report the CAHPS for MIPS
survey must meet the data submission requirements on the sample of the
Medicare Part B patients CMS provides.
In addition, we finalized an increased data completeness threshold
of 60 percent for MIPS for performance periods occurring in 2018 for
data submitted on quality measures using QCDRs, qualified registries,
via EHR, or Medicare Part B claims. We noted that these thresholds for
data submitted on quality measures using QCDRs, qualified registries,
via EHR, or Medicare Part B claims would increase for performance
periods occurring in 2019 and onward.
We are proposing to modify the previously established data
completeness criteria for MIPS payment year 2020. Specifically, we
would like to provide an additional year for individual MIPS eligible
clinicians and groups to gain experience with MIPS before increasing
the data completeness thresholds for data submitted on quality measures
using QCDRs, qualified registries, via EHR, or Medicare Part B claims.
We are concerned about the unintended consequences of accelerating the
data completeness threshold so quickly, which may jeopardize MIPS
eligible clinicians' ability to participate and perform well under the
MIPS, particularly those clinicians who are least experienced with MIPS
quality measure data submission. We want to ensure that an appropriate
yet achievable level of data completeness is applied to all MIPS
eligible clinicians. We continue to believe it is important to
incorporate higher data completeness thresholds in future years to
ensure a more accurate assessment of a MIPS eligible clinician's
performance on quality measures and to avoid any selection bias.
Therefore, we propose, below, a 60 percent data completeness threshold
for MIPS payment year 2021. We strongly encourage all MIPS eligible
clinicians to perform the quality actions associated with the quality
measures on their patients. The data submitted for each measure is
expected to be representative of the individual MIPS eligible
clinician's or group's overall performance for that measure. The data
completeness threshold of less than 100 percent is intended to reduce
burden and accommodate operational issues that may arise during data
collection during the initial years of the program. We are providing
this notice to MIPS eligible clinicians so that they can take the
necessary steps to prepare for higher data completeness thresholds in
future years.
Therefore, we propose to revise the data completeness criteria for
the quality performance category at Sec. 414.1340(a)(2) to provide
that MIPS eligible clinicians and groups submitting quality measures
data using the QCDR, qualified registry, or EHR submission mechanism
must submit data on at least 50 percent of the individual MIPS eligible
clinician's or group's patients that meet the measure's denominator
criteria, regardless of payer, for MIPS payment year 2020. We also
propose to revise the data completeness criteria for the quality
performance category at Sec. 414.1340(b)(2) to provide that MIPS
eligible clinicians and groups submitting quality measures data using
Medicare Part B claims, must submit data on at least 50 percent of the
applicable Medicare Part B patients seen during the performance period
to which the measure applies for MIPS payment year 2020. We further
propose at Sec. 414.1340(a)(3), that MIPS eligible clinicians and
groups submitting quality measures data using the QCDR, qualified
registry, or EHR submission mechanism must submit data on at least 60
percent of the individual MIPS eligible clinician or group's patients
that meet the measure's denominator criteria, regardless of payer for
MIPS payment year 2021. We also propose at Sec. 414.1340(b)(3), that
MIPS eligible clinicians and groups submitting quality measures data
using Medicare Part B claims, must submit data on at least 60 percent
of the applicable Medicare Part
[[Page 30042]]
B patients seen during the performance period to which the measure
applies for MIPS payment year 2021. We would like to note that we
anticipate for future MIPS payment years we will propose to increase
the data completeness threshold for data submitted using QCDRs,
qualified registries, EHR submission mechanisms, or Medicare Part B
claims. As MIPS eligible clinicians gain experience with the MIPS, we
would propose to steadily increase these thresholds for future years
through rulemaking. In addition, we are seeking comment on what data
completeness threshold should be established for future years.
In the CY 2017 Quality Payment Program final rule (81 FR 77125
through 77126), we finalized our approach of including all-payer data
for the QCDR, qualified registry, and EHR submission mechanisms because
we believed this approach provides a more complete picture of each MIPS
eligible clinician's scope of practice and provides more access to data
about specialties and subspecialties not currently captured in PQRS. In
addition, those clinicians who utilize a QCDR, qualified registry, or
EHR submission must contain a minimum of one quality measure for at
least one Medicare patient. We are not proposing any changes to these
policies in this proposed rule. As noted in the CY 2017 Quality Payment
Program final rule, those MIPS eligible clinicians who fall below the
data completeness thresholds will receive 3 points for the specific
measures that fall below the data completeness threshold in the
transition year of MIPS only. For the Quality Payment Program Year 2,
we are proposing that MIPS eligible clinicians would receive 1 point
for measures that fall below the data completeness threshold, with an
exception for small practices of 15 or fewer who would still receive 3
points for measures that fail data completeness. We refer readers to
section II.C.6.b.(3)(b) of this proposed rule for our proposed policies
on instances when MIPS eligible clinicians' measures fall below the
data completeness threshold.
(c) Summary of Data Submission Criteria
Table 5 reflects our proposed quality data submission criteria for
MIPS payment year 2020 via Medicare Part B claims, QCDR, qualified
registry, EHR, CMS Web Interface, and the CAHPS for MIPS survey. It is
important to note that while we finalized at Sec. 414.1325(d) in the
CY 2017 Quality Payment Program final rule that individual MIPS
eligible clinicians and groups may only use one submission mechanism
per performance category, in section II.C.6.a.(1) of this rule, we are
proposing to revise Sec. 414.1325(d) for purposes of the 2020 MIPS
payment year and future years to allow individual MIPS eligible
clinicians and groups to submit measures and activities, as applicable,
via as many submission mechanisms as necessary to meet the requirements
of the quality, improvement activities, or advancing care information
performance categories. We refer readers to section II.C.6.a.(1) of
this proposed rule for further discussion of this proposal.
Table 5--Summary of Proposed Quality Data Submission Criteria for MIPS Payment Year 2020 via Part B Claims,
QCDR, Qualified Registry, EHR, CMS Web Interface, and the CAHPS for MIPS Survey
----------------------------------------------------------------------------------------------------------------
Submission Submission
Performance period Clinician type mechanism criteria Data completeness
----------------------------------------------------------------------------------------------------------------
Jan 1-Dec 31.................... Individual MIPS Part B Claims..... Report at least 50 percent of
eligible six measures individual MIPS
clinicians. including one eligible
outcome measure, clinician's
or if an outcome Medicare Part B
measure is not patients for the
available report performance
another high period.
priority measure;
if less than six
measures apply
then report on
each measure that
is applicable.
Individual MIPS
eligible
clinicians would
have to select
their measures
from either the
set of all MIPS
measures listed
or referenced in
Table A or one of
the specialty
measure sets
listed in Table B
of the Appendix
in this proposed
rule.
Jan 1-Dec 31.................... Individual MIPS QCDR, Qualified Report at least 50 percent of
eligible Registry, & EHR. six measures individual MIPS
clinicians, including one eligible
groups or virtual outcome measure, clinician's,
groups. or if an outcome group's, or
measure is not virtual group's
available report patients across
another high all payers for
priority measure; the performance
if less than six period.
measures apply
then report on
each measure that
is applicable.
Individual MIPS
eligible
clinicians,
groups, or
virtual groups
would have to
select their
measures from
either the set of
all MIPS measures
listed or
referenced in
Table A or one of
the specialty
measure sets
listed in Table B
of the Appendix
in this proposed
rule.
Jan 1-Dec 31.................... Groups or virtual CMS Web Interface. Report on all Sampling
groups. measures included requirements for
in the CMS Web the group's or
Interface; AND virtual group's
populate data Medicare Part B
fields for the patients.
first 248
consecutively
ranked and
assigned Medicare
beneficiaries in
the order in
which they appear
in the group's or
virtual group's
sample for each
module/measure.
If the pool of
eligible assigned
beneficiaries is
less than 248,
then the group or
virtual group
would report on
100 percent of
assigned
beneficiaries.
[[Page 30043]]
Jan 1-Dec 31.................... Groups or virtual CAHPS for MIPS CMS-approved Sampling
groups. Survey. survey vendor requirements for
would need to be the group's or
paired with virtual group's
another reporting Medicare Part B
mechanism to patients.
ensure the
minimum number of
measures is
reported. CAHPS
for MIPS survey
would fulfill the
requirement for
one patient
experience
measure towards
the MIPS quality
data submission
criteria. CAHPS
for MIPS survey
would only count
for one measure
under the quality
performance
category.
----------------------------------------------------------------------------------------------------------------
As discussed in section II.C.4.d. of this proposed rule, we are
proposing to generally apply our previously finalized and proposed
group policies to virtual groups.
(4) Application of Quality Measures to Non-Patient Facing MIPS Eligible
Clinicians
In the CY 2017 Quality Payment Program final rule (81 FR 77127), we
finalized at Sec. 414.1335 that non-patient facing MIPS eligible
clinicians would be required to meet the applicable submission criteria
that apply for all MIPS eligible clinicians for the quality performance
category. We are not proposing any changes to this policy in this
proposed rule.
(5) Application of Facility-Based Measures
Section 1848(q)(2)(C)(ii) of the Act provides that the Secretary
may use measures used for payment systems other than for physicians,
such as measures used for inpatient hospitals, for purposes of the
quality and cost performance categories. However, the Secretary may not
use measures for hospital outpatient departments, except in the case of
items and services furnished by emergency physicians, radiologists, and
anesthesiologists. We refer readers to section II.C.7.a.(4) of this
proposed rule for a full discussion of our proposals regarding the
application of facility-based measures.
(6) Global and Population-Based Measures
In the CY 2017 Quality Payment Program final rule (81 FR 77136), we
did not finalize all of our proposals on global and population-based
measures as part of the quality score. Specifically, we did not
finalize our proposal to use the acute and chronic composite measures
of the AHRQ Prevention Quality Indicators (PQIs). We agreed with
commenters that additional enhancements, including the addition of risk
adjustment, needed to be made to these measures prior to inclusion in
MIPS. We did, however, calculate these measures at the TIN level,
through the QRURs released in September 2016, and this data can be used
by MIPS eligible clinicians for informational purposes.
We did finalize the all-cause hospital readmissions (ACR) measure
from the VM Program as part of the quality measure domain for the MIPS
total performance score. We finalized this measure with the following
modifications. We did not apply the ACR measure to solo practices or
small groups (groups of 15 or less). We did apply the ACR measure to
groups of 16 or more who meet the case volume of 200 cases. A group was
scored on the ACR measure even if it did not submit any quality
measures, if it submitted in other performance categories. Otherwise,
the group was not scored on the readmission measure if it did not
submit data in any of the performance categories. In our transition
year policies, the readmission measure alone would not produce a
neutral to positive MIPS payment adjustment since in order to achieve a
neutral to positive MIPS payment adjustment, an individual MIPS
eligible clinician or group must submit information on one of the three
performance categories as discussed in the CY 2017 Quality Payment
Program final rule (81 FR 77329). In addition, the ACR measure in the
MIPS transition year CY 2017 was based on the performance period
(January 1, 2017 through December 31, 2017). However, for MIPS eligible
clinicians who did not meet the minimum case requirements, the ACR
measure was not applicable. We are not proposing any changes for the
global and population-based measures in this proposed rule. As
discussed in section II.C.4.d. of this rule, we are proposing to
generally apply our previously finalized and proposed group policies to
virtual groups.
c. Selection of MIPS Quality Measures for Individual MIPS Eligible
Clinicians and Groups Under the Annual List of Quality Measures
Available for MIPS Assessment
(1) Background and Policies for the Call for Measures and Measure
Selection Process
Under section 1848(q)(2)(D)(i) of the Act, the Secretary, through
notice and comment rulemaking, must establish an annual list of MIPS
quality measures from which MIPS eligible clinicians may choose for
purposes of assessment for a performance period. The annual list of
MIPS quality measures must be published in the Federal Register no
later than November 1 of the year prior to the first day of a
performance period. Updates to the annual list of MIPS quality measures
must be published in the Federal Register no later than November 1 of
the year prior to the first day of each subsequent performance period.
Updates may include the addition of new MIPS quality measures,
substantive changes to MIPS quality measures, and removal of MIPS
quality measures. MIPS eligible clinicians reporting on the quality
performance category are required to use the most recent version of the
clinical quality measure (CQM) electronic specifications as indicated
in the CY 2017 Quality Payment Program final rule (81 FR 77291). For
purposes of the 2018 MIPS performance period, the spring 2017 version
of the eCQM annual update to the measure specifications and any
applicable addenda are available on the electronic clinical quality
improvement (eCQI) Resource Center Web site at https://ecqi.healthit.gov. The CMS Quality Measure Development Plan (MDP)
serves as a strategic framework for the future of the clinician quality
measure development to support MIPS and APMs. The MDP is available on
the CMS Web site and highlights known measurement gaps and recommends
[[Page 30044]]
approaches to close those gaps through development, use, and refinement
of quality measures that address significant variation in performance
gaps. We encourage stakeholders to develop additional quality measures
for MIPS that would address the gaps.
Under section 1848(q)(2)(D)(ii) of the Act, the Secretary must
solicit a ``Call for Quality Measures'' each year. Specifically, the
Secretary must request that eligible clinician organizations and other
relevant stakeholders identify and submit quality measures to be
considered for selection in the annual list of MIPS quality measures,
as well as updates to the measures. Under section 1848(q)(2)(D)(ii) of
the Act, eligible clinician organizations are professional
organizations as defined by nationally recognized specialty boards of
certification or equivalent certification boards. However, we do not
believe there needs to be any special restrictions on the type or make-
up of the organizations that submit measures for consideration through
the call for measures. Any such restriction would limit the type of
quality measures and the scope and utility of the quality measures that
may be considered for inclusion under the MIPS.
As we described previously in the CY 2017 Quality Payment Program
final rule (81 FR 77137), we will accept quality measures submissions
at any time, but only measures submitted during the timeframe provided
by us through the pre-rulemaking process of each year will be
considered for inclusion in the annual list of MIPS quality measures
for the performance period beginning 2 years after the measure is
submitted. This process is consistent with the pre-rulemaking process
and the annual call for measures, which are further described at
(https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Pre-Rule-Making.html).
Submission of potential quality measures, regardless of whether
they were previously published in a proposed rule or endorsed by an
entity with a contract under section 1890(a) of the Act, which is
currently the National Quality Forum, is encouraged. The annual Call
for Measures process allows eligible clinician organizations and other
relevant stakeholder organizations to identify and submit quality
measures for consideration. Presumably, stakeholders would not submit
measures for consideration unless they believe that the measure is
applicable to clinicians and can be reliably and validly measured at
the individual clinician level. The NQF-convened Measure Application
Partnership (MAP) provides an additional opportunity for stakeholders
to provide input on whether or not they believe the measures are
applicable to clinicians as well as feasible, scientifically
acceptable, and reliable and valid at the clinician level. Furthermore,
we must go through notice and comment rulemaking to establish the
annual list of quality measures, which gives stakeholders an additional
opportunity to review the measures and provide input on whether or not
they believe the measures are applicable to clinicians, as well as
feasible, scientifically acceptable, and reliable and valid at the
clinician level. Additionally, we are required by statute to submit new
measures to an applicable specialty-appropriate, peer-reviewed journal.
As previously noted, we encourage the submission of potential
quality measures regardless of whether such measures were previously
published in a proposed rule or endorsed by an entity with a contract
under section 1890(a) of the Act. However, we propose to request that
stakeholders apply the following considerations when submitting quality
measures for possible inclusion in MIPS:
Measures that are not duplicative of an existing or
proposed measure.
Measures that are beyond the measure concept phase of
development and have started testing, at a minimum, with strong
encouragement and preference for measures that complete or are near
completion of reliability and validity testing.
Measures that include a data submission method beyond
claims-based data submission.
Measures that are outcome-based rather than clinical
process measures.
Measures that address patient safety and adverse events.
Measures that identify appropriate use of diagnosis and
therapeutics.
Measures that address the domain for care coordination.
Measures that address the domain for patient and caregiver
experience.
Measures that address efficiency, cost, and resource use.
Measures that address significant variation in
performance.
We will apply these considerations when considering quality
measures for possible inclusion in MIPS.
In addition, we note that we are likely to reject measures that do
not provide substantial evidence of variation in performance; for
example, if a measure developer submits data showing a small variation
in performance among a group already composed of high performers, such
evidence would not be substantial enough to assure us that sufficient
variation in performance exists. We also note that we are likely to
reject measures that are not outcome-based measures, unless (1) there
is substantial documented and peer reviewed evidence that the clinical
process measured varies directly with the outcome of interest and (2)
it is not possible to measure the outcome of interest in a reasonable
timeframe.
We also note that retired measures that were in one of CMS's
previous quality programs, such as the Physician Quality Reporting
System (PQRS) program, will likely be rejected if proposed for
inclusion. This includes measures that were retired due to being topped
out, as defined below. For example, measures may be retired due to
attaining topped out status because of high performance, or measures
that are retired due to a change in the evidence supporting their use.
In the CY 2017 Quality Payment Program final rule (81 FR 77153), we
established that we will categorize measures into the six NQS domains
(patient safety, person- and caregiver-centered experience and
outcomes, communication and care coordination, effective clinical care,
community/population health, and efficiency and cost reduction). We
intend to submit future MIPS quality measures to the NQF-convened
Measure Application Partnership's (MAP), as appropriate, and we intend
to consider the MAP's recommendations as part of the comprehensive
assessment of each measure considered for inclusion under MIPS.
In the CY 2017 Quality Payment Program final rule (81 FR 77155), we
established that we use the Call for Quality Measures process as a
forum to gather the information necessary to draft the journal articles
for submission from measure developers, measure owners and measure
stewards since we do not always develop measures for the quality
programs. The submission of this information does not preclude us from
conducting our own research using Medicare claims data, Medicare survey
results, and other data sources that we possess. We submit new measures
for publication in applicable specialty-appropriate, peer-reviewed
journals before including such measures in the final annual list of
quality measures.
In the CY 2017 Quality Payment Program final rule (81 FR 77158), we
established at Sec. 414.1330(a)(2) that for purposes of assessing
performance of MIPS eligible clinicians on the quality performance
category, we use quality measures developed by QCDRs. In the
circumstances where a QCDR wants to
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use a QCDR measure for inclusion in the MIPS program for reporting,
those measures go through a CMS approval process during the QCDR self-
nomination period. We also established that we post the quality
measures for use by QCDRs by no later than January 1 for performance
periods occurring in 2018 and future years.
Previously finalized MIPS quality measures can be found in the CY
2017 Quality Payment Program final rule (81 FR 77558 through 77675).
Updates may include the proposal to add new MIPS quality measures,
including measures selected 2 years ago during the Call for Measures
process. The new MIPS quality measures proposed for inclusion in MIPS
for the 2018 performance period and future years are found in Table A.
The proposed new and modified MIPS specialty sets for the 2018
performance period and future years are listed in Table B, and include
existing measures that are proposed with modifications, new measures,
and measures finalized in the CY 2017 Quality Payment Program final
rule. We note that the modifications made to the specialty sets may
include the removal of certain quality measures that were previously
finalized. The specialty measure sets should be used as a guide for
eligible clinicians to choose measures applicable to their specialty.
To clarify, some of the MIPS specialty sets have further defined
subspecialty sets, each of which is effectively a separate specialty
set. In instances where an individual MIPS eligible clinician or group
reports on a specialty or subspecialty set, if the set has less than
six measures, that is all the clinician is required to report. MIPS
eligible clinicians are not required to report on the specialty measure
sets, but they are suggested measures for specific specialties.
Throughout measure utilization, measure maintenance should be a
continuous process done by the measure owners, to include environmental
scans of scientific literature about the measure. New information
gathered during this ongoing review may trigger an ad hoc review. The
specialty measure sets in Table B of the Appendix, include existing
measures that are proposed with modifications, new measures, and
measures that were previously finalized in the CY 2017 Quality Payment
Program final rule. Please note that these specialty specific measure
sets are not all inclusive of every specialty or subspecialty. On
January 25, 2017, we announced that we would be accepting
recommendations for potential new specialty measure sets for year 2 of
MIPS under the Quality Payment Program. These recommendations were
based on the MIPS quality measures finalized in the CY 2017 Quality
Payment Program final rule, and include recommendations to add or
remove the current MIPS quality measures from the specialty measure
sets. The current specialty measure sets can be found on the Quality
Payment Program Web site at https://qpp.cms.gov/measures/quality. All
specialty measure sets submitted for consideration were assessed to
ensure that they met the needs of the Quality Payment Program.
As a result, we propose to add new quality measures to MIPS (Table
A), revise the specialty measure sets in MIPS (Table B), remove
specific MIPS quality measures only from specialty sets (Table C.1),
and propose to remove specific MIPS quality measures from the MIPS
program for the 2018 performance period (Table C.2). The aforementioned
measure tables can be found in the Appendix of this proposed rule. In
addition, we are proposing to also remove cross cutting measures from
most of the specialty sets. Specialty groups and societies reported
that cross cutting measures may or may not be relevant to their
practices, contingent on the eligible clinicians or groups. CMS chose
to retain the cross cutting measures in Family Practice, Internal
Medicine and Pediatrics specialty sets because they are frequently used
in these practices. The proposed 2017 cross cutting measures, (81 FR
28447 through 28449), were compiled and placed in a separate table for
eligible clinicians to elect to use or not, for reporting. To clarify,
the cross-cutting measures are intended to provide clinicians with a
list of measures that are broadly applicable to all clinicians
regardless of the clinician's specialty. Even though it is not required
to report on cross-cutting measures, it is provided as a reference to
clinicians who are looking for additional measures to report outside
their specialty. We continue to consider cross-cutting measures to be
an important part of our quality measure programs, and seek comment on
ways to incorporate cross-cutting measures into MIPS in the future. The
proposed Table of Cross-Cutting Measures can be found in Table D of the
Appendix.
For MIPS quality measures that are undergoing substantive changes,
we propose to identify measures including, but not limited to measures
that have had measure specification, measure title, and domain changes.
MIPS quality measures with proposed substantive changes can be found at
Table E of the Appendix.
The measures that would be used for the APM scoring standard and
our authority for waiving certain measure requirements are described in
section II.C.6.g.(3)(b)(ii) and the measures that would be used to
calculate a quality score for the APM scoring standard are proposed in
Tables 14, 15, and 16.
We also seek comment for this rule, on whether there are any MIPS
quality measures that commenters believe should be classified in a
different NQS domain than what is being proposed, or that should be
classified as a different measure type (for example, process vs.
outcome) than what is being proposed in this rule.
(2) Topped Out Measures
As defined in the CY 2017 Quality Payment Program final rule at (81
FR 77136), a measure may be considered topped out if measure
performance is so high and unvarying that meaningful distinctions and
improvement in performance can no longer be made. Topped out measures
could have a disproportionate impact on the scores for certain MIPS
eligible clinicians, and provide little room for improvement for the
majority of MIPS eligible clinicians. We refer readers to section
II.C.7.a.(2)(c) of this proposed rule for additional information
regarding the scoring of topped out measures.
We noted in the CY 2017 Quality Payment Program final rule that we
anticipate removing topped out measures over time and sought comment on
what point in time we should remove topped out measures from MIPS (81
FR 77286). We received the following comments.
Many commenters recommended that we retain topped out quality
measures for 2 or more years because commenters believed they serve to
motivate continued high-quality care; more clinicians may participate
in MIPS compared to prior programs such as PQRS, and thus there may be
more performance variation in MIPS showing that the measure is not
actually topped out; declines in performance will not be captured if a
measure is eliminated; it will help provide stability and encourage
reporting in the early years of the MIPS program; removing topped out
measures could further limit the number of measures available to
specialists; and providing eligible clinicians and the public with
information about high performance is as important as informing them
about deficits.
A few commenters recommended that we publish information about
topped out and potentially topped out measures prior to the performance
period to allow clinicians time to adjust their reporting
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strategies, with one commenter noting that improvement may be rewarded
in addition to achievement. One commenter recommended pushing back the
baseline performance period for the purpose of identifying topped out
measures to 2018 because in the transition year it is unclear how many
eligible clinicians will be reporting at different times and for what
time period they will report.
Finally, a few commenters recommended that we consider specialty,
case mix, and rural location before determining that a measure is
topped out, specifically whether there is still room for improvement
among certain specialist groups and to ensure that rural provider
improvement is recognized. One commenter recommended that we determine
topped out measures based on reporting in the Quality Payment Program
rather than PQRS or value modifier reporting because the commenter
believed using historical performance disadvantages small groups. A few
commenters requested that the process for identifying and determining
the removal of topped out measures be transparent, evidence-based,
patient-centered, and include feedback from all appropriate
stakeholders, including the medical community and measures owner. A few
commenters specifically recommended that determining whether to remove
a topped out measure be part of a rulemaking process while another
commenter suggested that we seek out stakeholder input from the Measure
Applications Partnership (MAP) on whether a measure should be removed,
awarded lower points, or remain with benchmarks as a flat percentage.
We propose a 3-year timeline for identifying and proposing to
remove topped out measures. After a measure has been identified as
topped out for three consecutive years, we may propose to remove the
measure through comment and rulemaking for the 4th year. Therefore, in
the 4th year, if finalized through rulemaking, the measure would be
removed and would no longer be available for reporting during the
performance period. This proposal provides a path toward removing
topped out measures over time, and will apply to the MIPS quality
measures. QCDR measures that consistently are identified as topped out
according to the same timeline as proposed below, would not be approved
for use in year 4 during the QCDR self-nomination review process, and
would not go through the comment and rulemaking process described
below.
We propose to phase in this policy starting with a select set of
six highly topped out measures identified in section II.C.7.a.(2)(c) of
this proposed rule. In section II.C.7.a.(2)(c) of this proposed rule,
we are also proposing to phase in special scoring for measures
identified as topped out in the published benchmarks for two
consecutive performance periods, starting with the select set of highly
topped out measures for the 2018 MIPS performance period. An example
illustrating the proposed timeline for the removal and special scoring
of topped out measures, as it would be applied to the select set of
highly topped out measures identified in section II.C.7.a.(2)(c), is as
follows:
Year 1: The measures are identified as topped out in the
benchmarks published for the 2017 MIPS performance Period. The 2017
benchmarks are posted on the Quality Payment Program Web site: https://qpp.cms.gov/resources/education.
Year 2: Measures are identified as topped out in the
benchmarks published for the 2018 MIPS performance period. We refer
readers to section II.C.7.a.(2)(c) of this proposed rule for additional
information regarding the scoring of topped out measures.
Year 3: Measures are identified as topped out in the
benchmarks published for the 2019 MIPS performance period. The measures
identified as topped out in the benchmarks published for the 2019 MIPS
performance period and the previous two consecutive performance periods
would continue to have special scoring applied for the 2019 MIPS
performance period and would be considered, through notice-and-comment
rulemaking, for removal for the 2020 MIPS performance period.
Year 4: Topped out measures that are finalized for removal
are no longer available for reporting. For example, the measures in the
set of highly topped out measures identified as topped out for the
2017, 2018 and 2019 MIPS performance periods, and if subsequently
finalized for removal will not be available on the list of measures for
the 2020 MIPS performance period and future years.
For all other measures, the timeline would apply starting with the
benchmarks for the 2018 MIPS performance period. Thus, the first year
any other topped out measure could be proposed for removal would be in
rulemaking for the 2021 MIPS performance period, based on the
benchmarks being topped out in the 2018, 2019, and 2020 MIPS
performance periods. If the measure benchmark is not topped out during
one of the three MIPS performance periods, then the lifecycle would
stop and start again at year 1 the next time the measure benchmark is
topped out.
We seek comment on the above proposed timeline, specifically
regarding the number of years before a topped out measure is identified
and considered for removal, and under what circumstances we should
remove topped out measures once they reach that point. For example,
should we automatically remove topped out measures after they are
identified for the proposed number of years or should we review
measures identified for removal and consider certain criteria before
removing the measure? If so what criteria should be considered? We
would like to note that if for some reason a measure benchmark is
topped out for only one submission mechanism benchmark, then we would
remove that measure from the submission mechanism, but not remove the
measure from other submission mechanisms available for submitting that
measure.
We also seek comment on whether topped out Summary Survey Measures
(SSMs), if topped out, should be considered for removal from the
Consumer Assessment of Healthcare Providers and Systems (CAHPS) for
MIPS Clinician or Group Survey measure due to high, unvarying
performance within the SSM, or whether there is another alternative
policy that could be applied for topped out SSMs within the CAHPS for
MIPS Clinician or Group Survey measure.
In the CY 2017 Quality Payment Program final rule, we state that we
do not believe it would be appropriate to remove topped out measures
from the CMS Web Interface for the Quality Payment Program because the
CMS Web Interface measures are used in MIPS and in APMs, such as the
Shared Savings Program. Removing topped out measures from the CMS Web
Interface would not be appropriate because we have aligned policies
where possible, with the Shared Savings Program, such as using the
Shared Savings Program benchmarks for the CMS Web Interface measures
(81 FR 77285). In the CY 2017 Quality Payment Program final rule, we
also finalized that MIPS eligible clinicians reporting via the CMS Web
Interface must report all measures included in the CMS Web Interface
(81 FR 77116). Thus, if a CMS Web Interface measure is topped out, the
CMS Web Interface reporter cannot select other measures. We refer
readers to section II.C.7.a.(2) of this proposed rule for information
on scoring policies with regards to topped out measures from the CMS
Web Interface for the Quality Payment Program. We are not proposing to
include CMS Web Interface measures
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in our proposal on removing topped out measures.
(3) Non-Outcome Measures
In the CY 2017 Quality Payment Program final rule, we sought
comment on whether we should remove non-outcomes measures for which
performance cannot reliably be scored against a benchmark (for example,
measures that do not have 20 reporters with 20 cases that meet the data
completeness standard) for 3 years in a row (81 FR 77288).
A few commenters recommended that measures that cannot be scored
against a benchmark should be removed from the MIPS score. One
commenter recommended that non-outcome measures that are unscorable
should be given a weight of zero or re-weighted in the performance
category. One commenter supported removing non-outcomes measures for
which performance cannot reliably be scored against a benchmark for 3
years in a row. One commenter believed it would also be appropriate to
remove outcomes measures under a separate more protracted timeline
because the commenter believed the reporting of outcome measures is
more difficult and expected to increase at a slower pace, while
maintaining outcome measures would encourage the testing and
availability of such measures.
Based on the need for CMS to further assess this issue, we are not
proposing to remove non-outcome measures in this proposed rule.
However, we seek comment on what the best timeline for removing both
non-outcome and outcome measures that cannot be reliably scored against
a benchmark for 3 years. We intend to revisit this issue and make
proposals in future rulemaking.
(4) Quality Measures Determined To Be Outcome Measures
Under the MIPS, individual MIPS eligible clinicians are generally
required to submit at least one outcome measure, or, if no outcome
measure is available, one high priority measure. As such, our
determinations as to whether a measure is an outcome measure is of
importance to stakeholders. We utilize the following as a basis to
determine if a measure is considered an outcome measure:
Measure Steward and National Quality Forum (NQF)
designation--For most measures, we will utilize the designation as
determined by the measure steward and the measure's NQF designation to
determine if it is an outcome measure or not. If this is not clear, we
will consider the following step.
Utilization of the CMS Blueprint definitions for outcome
measures: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint-130.pdf. An outcome of
care is a health state of a patient resulting from health care. Outcome
measures are supported by evidence that the measure has been used to
detect the impact of one or more clinical interventions. Clinical
analysts are utilized to evaluate the measure.
We also note that patient-reported outcome measures are considered
outcome measures, as they measure the health of the patient directly
resulting from the health care provided. Efficiency measures are not
considered outcome measures, as they are measuring the cost of care
associated with a specific level of care, but we do note that
efficiency is considered a high priority measure.
After a MIPS quality measure is established in the program, it is
generally only reviewed again if there are significant changes to a
measure for the next program year that might warrant a change to the
designation of outcome or not. In most cases, these updates are
significant enough that they are usually presented as a new measure
from the measure owner. New measures to the program will follow the
criteria outlined above. QCDR measures however, are reviewed on a
yearly basis (during the fall) regardless if there is a significant
change or not. We refer readers to section II.C.10.a. for additional
information on the QCDR self-nomination and measures review and
approval process.
We seek comment on the criteria and process outlined above on how
we designate outcome measures. Specifically are there additional
criteria we should take into consideration when we determine if a
measure meets the criteria of an outcome measure? Should we use
different criteria for MIPS measures versus QCDR measures?
d. Cost Performance Category
(1) Background
(a) General Overview
Measuring cost is an integral part of measuring value as part of
MIPS. In implementing the cost performance category for the transition
year (2017 MIPS performance period/2019 MIPS payment year), we started
with measures that had been used in previous programs but noted our
intent to move towards episode-based measurement as soon as possible,
consistent with the statute and the feedback from the clinician
community. Specifically, we adopted 2 measures that had been used in
the VM: The total per capita costs for all attributed beneficiaries
measure (referred to as the total per capita cost measure) and the MSPB
measure (81 FR 77166 through 77168). We also adopted 10 episode-based
measures that had previously been included in the Supplemental Quality
and Resource Use Reports (sQRURs) (81 FR 77171 through 77174).
At Sec. 414.1325(e), we finalized that all measures used under the
cost performance category would be derived from Medicare administrative
claims data and, thus, participation would not require additional data
submission. We finalized a reliability threshold of 0.4 for measures in
the cost performance category (81 FR 77170). We also finalized a case
minimum of 35 for the MSPB measure (81 FR 77171) and 20 for the total
per capita cost measure (81 FR 77170) and each of the 10 episode-based
measures (81 FR 77175) in the cost performance category to ensure the
reliability threshold is met.
For the transition year, we finalized a policy to weight the cost
performance category at zero percent in the final score in order to
give clinicians more opportunity to understand the attribution and the
scoring methodology and gain more familiarity with the measures through
performance feedback (81 FR 77165 through 77166) so that clinicians may
be able to act to improve their performance. In the CY 2017 Quality
Payment Program final rule, we finalized a cost performance category
weight of 10 percent for the 2020 MIPS payment year (81 FR 77165). For
the 2021 MIPS payment year and beyond, the cost performance category
will have a weight of 30 percent of the final score as required by
section 1848(q)(5)(E)(i)(II)(aa) of the Act.
For descriptions of the statutory basis and our existing policies
for the cost performance category, we refer readers to the CY 2017
Quality Payment Program final rule (81 FR 77162 through 77177).
As finalized at Sec. 414.1370(g)(2), the cost performance category
is weighted at zero percent for MIPS eligible clinicians scored under
the MIPS APM scoring standard because many MIPS APM models incorporate
cost measurement in other ways. For more on the APM scoring standard,
see II.C.6.E. of this proposed rule.
(2) Weighting in the Final Score
We are proposing at Sec. 414.1350(b)(2) to change the weight of
the cost performance category from 10 percent to zero percent for the
2020 MIPS payment year. We continue to have concerns
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about the level of familiarity and understanding of cost measures among
clinicians. We will use this additional year in which the score in the
cost performance category does not count towards the final score for
outreach to increase understanding of the measures so that clinicians
will be more comfortable with their role in reducing costs for their
patients. In addition, we will use this additional year to develop more
episode-based measures, which are cost measures that are focused on a
clinical conditions or procedures. We intend to propose in future
rulemaking to adopt episode-based measures currently in development.
Although we believe reducing this weight is appropriate given the
level of understanding of the measures and the scoring standards, we
note that section 1848(q)(5)(E)(i)(II)(aa) of the Act requires the cost
performance category be assigned a weight of 30 percent of the MIPS
final score beginning in the 2021 MIPS payment year. We recognize that
assigning a zero percent weight to the cost performance category for
the 2020 MIPS payment year may not provide a smooth enough transition
for integrating cost measures into MIPS and may not provide enough
encouragement to clinicians to review their performance on cost
measures. This policy could reduce understanding of the measures when
we reach the 2021 MIPS payment year and the cost performance category
will be used to determine 30 percent of the final score for MIPS
eligible clinicians, when in the two previous years it was weighted at
zero. Therefore, we also seek comment on keeping the weight of the cost
performance category at 10 percent for the 2020 MIPS payment year.
In our discussions with clinicians and clinician societies,
clinicians expressed their desire to down-weight the cost performance
category to zero percent for an additional year with full knowledge
that the cost performance category weight is set at 30 percent under
the statute for the 2021 MIPS payment year. The clinicians we spoke
with preferred a low weighting and noted that they are actively
preparing for cost performance category implementation and would be
prepared for the 30 percent statutory weight for the cost performance
category for the 2021 MIPS payment year. We intend to continue to
provide education to clinicians to help them prepare for the upcoming
30 percent weight.
We invite public comments on this proposal of a zero percent
weighting for the cost performance category and the alternative option
of 10 percent weighting for the cost performance category for the 2020
MIPS payment year.
(3) Cost Criteria
(a) Measures Proposed for the MIPS Cost Performance Category
(i) Background
Under Sec. 414.1350(a), we specify cost measures for a performance
period to assess the performance of MIPS eligible clinicians on the
cost performance category. For the 2017 MIPS performance period, we
will utilize 12 cost measures that are derived from Medicare
administrative claims data. Two of these measures, the MSPB measure and
total per capita cost measure, have been used in the VM (81 FR 77166
through 77168), and the remaining 10 are episode-based measures that
were included in the sQRURs in 2014 and 2015 (81 FR 77171 through
77174).
Section 1848(r) of the Act specifies a series of steps and
activities for the Secretary to undertake to involve the physician,
practitioner, and other stakeholder communities in enhancing the
infrastructure for cost measurement, including for purposes of MIPS.
Section 1848(r)(2) of the Act requires the development of care episode
and patient condition groups, and classification codes for such groups,
and provides for care episode and patient condition groups to account
for a target of an estimated one-half of expenditures under Parts A and
B (with this target increasing over time as appropriate). Section
1848(r) of the Act requires us to consider several factors when
establishing these groups. For care episode groups, we must consider
the patient's clinical problems at the time items and services are
furnished during an episode of care, such as clinical conditions or
diagnoses, whether inpatient hospitalization occurs, the principal
procedures or services furnished, and other factors determined
appropriate by the Secretary. For patient condition groups, we must
consider the patient's clinical history at the time of a medical visit,
such as the patient's combination of chronic conditions, current health
status, and recent significant history (such as hospitalization and
major surgery during a previous period), and other factors determined
appropriate.
Section 1848(r)(2) of the Act requires us to post on the CMS Web
site a draft list of care episode and patient condition groups and
codes for solicitation of input from stakeholders, and subsequently,
post on the CMS Web site an operational list of such groups and codes.
In December 2016, we published the Episode-Based Cost Measure
Development for the Quality Program (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Episode-Based-Cost-Measure-Development-for-the-Quality-Payment-Program.pdf) and requested input on a draft
list of care episode and patient condition groups and codes as required
by section 1848(r)(2)(E) and (F) of the Act. We additionally requested
feedback on our overall approach to cost measure development, including
several pages of specific questions on the proposed approach for
clinicians and stakeholders to provide feedback on. This feedback will
be used to modify our cost measure development and ensure that our
approach is continually informed by stakeholder feedback. We are
currently reviewing the feedback that was recently received on that
posting and will share plans to work with clinicians and others on the
further developments of these episodes in the future.
We will be posting the operational list of care episode and patient
condition groups in December 2017, as required by section 1848(r)(2)(G)
of the Act. Section 1848(r)(2)(H) of the Act also requires that not
later than November 1 of each year (beginning with 2018), the Secretary
shall, through rulemaking, revise the operational list as the Secretary
determines may be appropriate.
(ii) Total Per Capita Cost and MSPB Measures
For the 2018 MIPS performance period and future performance
periods, we are proposing to include in the cost performance category
the total per capita cost measure and the MSPB measure as finalized for
the 2017 MIPS performance period. We refer readers to the description
of these measures in the CY 2017 Quality Payment Program final rule (81
FR 77164 through 77171). We are proposing to include the total per
capita cost measure because it is a global measure of all Medicare Part
A and Part B costs during the performance period. MIPS eligible
clinicians are familiar with the total per capita cost measure because
the measure has been used in the VM since the 2015 payment adjustment
period and performance feedback has been provided through the annual
QRUR since 2013 (for a subset of groups that had 20 or more eligible
professionals, based on 2014 performance) and to all groups in the
annual QRUR since 2014 (based on 2013 performance) and mid-year QRUR
since 2015. We are proposing to use the MSPB measure because many MIPS
eligible
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clinicians will be familiar with the measure from the VM, where it has
been included since the 2016 payment adjustment period and in annual
QRUR since 2014 (based on 2013 performance) and the mid-year QRUR since
2015, or its hospital-specified version, which has been a part of the
Hospital VBP Program since 2015, based on 2013 performance. In addition
to familiarity, these two measures cover a large number of patients and
provide an important measurement of clinician contribution to the
overall population that a clinician encounters.
We are not proposing any changes to the methodologies for payment
standardization, risk adjustment, and specialty adjustment for these
measures and refer readers to the CY 2017 Quality Payment Program final
rule (81 FR 77164 through 77171) for more information about these
methodologies.
We will continue to evaluate cost measures that are included in
MIPS on a regular basis and anticipate that measures could be added or
removed, subject to rulemaking under applicable law, as measure
development continues. We will also maintain the measures that are used
in the cost performance category by updating specifications, risk
adjustment, and attribution as appropriate. We anticipate including a
list of cost measures for a given performance period in annual
rulemaking.
We invite public comments on these proposals.
(iii) Episode-Based Measures
Episode-based measures differ from the total per capita cost
measure and MSPB measure because their specifications only include
services that are related to the episode of care for a clinical
condition or procedure (as defined by procedure and diagnosis codes),
as opposed to including all services that are provided to a patient
over a given period of time. For the 2018 MIPS performance period, we
are not proposing to include in the cost performance category the 10
episode-based measures that we adopted for the 2017 MIPS performance
period in the CY 2017 Quality Payment Program final rule (81 FR 77171
through 77174). We instead will work to develop new episode-based
measures, with significant clinician input, for future performance
periods.
We received extensive comments on our proposal to include 41 of
these episode-based measures for the 2017 MIPS performance period,
which we responded to in the CY 2017 Quality Payment Program final rule
(81 FR 77171 through 77174). We also received additional comments after
publication of that final rule with comment period about the decision
to include 10 episode-based measures for the 2017 MIPS performance
period. Although comments were generally in favor of the inclusion of
episode-based measures in the future, there was also overwhelming
stakeholder interest in more clinician involvement in the development
of these episode-based measures as required by section 1848(r)(2) of
the Act. Although there was an opportunity for clinician involvement in
the development of some of the episode-based measures included for the
2017 MIPS performance period, it was not as extensive as the process we
are currently using to develop episode-based measures. We believe that
the new episode-based measures, which we intend to propose in future
rulemaking to include in the cost performance category for the 2019
MIPS performance period, will be substantially improved by more
extensive stakeholder feedback and involvement in the process.
Thus far, stakeholder feedback has been sought in several ways.
First, stakeholder feedback has been sought through various public
postings. In October 2015 and April 2016, pursuant to section
1848(r)(2)(B) and (C) of the Act, we gathered input from stakeholders
on the episode groups previously developed under section 1848(n)(9)(A)
of the Act that has been used to inform the process of constructing the
new episode-based cost measures. This feedback emphasized several key
aspects of cost measure development such as attribution, risk
adjustment, and alignment with quality measurement and patient
outcomes. Stakeholders have also emphasized that feedback related to
cost measures should be actionable and timely. In addition, a draft
list of care episode and patient condition groups, along with trigger
codes, was posted for comment in December 2016 (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Episode-Based-Cost-Measure-Development-for-the-Quality-Payment-Program.pdf) as required by section
1848(r)(2)(E) of the Act and comments were accepted as required by
section 1848(r)(2)(F) of the Act.
This draft list of care episode and patient condition groups and
trigger codes was informed by engagement with clinicians from over 50
clinician specialty societies through a Clinical Committee formed to
participate in cost measure development. The Clinical Committee work
has provided input from a diverse array of clinicians on identifying
conditions and procedures for episode groups. Moving forward, the
Clinical Committee will recommend which services or claims would be
counted in episode costs. This will ensure that cost measures in
development are directly informed by a substantial number of clinicians
and members of specialty societies.
In addition, a technical expert panel has met 3 times to provide
oversight and guidance for our development of episode-based cost
measures. The technical expert panel has offered recommendations for
defining an episode group, assigning costs to the group, and
attributing episode groups to clinicians. This expert feedback has been
built into the current cost measure development process.
As this process continues, we are continuing to seek input from
clinicians. Earlier this year, we opened an opportunity to submit the
names of clinicians to participate in this process. This process
remains open to additional individuals. We believe that episode-based
measures will benefit from this comprehensive approach to development.
In addition, because it is possible that the new episode-based measures
under development could address similar conditions as those in the
episode-based measures finalized for the 2017 MIPS performance period,
we believe that it would be better to focus attention on the new
episode-based measures, so that clinicians would not receive feedback
or scores from two measures for the same patient condition or
procedure. Recognizing that under section 1848(q)(5)(E)(i)(II)(aa) of
the Act, we must assign a weight of 30 percent to the cost performance
category for the 2021 MIPS payment year, we will endeavor to have as
many episode-based measures available as possible for the proposed 2019
MIPS performance period.
We plan to include episode-based measures in the cost performance
category in future years as they are developed and would propose new
measures in future rulemaking.
Although we are not proposing to include any episode-based measures
in calculating the cost performance category score for the 2020 MIPS
payment year, we do plan to continue to provide confidential
performance feedback to clinicians on their performance on episode-
based measures developed under the processes required by section
1848(r)(2) of the Act as appropriate in order to increase familiarity
with the concept of episode-based measurement as well as the specific
episodes that could be included
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in determining the cost performance category score in the future.
Because these measures will be generated based on claims data like
other cost measures, we will not collect any additional data from
clinicians. As we develop new episode-based measures, we believe it is
likely that they would cover similar clinical topics to those that are
in the previously developed episode-based measures because of our
intent to address common clinical conditions with episode-based
measures. We aim to provide an initial opportunity for clinicians to
review their performance based on the new episode-based measures at
some point in the fall of 2017, as the measures are developed and as
the information is available. We note that this feedback will be
specific to the new episode-based measures that are developed under the
process described above and may be presented in a different format than
MIPS eligible clinicians' performance feedback as described in section
II.C.9.a. of this proposed rule. However, our intention is to align the
feedback as much as possible to ensure clinicians receive opportunities
to review their performance on potential new episode-based measures for
the cost performance category prior to the proposed 2019 MIPS
performance period. We are unable to offer a list of new episode-based
measures on which we will provide feedback because that will be
determined in our ongoing development work described above. We are
concerned that continuing to provide feedback on the older episode-
based measures along with feedback on new episode-based measures will
be confusing and a poor use of resources. Because we are focusing on
development of new episode-based measures, our feedback on episode-
based measures that were previously developed will discontinue after
2017 as these measures would no longer be maintained or reflect changes
in diagnostic and procedural coding. As described in section II.C.9.a.
of this proposed rule, we intend to provide feedback on these new
measures as they become available in a new format around summer 2018.
We note that the feedback provided in the summer of 2018 will go to
those MIPS eligible clinicians for whom we are able to calculate the
episode-based measures, which means it would be possible a clinician
may not receive feedback on episode-based measures in both the fall of
2017 and the summer of 2018. We believe that receiving feedback on the
new episode-based measures, along with the previously-finalized total
per capita cost and MSPB measures, will support clinicians in their
readiness for the proposed 2019 MIPS performance period.
As previously finalized in the CY 2017 Quality Payment Program
final rule (81 FR 77173), the episode-based measures that we are not
proposing for the 2018 MIPS performance period will be used for
determining the cost performance category score for the 2019 MIPS
payment year, although the cost performance category score will be
weighted at zero percent in that year.
We invite public comments on this proposal.
(iv) Attribution
In the CY 2017 Quality Payment Program final rule, we changed the
list of primary care services that had been used to determine
attribution for the total per capita cost measure by adding
transitional care management (CPT codes 99495 and 99496) codes and a
chronic care management code (CPT code 99490) (81 FR 77169). In the CY
2017 Physician Fee Schedule final rule, we changed the payment status
for two existing CPT codes (CPT codes 99487 and 99489) that could be
used to describe care management from B (bundled) to A (active) meaning
that the services would be paid under the Physician Fee Schedule (81 FR
80349). The services described by these codes are substantially similar
to those described by the chronic care management code that we added to
the list of primary care services beginning with the 2017 performance
period. We therefore propose to add CPT codes 99487 and 99489, both
describing complex chronic care management, to the list of primary care
services used to attribute patients under the total per capita cost
measure.
We are not proposing any changes to the attribution methods for the
MSPB measure and refer readers to the CY 2017 Quality Payment Program
final rule (81 FR 77168 through 77169) for more information.
We invite public comment on our proposals.
(v) Reliability
In the CY 2017 Quality Payment Program final rule (81 FR 77169
through 77170), we finalized a reliability threshold of 0.4 for
measures in the cost performance category. Reliability is an important
evaluation for cost measures to ensure that differences in performance
are not the result of random variation. Statistically, reliability
depends on performance variation for a measure across clinicians
(``signal''), the random variation in performance for a measure within
a clinician's attributed beneficiaries (``noise''), and the number of
beneficiaries attributed to the clinician. High reliability for a
measure suggests that comparisons of relative performance among
clinicians are likely to be stable over different performance periods
and that the performance of one clinician on the measure can be
confidently distinguished from another. As an example of the
statistical concept of reliability, a test in which the same individual
received very different scores depending on how the included questions
are framed would not be reliable. Potential reliability values range
from 0.00 to 1.00, where 1.00 (highest possible reliability) signifies
that all variation in the measure's rates is the result of variation in
differences in performance across clinicians, whereas 0.0 (lowest
possible reliability) signifies that all variation could be a result of
measurement error. The 0.4 reliability threshold that we adopted for
the cost performance category measures in MIPS means that the majority
of MIPS eligible clinicians and groups who meet the case minimum
required for scoring under a measure have measure reliability scores
that exceed 0.4. We generally consider reliability levels between 0.4
and 0.7 to indicate ``moderate'' reliability and levels above 0.7 to
indicate ``high'' reliability.
We addressed comments we received on the CY 2017 Quality Payment
Program proposed rule (81 FR 77169 through 77171), that expressed
concern that our 0.4 reliability threshold was too low. Many commenters
recommended that cost measures be included only when they could meet
the standard of ``high'' reliability (0.7 or above). Many commenters on
the CY 2017 Quality Payment Program final rule made similar comments.
Commenters emphasized the importance of reliability; however, we have
also seen commenters incorrectly refer to measures as being 40 percent
reliable. Reliability is not a percentage but is instead a coefficient
so a measure with 0.4 reliability does not reflect that it is only
correct for 40 percent of those measured. We encourage a review of our
analysis of reliability for the total per capita cost measure (80 FR
71282) and MSPB (81 FR 77169 through 77171).
Reliability is an important evaluation tool for an individual
measure, but it is only one element of evaluation. Reliability
generally increases as we increase the case size but a high reliability
may also reflect low variation. A measure in which all clinicians
perform at nearly the same rate would be reliable but not valuable in a
program
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that attempts to recognize and reward differential performance. A
measure in which there is very little variation provides little value
in a program like MIPS given the devotion of resources to developing
and maintaining that measure over other potential measures. Reliability
must also be considered in the context of a measurement system like
MIPS which incorporates other elements of measurement. We understand
and appreciate the concerns that have been expressed about reliability
of measures. Medicine, however, always has a certain amount of
variability which may affect the reliability score. We want strong
reliability, but not at the expense of losing valuable information
about clinicians. We are concerned that placing too much of an emphasis
on reliability calculations could limit the applicability of cost
measures to large group practices who, by nature of their size, have
larger patient populations, thus depriving solo clinicians and
individual reporters from being rewarded for efforts to better manage
patients. Therefore, we are not proposing any adjustments to our
reliability policies, but we will continue to evaluate reliability as
we develop new measures and to ensure that our measures meet an
appropriate standard.
(b) Attribution for Individuals and Groups
We are not proposing any changes for how we attribute cost measures
to individual and group reporters. We refer readers to the CY 2017
Quality Payment Program final rule for more information (81 FR 77175
through 77176).
(c) Incorporation of Cost Measures With SES or Risk Adjustment
Both measures proposed for inclusion in the cost performance
category for the 2018 MIPS performance period are risk adjusted at the
measure level. Although the risk adjustment of the 2 measures is not
identical, in both cases it is used to recognize the higher risk
associated with demographic factors (such as age) or certain clinical
conditions. We recognize that the risks accounted for with this
adjustment are not the only potential attributes that could lead to a
higher cost patient. Stakeholders have pointed to many other factors
such as income level, race, and geography that they believe contribute
to increased costs. These issues and our plans for attempting to
address them are discussed in length in section II.C.7.b.(1)(a) of this
rule.
(d) Incorporation of Cost Measures With ICD-10 Impacts
In section II.C.7.a.(1)(c) of this proposed rule, we discuss our
proposal to assess performance on any measures impacted by ICD-10
updates based only on the first 9 months of the 12-month performance
period. Because the total per capita cost and MSPB measures include
costs from all Medicare Part A and B services, regardless of the
specific ICD-10 codes that are used on claims, and do not assign
patients based on ICD-10, we do not anticipate that any measures for
the cost performance category would be affected by this ICD-10 issue
during the 2018 MIPS performance period. However, as we continue our
plans to expand cost measures to incorporate episode-based measures,
ICD-10 changes could become important. Episode-based measures may be
opened (triggered) by and may assign services based on ICD-10 codes.
Therefore, a change to ICD-10 coding could have a significant effect on
an episode-based measure. Changes to ICD-10 codes will be incorporated
into the measure specifications on a regular basis through the measure
maintenance process.
(e) Application of Measures to Non-Patient Facing MIPS Eligible
Clinicians
We are not proposing changes to the policy we finalized in the CY
2017 Quality Payment Program final rule (81 FR 77176) that we will
attribute cost measures to non-patient facing MIPS eligible clinicians
who have sufficient case volume, in accordance with the attribution
methodology.
Section 1848(q)(2)(C)(iv) of the Act requires the Secretary to
consider the circumstances of professional types who typically furnish
services without patient facing interaction (non-patient facing) when
determining the application of measures and activities. In addition,
this section allows the Secretary to apply alternative measures or
activities to non-patient facing MIPS eligible clinicians that fulfill
the goals of a performance category. Section 1848(q)(5)(F) of the Act
allows the Secretary to re-weight MIPS performance categories if there
are not sufficient measures and activities applicable and available to
each type of MIPS eligible clinician involved.
We believe that non-patient facing clinicians are an integral part
of the care team and that their services do contributed to the overall
costs but at this time we believe it better to focus on the development
of a comprehensive system of episode-based measures which focus on the
role of patient-facing clinicians. Accordingly, for the 2018 MIPS
performance period, we are not proposing alternative cost measures for
non-patient facing MIPS eligible clinicians or groups. This means that
non-patient facing MIPS eligible clinicians or groups are unlikely to
be attributed any cost measures that are generally attributed to
clinicians who have patient-facing encounters with patients. Therefore,
we anticipate that, similar to MIPS eligible clinicians or groups that
do not meet the required case minimums for any cost measures, many non-
patient facing MIPS eligible clinicians may not have sufficient cost
measures applicable and available to them and would not be scored on
the cost performance category under MIPS. We continue to consider
opportunities to develop alternative cost measures for non-patient
facing clinicians and solicit comment on this topic to inform our
future rulemaking.
(f) Facility-Based Measurement as it Relates to the Cost Performance
Category
In section II.C.7.a.(4) of this proposed rule, we discuss our
proposal to implement section 1848(q)(2)(C)(ii) of the Act by assessing
clinicians who meet certain requirements and elect participation based
on the performance of their associated hospital in the Hospital VBP
Program. We refer readers to that section for full details on our
proposals related to facility-based measurement, including the measures
and how the measures are scored, for the cost performance category.
e. Improvement Activity Criteria
(1) Background
Section 1848(q)(2)(C)(v)(III) of the Act defines an improvement
activity as an activity that relevant eligible clinician organizations
and other relevant stakeholders identify as improving clinical practice
or care delivery, and that the Secretary determines, when effectively
executed, is likely to result in improved outcomes. Section
1848(q)(2)(B)(iii) of the Act requires the Secretary to specify
improvement activities under subcategories for the performance period,
which must include at least the subcategories specified in section
1848(q)(2)(B)(iii)(I) through (VI) of the Act, and in doing so to give
consideration to the circumstances of small practices, and practices
located in rural areas and geographic health professional shortage
areas (HPSAs).
Section 1848(q)(2)(C)(iv) of the Act generally requires the
Secretary to give consideration to the circumstances of
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non-patient facing individual MIPS eligible clinicians or groups and
allows the Secretary, to the extent feasible and appropriate, to apply
alternative measures and activities to such individual MIPS eligible
clinicians and groups.
Section 1848(q)(2)(C)(v) of the Act required the Secretary to use a
request for information (RFI) to solicit recommendations from
stakeholders to identify improvement activities and specify criteria
for such improvement activities, and provides that the Secretary may
contract with entities to assist in identifying activities, specifying
criteria for the activities, and determining whether individual MIPS
eligible clinicians or groups meet the criteria set. For a detailed
discussion of the feedback received from the MIPS and APMs RFI, see the
CY 2017 Quality Payment Program 2017 final rule (81 FR 77177).
We defined improvement activities at Sec. 414.1305 as an activity
that relevant MIPS eligible clinicians, organizations and other
relevant stakeholders identify as improving clinical practice or care
delivery and that the Secretary determines, when effectively executed,
is likely to result in improved outcomes.
In the CY 2017 Quality Payment Program final rule (81 FR 77199), we
solicited comments on activities that would advance the usage of health
IT to support improvement activities. We received several comments in
support of the concept to include emerging certified health IT
capabilities as part of the activities in the Improvement Activities
Inventory and several commenters supported our assessment that using
CEHRT can aid in improving clinical practices and help healthcare
organizations achieve success on numerous improvement activities, as
well as the continued integration of improvement activities and
advancing clinical information. However, several commenters expressed
concern about health IT-associated burdens and costs and recommended
that we also continue to offer diverse activities that do not rely on
emerging capabilities of certified health IT, as they are not
universally available or may only be offered as high cost add-on
capabilities. Some commenters also requested that we be less
prescriptive in our requirements for the use of health IT.
In response to the comments, we will continue to focus on
incentivizing the use of health IT, telehealth, and connection of
patients to community-based services. The use of health IT is an
important aspect of care delivery processes described in many of the
proposed new improvement activities in Table F in the Appendix of this
proposed rule, and in Table H: Finalized Improvement Activities
Inventory that we finalized in the CY 2017 Quality Payment Program
final rule (81 FR 77817 through 77831). In that same final rule, we
also finalized a policy to allow MIPS eligible clinicians to achieve a
bonus in the advancing care information performance category when they
use functions included in CEHRT to complete eligible activities from
the Improvement Activities Inventory. Please refer to section
II.C.6.f.(2)(d) of this proposed rule for details on how improvement
activities using CEHRT relate to the objectives and measures of the
advancing care information and improvement activities performance
categories. We are not proposing any changes to these policies for
incentivizing the use of health IT in this proposed rule; however, we
will continue to consider including emerging certified health IT
capabilities as part of activities within the Improvement Activities
Inventory in future years.
In addition, as noted previously, we believe a key goal of the
Quality Payment Program is to establish a program that allows for close
alignment of the four performance categories. Although we are not
proposing any specific new policies, we seek comment on how we might
provide flexibility for MIPS eligible clinicians to effectively
demonstrate improvement through health IT usage while also measuring
such improvement. We welcome public comment on these considerations.
(2) Contribution to the Final Score
In the CY 2017 Quality Payment Program final rule (81 FR 77179
through 77180), we finalized at Sec. 414.1355 that the improvement
activities performance category would account for 15 percent of the
final score. We also finalized at Sec. 414.1380(b)(3)(iv) criteria for
recognition as a certified-patient centered medical home or comparable
specialty practice. We are proposing to clarify the term ``certified''
patient-centered medical home finalized at Sec. 414.1380(b)(3)(iv). It
has come to our attention that the common terminology utilized in the
general medical community for ``certified'' patient-centered medical
home is ``recognized'' patient-centered medical home. Therefore, in
order to provide clarity we are proposing that the term ``recognized''
be accepted as equivalent to the term ``certified'' when referring to
the requirements for a patient-centered medical home to receive full
credit for the improvement activities performance category for MIPS.
Specifically, we propose to revise Sec. 414.1380(b)(3)(iv) to provide
that a MIPS eligible clinician or group in a practice that is certified
or recognized as a patient-centered medical home or comparable
specialty practice, as determined by the Secretary, receives full
credit for performance on the improvement activities performance
category. For purposes of Sec. 414.1380 (b)(3)(iv), ``full credit''
means that the MIPS eligible clinician or group has met the highest
potential category score of 40 points. A practice is certified or
recognized as a patient-centered medical home if it meets any of the
criteria specified under Sec. 414.1380(b)(3)(iv).
In the CY 2017 Quality Payment Program final rule (81 FR 77198), we
requested commenters' specific suggestions for additional activities or
activities that may merit additional points beyond the ``high'' level.
Several commenters urged us to increase the overall number of high-
weighted activities in this performance category. Some commenters
recommended additional criteria for designating high-weighted
activities, such as an improvement activity's impact on population
health, medication adherence, and shared decision-making tools, and
encouraged us to be more transparent in our weighting decisions.
Several commenters recommended that we weight registry-related
activities as high, and suggested that we award individual MIPS
eligible clinicians and groups in APMs full credit in this performance
category. The commenters also offered many recommendations for changing
current medium-weighted activities to high and offered many specific
suggestions for new high-weighted improvement activities.
In response to the comments, we are proposing new, high-weighted
activities in Table F in the Appendix of this proposed rule. As
explained in the CY 2017 Quality Payment Program final rule (81 FR
77194), we believe that high weighting should be used for activities
that directly address areas with the greatest impact on beneficiary
care, safety, health, and well-being. We are not proposing changes to
this approach in this proposed rule; however, we will take these
suggested additional criteria into consideration for designating high-
weighted activities in future rulemaking. For MIPS eligible clinicians
participating in MIPS APMs, we finalized a policy to reduce reporting
burden through the APM scoring standard for this category to recognize
improvement activities work performed through participation in MIPS
APMs. This policy is codified at Sec. 414.1370(g)(3), and we refer
readers to the CY 2017 Quality Payment Program
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final rule for further details on reporting and scoring this category
under the APM Scoring Standard (81 FR 77259 through 77260).
(3) Improvement Activities Data Submission Criteria
(a) Submission Mechanisms
In the CY 2017 Quality Payment Program final rule (81 FR 77180), we
discussed that for the transition year of MIPS we would allow for
submission of data for the improvement activities performance category
using the qualified registry, EHR, QCDR, CMS Web Interface, and
attestation data submission mechanisms through attestation.
Specifically, we finalized a policy that regardless of the data
submission method, with the exception of MIPS eligible clinicians in
MIPS APMs, all individual MIPS eligible clinicians or groups must
select activities from the Improvement Activities Inventory. In
addition, we finalized at Sec. 414.1360 that for the transition year
of MIPS, all individual MIPS eligible clinicians or groups, or third
party intermediaries such as health IT vendors, QCDRs and qualified
registries that submit on behalf of an individual MIPS eligible
clinician or group, must designate a ``yes'' response for activities on
the Improvement Activities Inventory. In the case where an individual
MIPS eligible clinician or group is using a health IT vendor, QCDR, or
qualified registry for their data submission, the individual MIPS
eligible clinician or group will certify all improvement activities
were performed and the health IT vendor, QCDR, or qualified registry
would submit on their behalf. We would like to maintain stability in
the Quality Payment Program and continue this policy into future years.
Therefore, we are proposing at Sec. 414.1360 that for purposes of the
transition year of MIPS and future years all individual MIPS eligible
clinicians or groups, or third party intermediaries such as health IT
vendors, QCDRs and qualified registries that submit on behalf of an
individual MIPS eligible clinician or group, must designate a ``yes''
response for activities on the Improvement Activities Inventory. In the
case where an individual MIPS eligible clinician or group is using a
health IT vendor, QCDR, or qualified registry for their data
submission, the MIPS eligible clinician or group will certify all
improvement activities were performed and the health IT vendor, QCDR,
or qualified registry would submit on their behalf. In addition, as
discussed in section II.C.4.d. of this proposed rule, we are proposing
to generally apply our previously finalized and proposed group policies
to virtual groups.
We would like to note that while we finalized at Sec. 414.1325(d)
in the CY 2017 Quality Payment Program final rule that individual MIPS
eligible clinicians and groups may only use one submission mechanism
per performance category, in section II.C.6.a.(1) of this proposed
rule, we are proposing to revise Sec. 414.1325(d) for purposes of the
2020 MIPS payment year and future years to allow individual MIPS
eligible clinicians and groups to submit measures and activities, as
applicable, via as many submission mechanisms as necessary to meet the
requirements of the quality, improvement activities, or advancing care
information performance categories. We refer readers to section
II.C.6.a.(1) of this proposed rule for further discussion of this
proposal.
We also included a designation column in the Improvement Activities
Inventory at Table H in the Appendix of the CY 2017 Quality Payment
Program final rule (81 FR 77817) that indicated which activities
qualified for the advancing care information bonus finalized at Sec.
414.1380. In future updates to the Improvement Activities Inventory we
intend to continue to indicate which activities qualify for the
advancing care information performance category bonus.
In the CY 2017 Quality Payment Program final rule (81 FR 77181), we
clarified that if one MIPS eligible clinician (NPI) in a group
completed an improvement activity, the entire group (TIN) would receive
credit for that activity. In addition, we specified that all MIPS
eligible clinicians reporting as a group would receive the same score
for the improvement activities performance category if at least one
clinician within the group is performing the activity for a continuous
90 days in the performance period. As discussed in section II.C.4.d. of
this proposed rule, we are proposing to generally apply our previously
finalized and proposed group policies to virtual groups. We are not
proposing any changes to this policy in this proposed rule. However, we
are requesting comment on whether we should establish a minimum
threshold (for example, 50 percent) of the clinicians (NPIs) that must
complete an improvement activity in order for the entire group (TIN) to
receive credit in the improvement activities performance category in
future years. In addition, we are requesting comments on recommended
minimum threshold percentages and whether we should establish different
thresholds based on the size of the group. For example, in considering
different thresholds we could attribute recognition as a certified or
recognized patient-centered medical home or comparable specialty
practice at the individual TIN/NPI level, and attribute this
designation to the group under which they bill if they are
participating in MIPS as a group or as part of a virtual group. A group
or virtual group consisting of 100 NPIs could have a reporting
threshold of 50 percent while a group consisting of 10 NPIs could have
a lower reporting threshold of 10 percent. We are concerned that while
establishing any specific threshold for the percentage of NPIs in a TIN
that must participate in an improvement activity for credit will
incentivize some groups to move closer to the threshold, it may have
the unintended consequence of incentivizing groups who are exceeding
the threshold to gravitate back toward the threshold. Therefore, we are
requesting comments on how to set this threshold while maintaining the
goal of promoting greater participation in an improvement activity.
Additionally, we noted in the CY 2017 Quality Payment Program final
rule (81 FR 77197) that we intended, in future years, to score the
improvement activities performance category based on performance and
improvement, rather than simple attestation. We seek comment on how we
could measure performance and improvement; we are especially interested
in ways to measure performance without imposing additional burden on
eligible clinicians, such as by using data captured in eligible
clinicians' daily work.
(b) Submission Criteria
In the CY 2017 Quality Payment Program final rule (81 FR 77185), we
finalized at Sec. 414.1380 to set the improvement activities
submission criteria under MIPS, to achieve the highest potential score,
at two high-weighted improvement activities or four medium-weighted
improvement activities, or some combination of high and medium-weighted
improvement activities. While the minimum reporting period for one
improvement activity is 90 days, the maximum frequency with which an
improvement activity may be reported would be once during the 12-month
performance period. In addition, as discussed in section II.C.4.d. of
this proposed rule, we are proposing to generally apply our previously
finalized and proposed group policies to virtual groups.
We established exceptions to the above for: small practices;
practices located in rural areas; practices located in geographic
HPSAs; non-patient facing
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individual MIPS eligible clinicians or groups; and individual MIPS
eligible clinicians and groups that participate in a MIPS APM or a
patient-centered medical home submitting in MIPS. Specifically, for
individual MIPS eligible clinicians and groups that are small
practices, practices located in rural areas or geographic HPSAs, or
non-patient facing individual MIPS eligible clinicians or groups, to
achieve the highest score, one high-weighted or two medium-weighted
improvement activities are required. For these individual MIPS eligible
clinicians and groups, in order to achieve one-half of the highest
score, one medium-weighted improvement activity is required.
Under the APM scoring standard, all clinicians identified on the
Participation List of an APM receive at least one-half of the highest
score applicable to the MIPS APM. To develop the improvement activities
score assigned to each MIPS APM, we compare the requirements of the
specific MIPS APM with the list of activities in the Improvement
Activities Inventory and score those activities in the same manner that
they are otherwise scored for MIPS eligible clinicians. If by our
assessment the MIPS APM does not receive the maximum improvement
activities performance category score then the APM entity can submit
additional improvement activities. All other individual MIPS eligible
clinicians or groups that we identify as participating in APMs that are
not MIPS APMs will need to select additional improvement activities to
achieve the improvement activities highest score. We refer readers to
section II.C.6.g. of this proposed rule for further discussion of the
APM scoring standard.
We also provided full credit for the improvement activities
performance category, as required by law, for an individual MIPS
eligible clinician or group that has received certification or
accreditation as a patient-centered medical home or comparable
specialty practice from a national program or from a regional or state
program, private payer or other body that administers patient-centered
medical home accreditation and certifies 500 or more practices for
patient-centered medical home accreditation or comparable specialty
practice certification, or for an individual MIPS eligible clinician or
group that is a participant in a medical home model.
We also noted in the CY 2017 Quality Payment Program final rule
that practices may receive this designation at a practice level and
that TINs may be comprised of both undesignated practices and
designated practices (81 FR 77178). We finalized at Sec.
414.1380(b)(3)(viii) that to receive full credit as a certified
patient-centered medical home or comparable specialty practice, a TIN
that is reporting must include at least one practice that is a
certified patient-centered medical home or comparable specialty
practice. We also indicated that we would continue to have more
stringent requirements in future years, and would lay the groundwork
for expansion towards continuous improvement over time (81 FR 77189).
We received many comments on the CY 2017 Quality Payment Program final
rule regarding our transition year policy that only one practice site
within a TIN needs to be certified as a patient-centered medical home
for the entire TIN to receive full credit in the improvement activities
performance category. While several commenters supported our transition
year policy, others disagreed and suggested to move to a more stringent
requirement in future years while still offering some flexibility.
Accordingly, we propose to revise Sec. 414.1380(b)(3)(x) to provide
that for the 2020 MIPS payment year and future years, to receive full
credit as a certified or recognized patient-centered medical home or
comparable specialty practice, at least 50 percent of the practice
sites within the TIN must be recognized as a patient-centered medical
home or comparable specialty practice. This is an increase to the
requirement that only one practice site within a TIN needs to be
certified as a patient-centered medical home, but does not require
every site be certified, which could be overly restrictive given that
some sites within a TIN may be in the process of being certified as
patient-centered medical homes. In addition, we believe a 50 percent
threshold is achievable which is supported by a study of physician-
owned primary care groups in a recent Annals of Family Medicine article
(Casalino, et al., 2016) http://www.annfammed.org/content/14/1/16.full.
For nearly all groups in this study (sampled with variation in size and
geographic area) at least 50 percent of the practice sites within the
group had a medical home designation. If the group is unable to meet
the 50 percent threshold then the individual MIPS eligible clinician
may choose to receive full credit as a certified patient-centered
medical home or comparable specialty practice by reporting as an
individual for all performance categories. In addition, as discussed in
section II.C.4.d. of this proposed rule, we are proposing to generally
apply our previously finalized and proposed group policies to virtual
groups. Further, we welcome suggestions on an appropriate threshold for
the number of NPIs within the TIN that must be recognized as a
certified patient-centered medical home or comparable specialty
practice to receive full credit in the improvement activities
performance category.
We have determined that the Comprehensive Primary Care Plus (CPC+)
APM design satisfies the requirements to be designated as a medical
home model, as defined in Sec. 414.1305, and is therefore a certified
or recognized patient-centered medical home for purposes of the
improvement activities performance category. The CPC+ model meets the
criteria to be an Advanced APM. CPC+ eligibility criteria for practices
include, but are not limited to, the use of CEHRT and care delivery
activities such as: Assigning patients to clinician panels; providing
24/7 clinician access; and supporting quality improvement activities.
Control groups in CPC+ are required to meet the same eligibility
criteria as those selected to be active participants in the model. For
Round 2 of CPC+, CMS is randomly assigning accepted practices into the
intervention group or a control group. Practices accepted into CPC+ and
randomized into the control group have satisfied the requirements for
participation in CPC+, a medical home model, and we believe that the
MIPS eligible clinicians in the control group should therefore receive
full credit for the improvement activities performance category. In
addition, the practices randomized to the CPC+ control group must sign
a Participation Agreement with us; the agreement will require practices
in a control group to maintain a Practitioner Roster of all MIPS
eligible clinicians in the practice.
Accordingly, we are proposing that MIPS eligible clinicians in
practices that have been randomized to the control group in the CPC+
APM would receive full credit as a medical home model, and therefore a
certified patient-centered medical home, for the improvement activities
performance category. MIPS eligible clinicians who attest that they are
in practices that have been randomized to the control group in the CPC+
APM would receive full credit for the improvement activities
performance category for each performance period in which they are on
the Practitioner Roster, the official list of eligible clinicians
participating in a practice in the CPC+ control group. The inclusion of
MIPS eligible clinicians in practices that have been randomized into
the CPC+ control group recognizes that they have met the
[[Page 30055]]
requirements to receive full credit for performance in the improvement
activities performance category as a medical home model, and will help
ensure more equitable treatment of the CPC+ control group by allowing
clinicians in the control group that have met the criteria for
participation in the CPC+ APM to receive the same recognition as those
actively participating in the CPC+ intervention group.
We request comments on these proposals.
(c) Required Period of Time for Performing an Activity
In the CY 2017 Quality Payment Program final rule (81 FR 77186), we
specified at Sec. 414.1360 that MIPS eligible clinicians or groups
must perform improvement activities for at least 90 consecutive days
during the performance period for improvement activities performance
category credit. Activities, where applicable, may be continuing (that
is, could have started prior to the performance period and are
continuing) or be adopted in the performance period as long as an
activity is being performed for at least 90 days during the performance
period. In addition, as discussed in section II.C.4.d. of this proposed
rule, we are proposing to generally apply our previously finalized and
proposed group policies to virtual groups. We are not proposing any
changes to the required period of time for performing an activity for
the improvement activities performance category in this proposed rule.
(4) Application of Improvement Activities to Non-Patient Facing
Individual MIPS Eligible Clinicians and Groups
In the CY 2017 Quality Payment Program final rule (81 FR 77187), we
specified at Sec. 414.1380(b)(3)(vii) that for non-patient facing
individual MIPS eligible clinicians or groups, to achieve the highest
score one high-weighted or two medium-weighted improvement activities
are required. For these individual MIPS eligible clinicians and groups,
in order to achieve one-half of the highest score, one medium-weighted
improvement activity is required. We are not proposing any changes to
the application of improvement activities to non-patient facing
individual MIPS eligible clinicians and groups for the improvement
activities performance category in this proposed rule.
(5) Special Consideration for Small, Rural, or Health Professional
Shortage Areas Practices
In the CY 2017 Quality Payment Program final rule (81 FR 77188), we
finalized at Sec. 414.1380(b)(3)(vii) that one high-weighted or two
medium-weighted improvement activities are required for individual MIPS
eligible clinicians and groups that are small practices or located in
rural areas, or geographic HPSAs, to achieve full credit. In addition,
we specified at Sec. 414.1305 that a rural area means ZIP codes
designated as rural, using the most recent HRSA Area Health Resource
File data set available. Lastly, we finalized the following definitions
at Sec. 414.1305: (1) Small practices is defined to mean practices
consisting of 15 or fewer clinicians and solo practitioners; and (2)
Health Professional Shortage Areas (HPSA) refers to areas as designated
under section 332(a)(1)(A) of the Public Health Service Act. We are not
proposing any changes to the special consideration for small, rural, or
health professional shortage areas practices for the improvement
activities performance category in this proposed rule.
(6) Improvement Activities Subcategories
In the CY 2017 Quality Payment Program final rule (81 FR 77190), we
finalized at Sec. 414.1365 that the improvement activities performance
category will include the subcategories of activities provided at
section 1848(q)(2)(B)(iii) of the Act. In addition, we finalized at
Sec. 414.1365 the following additional subcategories: Achieving Health
Equity; Integrated Behavioral and Mental Health; and Emergency
Preparedness and Response. We are not proposing any changes to the
improvement activities subcategories for the improvement activities
performance category in this proposed rule.
(7) Improvement Activities Inventory
(a) Proposed Approach on the Annual Call for Activities Process for
Adding New Activities
In Table H in the Appendix of the CY 2017 Quality Payment Program
final rule (81 FR 77817), we finalized the Improvement Activities
Inventory for MIPS. In addition, through subregulatory guidance we
provided an informal process for submitting new improvement activities
for potential inclusion in the comprehensive Improvement Activities
Inventory for the Quality Payment Program Year 2. During this
transition period we received input from various MIPS eligible
clinicians and organizations suggesting possible new activities via a
nomination form that was posted on the CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallForMeasures.html. We are proposing new activities
and changes to the Improvement Activities Inventory in Tables F and G
of the Appendix of this proposed rule.
For the Quality Payment Program Year 3 and future years, we are
proposing to formalize an Annual Call for Activities process for adding
possible new activities to the Improvement Activities Inventory. We
believe this is a way to engage eligible clinician organizations and
other relevant stakeholders, including beneficiaries, in the
identification and submission of improvement activities for
consideration. We propose that individual MIPS eligible clinicians or
groups and other relevant stakeholders may recommend activities for
potential inclusion in the Improvement Activities Inventory via a
similar nomination form utilized in the transition year of MIPS found
on the Quality Payment Program Web site at www.qpp.cms.gov. As part of
the process, individual MIPS eligible clinicians, groups, and other
relevant stakeholders would be able to nominate additional improvement
activities that we may consider adding to the Improvement Activities
Inventory. Individual MIPS eligible clinicians and groups and relevant
stakeholders would be able to provide an explanation via the nomination
form of how the improvement activity meets all the criteria we have
identified in section II.C.6.e.(7)(b) of this proposed rule. The 2018
proposed new improvement activities and the 2018 proposed improvement
activities with changes can be found in Tables F and G of the Appendix
of this proposed rule and will be available on the CMS Web site.
We request comments on this proposed annual Call for Activities
process.
(b) Criteria for Nominating New Improvement Activities for the Annual
Call for Activities
We propose for the Quality Payment Program Year 2 and future years
that stakeholders would apply one or more of the following criteria
when submitting improvement activities in response to the Annual Call
for Activities:
Relevance to an existing improvement activities
subcategory (or a proposed new subcategory);
Importance of an activity toward achieving improved
beneficiary health outcome;
[[Page 30056]]
Importance of an activity that could lead to improvement
in practice to reduce health care disparities;
Aligned with patient-centered medical homes;
Activities that may be considered for an advancing care
information bonus;
Representative of activities that multiple individual MIPS
eligible clinicians or groups could perform (for example, primary care,
specialty care);
Feasible to implement, recognizing importance in
minimizing burden, especially for small practices, practices in rural
areas, or in areas designated as geographic HPSAs by HRSA;
Evidence supports that an activity has a high probability
of contributing to improved beneficiary health outcomes; or
CMS is able to validate the activity.
We note that in future rulemaking, activities that overlap with
other performance categories may be included if such activities support
the key goals of the program.
We request comments on this proposal.
(c) Submission Timeline for Nominating New Improvement Activities for
the Annual Call for Activities
It is our intention that the nomination and acceptance process
will, to the best extent possible, parallel the Annual Call for
Measures process already conducted for MIPS quality measures. Aligned
with this approach, we propose to accept submissions for prospective
improvement activities at any time during the performance period for
the Annual Call for Activities and create an Improvement Activities
under Review (IAUR) list. This list will be considered by us and may
include federal partners in collaboration with stakeholders. The IAUR
list will be analyzed with consideration of the proposed criteria for
inclusion of improvement activities in the Improvement Activities
Inventory. In addition, we propose that for the Annual Call for
Activities, only activities submitted by March 1 would be considered
for inclusion in the Improvement Activities Inventory for the
performance periods occurring in the following calendar year. This
proposal is slightly different than the Call for Measures timeline. The
Annual Call for Measures requires a 2-year implementation timeline
because the measures being considered for inclusion in MIPS undergo the
pre-rulemaking process with review by the Measures Application
Partnership (MAP). We are not proposing that improvement activities
undergo MAP review. Therefore, our intention is to close the Annual
Call for Activities submissions by March 1 before the applicable
performance period, which will enable us to propose the new improvement
activities for adoption in the same year's rulemaking cycle for
implementation in the following year. For example, an improvement
activity submitted prior to March 1, 2018, would be considered for
performance periods occurring in 2019. In addition, we propose that we
will add new improvement activities to the inventory through notice-
and-comment rulemaking. In future years we anticipate developing a
process and establishing criteria for identifying activities for
removal from the Improvement Activities Inventory through the Annual
Call for Activities process. We are requesting comments on what
criteria should be used to identify improvement activities for removal
from the Improvement Activities Inventory.
(8) Approach for Adding New Subcategories
In the CY 2017 Quality Payment Program final rule (81 FR 77197), we
finalized the following criteria for adding a new subcategory to the
improvement activities performance category:
The new subcategory represents an area that could
highlight improved beneficiary health outcomes, patient engagement and
safety based on evidence.
The new subcategory has a designated number of activities
that meet the criteria for an improvement activity and cannot be
classified under the existing subcategories.
Newly identified subcategories would contribute to
improvement in patient care practices or improvement in performance on
quality measures and cost performance categories.
We are not proposing any changes to the approach for adding new
subcategories for the improvement activities performance category in
this proposed rule. However, we are proposing that in future years of
the Quality Payment Program we will add new improvement activities
subcategories through notice-and-comment rulemaking. In addition, we
are seeking comments on new improvement activities subcategories.
A number of stakeholders have suggested that a separate subcategory
for improvement activities specifically related to health IT would make
it easier for MIPS eligible clinicians and vendors to understand and
earn points toward their final score through the use of health IT. Such
a health IT subcategory could include only improvement activities that
are specifically related to the advancing care information performance
category measures and allow MIPS eligible clinicians to earn credit in
the improvement activities performance category, while receiving a
bonus in the advancing care information performance category as well.
We are seeking suggestions on how a health IT subcategory within the
improvement activities performance category could be structured to
afford MIPS eligible clinicians with flexible opportunities to gain
experience in using CEHRT and other health IT to improve their
practice. Should the current policies where improvement activities earn
bonus points within the advancing care information performance category
be enhanced? Are there additional policies that should be explored in
future rulemaking? We welcome public comment on this potential health
IT subcategory.
(9) CMS Study on Burdens Associated With Reporting Quality Measures
In the CY 2017 Quality Payment Program final rule (81 FR 77195), we
finalized specifics regarding the CMS Study on Improvement Activities
and Measurement including the study purpose, study participation credit
and requirements, and the study procedure. We are modifying the name of
the study in this proposed rule to the ``CMS study on burdens
associated with reporting quality measures'' to more accurately reflect
the purpose of the study. The study assesses clinician burden and data
submission errors associated with the collection and submission of
clinician quality measures for MIPS, enrolling groups of different
sizes and individuals in both rural and non-rural settings and also
different specialties. We also noted that study participants would
receive full credit in the improvement activities performance category
after successfully electing, participating, and submitting data to the
study coordinators at CMS for the full calendar year (81 FR 77196). We
requested comment on the study, and received generally supportive
feedback for the study.
We are not proposing any changes to the study purpose. We are
proposing changes to the study participation credit and requirements
sample size, how the study sample is categorized into groups, and the
frequency of quality data submission, focus groups, and surveys. In
addition to performing descriptive statistics to compare the trends in
errors and burden between study years 2017 and 2018, we would like to
perform a more rigorous statistical analysis with the 2018 data, which
will require a larger sample size. We propose this increase in the
sample size for 2018 to
[[Page 30057]]
provide the minimum sample needed to get a significant result with
adequate power for the following investigation.
Specifically, we are interested in whether there are any
significant differences in quality measurement data submission errors
and/or clinician burdens between rural clinicians submitting either
individually or as a group, and urban clinicians submitting as an
individual or as a group. A statistical power analysis was performed
and a total sample size of 118 will be adequate for the main objective
of the study. However, allowance will be made to account for attrition
and other additional (or secondary) analysis.
This analysis would be compared at different sizes of practices (<3
eligible clinicians, between 3-8 eligible clinicians, etc.). This
assessment is important since it facilitates tracing the root causes of
measurement burdens and data submission errors that may be associated
with any sub-group of clinician practice. This comparison may further
break the sample down into more than four categories and a much larger
sample size is a requisite for significant results with adequate
probability of certainty.
The sample size for performance periods occurring in 2017 consisted
of 42 MIPS groups as stated by MIPS criteria from the following seven
categories:
10 urban individual or groups of <3 eligible clinicians.
10 rural individual or groups of <3 eligible clinicians.
10 groups of 3-8 eligible clinicians.
5 groups of 8-20 eligible clinicians.
3 groups of 20-100 eligible clinicians.
2 groups of 100 or greater eligible clinicians.
2 specialty groups.
We are proposing to increase the sample size for the performance
periods occurring in 2018 to a minimum of:
20 urban individual or groups of <3 eligible clinicians--
(broken down into 10 individuals & 10 groups).
20 rural individual or groups of <3 eligible clinicians--
(broken down into 10 individuals & 10 groups).
10 groups of 3-8 eligible clinicians.
10 groups of 8-20 eligible clinicians.
10 groups of 20-100 eligible clinicians.
10 groups of 100 or greater eligible clinicians.
6 groups of >20 eligible clinicians reporting as
individuals--(broken down into 3 urban & 3 rural).
6 specialty groups--(broken down into 3 reporting
individually & 3 reporting as a group).
Up to 10 non-MIPS eligible clinicians reporting as a group
or individual (any number of individuals and any group size).
In addition, we are proposing changes to the study procedures. In
the transition year of MIPS, study participants were required to attend
a monthly focus group to share lessons learned in submitting quality
data along with providing survey feedback to monitor effectiveness.
However, an individual MIPS eligible clinician or group who chooses to
report all 6 measures within a period of 90 days may not need to be a
part of all of the focus groups and survey sessions after their first
focus group and survey following the measurement data submission. This
is because they may have nothing new to contribute in terms of
discussion of errors or clinician burdens. This also applies to MIPS
eligible clinicians that submit only three MIPS measures within the
performance period, if they submitted all three measures within the 90-
day period or at one submission. All study participants would
participate in surveys and focus group meetings at least once after
each measures data submission. For those who elect to report data for a
90-day period, we would make further engagement optional. Therefore, we
are proposing that for Quality Payment Program Year 2 and future years
that study participants would be required to attend as frequently as
four monthly surveys and focus group sessions throughout the year, but
certain study participants would be able to attend less frequently.
Further, the CY 2017 study requires study measurement data to be
collected at baseline and at every 3 months (quarterly basis)
afterwards for the duration of the calendar year. It also calls for a
minimum requirement of three MIPS quality measures four times within
the year. We believe this is inconsistent with clinicians reporting a
full year's data as we believe some study participants may choose to
submit data for all measures at one time, or alternatively, may choose
to submit data up to six times during the 1-year period. We are
proposing for the Quality Payment Program Year 2 and future years to
offer study participants flexibility in their submissions so that they
could submit once, as can occur in the MIPS program, and participate in
study surveys and focus groups while still earning improvement
activities credit.
It must be noted that although the aforementioned activities
constitute an information collection request as defined in the
implementing regulations of the Paperwork Reduction Act of 1995 (5 CFR
1320), the associated burden is exempt from application of the
Paperwork Reduction Act. Specifically, section 1848(s)(7) of the Act,
as added by section 102 of the MACRA (Pub. L. 114-10) states that
Chapter 35 of title 44, United States Code, shall not apply to the
collection of information for the development of quality measures. Our
goals for new measures are to develop new high quality, low cost
measures that are meaningful, easily understandable and operable, and
also, reliably and validly measure what they purport. This study shall
inform us (and our contractors) on the root causes of clinicians'
performance measure data collection and data submission burdens and
challenges that hinders accurate and timely quality measurement
activities. In addition, this study will inform us on the
characteristic attributes that our new measures must possess to be able
to accurately capture and measure the priorities and gaps MACRA aims
for, as described in the Quality Measures Development Plan.\2\ This
study, therefore, serves as the initial stage of developing new
measures and also adapting existing measures. We believe that
understanding clinician's challenges and skepticisms, and especially,
understanding the factors that undermine the optimal functioning and
effectiveness of quality measures are requisites of developing measures
that are not only measuring what it purports but also that are user
friendly and understandable for frontline clinicians--our main
stakeholders in measure development. This will lead to the creation of
practice-derived, tested measures that reduces burden and create a
culture of continuous improvement in measure development.
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\2\ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf (assessed: 06/02/2017).
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We request comments on our study on burdens associated with
reporting quality measures proposals regarding sample size for the
performance periods occurring in 2018, study procedures for the
performance periods occurring in 2018 and future years, and data
submissions for the performance periods occurring in 2018 and future
years.
f. Advancing Care Information Performance Category
(1) Background
Section 1848(q)(2)(A) of the Act includes the meaningful use of
CEHRT as a performance category under the MIPS. We refer to this
performance
[[Page 30058]]
category as the advancing care information performance category, and it
is reported by MIPS eligible clinicians as part of the overall MIPS
program. As required by sections 1848(q)(2) and (5) of the Act, the
four performance categories of the MIPS shall be used in determining
the MIPS final score for each MIPS eligible clinician. In general, MIPS
eligible clinicians will be evaluated under all four of the MIPS
performance categories, including the advancing care information
performance category.
(2) Scoring
Section 1848(q)(5)(E)(i)(IV) of the Act states that 25 percent of
the MIPS final score shall be based on performance for the advancing
care information performance category. We established at Sec.
414.1380(b)(4) that the score for the advancing care information
performance category would be comprised of a base score, performance
score, and potential bonus points for reporting on certain measures and
activities. For further explanation of our scoring policies for the
advancing care information performance category, we refer readers to 81
FR 77216-77227.
(a) Base Score
For the CY 2018 performance period, we are not proposing any
changes to the base score methodology as established in the CY 2017
Quality Payment Program final rule (81 FR 77217-77223). We established
the policy that MIPS eligible clinicians must report a numerator of at
least one for the numerator/denominator measures, or a ``yes'' response
for the yes/no measure in order to earn the 50 percentage points in the
base score. In addition, if the base score requirements are not met, a
MIPS eligible clinician would receive a score of zero for the ACI
performance category.
(b) Performance Score
In the CY 2017 Quality Payment Program final rule (81 FR 77223
through 77226), we finalized that MIPS eligible clinicians can earn 10
percentage points in the performance score for meeting the Immunization
Registry Reporting Measure. We believe we should modify this policy
because we have learned that there are areas of the country where
immunization registries are not available, and we did not intend to
disadvantage MIPS eligible clinicians practicing in those areas. Thus,
we are proposing to modify the scoring of the Public Health and
Clinical Data Registry Reporting objective beginning with the
performance period in CY 2018. We propose if a MIPS eligible clinician
fulfills the Immunization Registry Reporting Measure, the MIPS eligible
clinician would earn 10 percentage points in the performance score. If
a MIPS eligible clinician cannot fulfill the Immunization Registry
Reporting Measure, we are proposing that the MIPS eligible clinician
could earn 5 percentage points in the performance score for each public
health agency or clinical data registry to which the clinician reports
for the following measures, up to a maximum of 10 percentage points:
Syndromic Surveillance Reporting; Electronic Case Reporting; Public
Health Registry Reporting; and Clinical Data Registry Reporting. A MIPS
eligible clinician who chooses to report to more than one public health
agency or clinical data registry may receive credit in the performance
score for the submission to more than one agency or registry; however,
the MIPS eligible clinician would not earn more than a total of 10
percentage points for such reporting.
We further propose similar flexibility for MIPS eligible clinicians
who choose to report the measures specified for the Public Health
Reporting Objective of the 2018 Advancing Care Information Transition
Objective and Measure set. (In section II.C.6.f.(6)(b) of this proposed
rule, we are proposing to allow MIPS eligible clinicians to report
using the 2018 Advancing Care Information Transition Objectives and
Measures in 2018.) We propose if a MIPS eligible clinician fulfills the
Immunization Registry Reporting Measure, the MIPS eligible clinician
would earn 10 percentage points in the performance score. If a MIPS
eligible clinician cannot fulfill the Immunization Registry Reporting
Measure, we are proposing that the MIPS eligible clinician could earn 5
percentage points in the performance score for each public health
agency or specialized registry to which the clinician reports for the
following measures, up to a maximum of 10 percentage points: Syndromic
Surveillance Reporting; Specialized Registry Reporting. A MIPS eligible
clinician who chooses to report to more than one specialized registry
or public health agency to submit syndromic surveillance data may earn
5 percentage points in the performance score for reporting to each one,
up to a maximum of 10 percentage points.
By proposing to expand the options for fulfilling the Public Health
and Clinical Data Registry Reporting and the Public Health Reporting
objectives, we believe that we are adding flexibility so that
additional MIPS eligible clinicians can successfully fulfill this
objective and earn 10 percentage points in the performance score. We
are not proposing to change the maximum performance score that a MIPS
eligible clinician can earn; it remains at 90 percent.
We are inviting public comment on these proposals.
(c) Bonus Score
In the CY 2017 Quality Payment Program final rule (81 FR 77220
through 77226), for the Public Health and Clinical Data Registry
Reporting objective and the Public Health Reporting objective, we
finalized that MIPS eligible clinicians who report to one or more
public health agencies or clinical data registries beyond the
Immunization Registry Reporting Measure will earn a bonus score of 5
percentage points in the advancing care information performance
category. (In section II.C.6.f.(6)(b) of this proposed rule, we are
proposing to allow MIPS eligible clinicians to report using the 2018
Advancing Care Information Transition Objectives and Measures in 2018.)
Based on our proposals above to allow MIPS eligible clinicians who
cannot fulfill the Immunization Registry Reporting Measure to earn
additional points in the performance score, we believe we should modify
this policy so that MIPS eligible clinicians cannot earn points in both
the performance score and bonus score for reporting to the same public
health agency or clinical data registry. We are proposing to modify our
policy beginning with the performance period in CY 2018. We are
proposing that a MIPS eligible clinician may only earn the bonus score
of 5 percentage points for reporting to at least one additional public
health agency or clinical data registry that is different from the
agency/agencies or registry/or registries to which the MIPS eligible
clinician reports to earn a performance score. For example, if a MIPS
eligible clinician reports to a public health agency and a clinical
data registry for the performance score, they could earn the bonus
score of 5 percentage points by reporting to a different agency or
registry that the clinician did not identify for purposes of the
performance score. A MIPS eligible clinician would not receive credit
under both the performance score and bonus score for reporting to the
same agency or registry.
We are proposing that for the Advancing Care Information Objectives
and Measures, a bonus of 5 percentage points would be awarded if the
MIPS eligible clinician reports ``yes'' for any one of the following
measures associated with the Public Health and Clinical Data Registry
Reporting
[[Page 30059]]
objective: Syndromic Surveillance Reporting; Electronic Case Reporting;
Public Health Registry Reporting; or Clinical Data Registry Reporting.
We are proposing that for the 2018 Advancing Care Information
Transition Objectives and Measures, a bonus of 5 percent would be
awarded if the MIPS eligible clinician reports ``yes'' for any one of
the following measures associated with the Public Health Reporting
objective: Syndromic Surveillance Reporting or Specialized Registry
Reporting. We are proposing that to earn the bonus score, the MIPS
eligible clinician must be in active engagement with one or more
additional public health agencies or clinical data registries that is/
are different from the agency or registry that they identified to earn
a performance score.
We are inviting public comment on this proposal.
(d) Improvement Activities Bonus Score Under the Advancing Care
Information Performance Category
In the CY 2017 Quality Payment Program final rule (81 FR 77202), we
discussed our approach to the measurement of the use of health IT to
allow MIPS eligible clinicians and groups the flexibility to implement
health IT in a way that supports their clinical needs. In addition, we
discussed the need to move toward measurement of health IT use with
respect to its contribution to effective care coordination and
improving outcomes for patients. We stated that this approach would
allow us to more directly link health IT adoption and use to patient
outcomes, moving MIPS beyond the measurement of EHR adoption and
process measurement and into a more patient-focused health IT program.
Toward that end, we adopted a policy to award a bonus score to MIPS
eligible clinicians who use CEHRT to complete certain activities in the
improvement activities performance category based on our belief that
the use of CEHRT in carrying out these activities could further the
outcomes of clinical practice improvement.
We adopted a final policy to award a 10 percent bonus for the
advancing care information performance category if a MIPS eligible
clinician attests to completing at least one of the improvement
activities we have specified using CEHRT (81 FR 77209). We refer
readers to Table 8 in the CY 2017 Quality Payment Program final rule
(81 FR 77202-77209) for a list of the improvement activities eligible
for the advancing care information performance category bonus. In this
proposed rule, we are proposing to expand this policy beginning with
the CY 2018 performance period by identifying additional improvement
activities in Table 6 that would be eligible for the advancing care
information performance category bonus score if they are completed
using CEHRT functionality. The activities eligible for the bonus score
would include those listed in Table 6, as well as those listed in Table
8 in last year's final rule. We refer readers to the Improvement
Activities section of this proposed rule (section II.C.6.e. of this
proposed rule) for a discussion of the proposed new improvement
activities and proposed changes to the improvement activities for 2018.
Ten percentage points is the maximum bonus a MIPS eligible
clinician would receive if they attest to using CEHRT for one or more
of the activities we have identified as eligible for the bonus. This
bonus is intended to support progression toward holistic health IT use
and measurement; attesting to even one improvement activity
demonstrates that the MIPS eligible clinician is working toward this
holistic approach to the use of their CEHRT. The weight of the
improvement activity for the improvement activities performance
category has no effect on the bonus awarded in the advancing care
information performance category.
We invite comment on this proposal.
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(3) Performance Periods for the Advancing Care Information Performance
Category
In the CY 2017 Quality Payment Program final rule (81 FR 77210
through 77211), we established a performance period for the advancing
care information performance category to align with the overall MIPS
performance period of one full year to ensure all four performance
categories are measured and scored based on the same period of time. We
believe this will lower reporting burden, focus clinician quality
improvement efforts and align administrative actions so that MIPS
eligible clinicians can use common systems and reporting pathways. We
stated for the first and second performance periods of MIPS (CYs 2017
and 2018), we will accept a minimum of 90 consecutive days of data and
encourage MIPS eligible clinicians to report data for the full year
performance period. We are maintaining this policy as finalized for the
performance period in CY 2018, and will accept a minimum of 90
consecutive days of data in CY 2018. We are proposing the same policy
for the advancing care information performance category for the
performance period in CY 2019, Quality Payment Program Year 3, and
would accept a minimum of 90 consecutive days of data in CY 2019. We
refer readers to section II.C.5. in this proposed rule for additional
information on the MIPS performance period.
(4) Certification Requirements
In the CY 2017 Quality Payment Program final rule (81 FR 77211
through 77213), we outlined the requirements for MIPS eligible
clinicians using CEHRT during the CY 2017 performance period for the
advancing care information performance category as it relates to the
objectives and measures they select to report, and also outlined
requirements for the CY 2018 performance period. We additionally
adopted a definition of CEHRT at Sec. 414.1305 for MIPS eligible
clinicians that is based on the definition that applies in the EHR
Incentive Programs under Sec. 495.4.
For the CY 2017 performance period, we adopted a policy by which
MIPS eligible clinicians may use EHR
[[Page 30064]]
technology certified to either the 2014 or 2015 Edition certification
criteria, or a combination of the two. For the CY 2018 performance
period, we previously stated that MIPS eligible clinicians must use EHR
technology certified to the 2015 Edition to meet the objectives and
measures specified for the advancing care information performance
category.
We received significant comments and feedback from stakeholders
requesting that we extend the use of 2014 Edition CEHRT beyond CY 2017
into CY 2018 and even CY 2019. Many commenters noted the lack of
products certified to the 2015 Edition. Others stated that switching
from the 2014 Edition to the 2015 Edition requires a large amount of
time and planning and if it is rushed there is a potential risk to
patient health. Some commenters noted the significant burden of
combining outputs from multiple CEHRTs. A few mentioned that the cost
to switch to the 2015 Edition is prohibitive for smaller practices.
Our experience with the transition from EHR technology certified to
the 2011 Edition to EHR technology certified to the 2014 Edition did
make us aware of the many issues associated with the adoption of EHR
technology certified to a new Edition. These include the time that will
be necessary to effectively deploy EHR technology certified to the 2015
Edition standards and certification criteria and to make the necessary
patient safety, staff training, and workflow investments to be prepared
to report for the advancing care information performance category for
2018. We understand and appreciate these concerns, and are working in
collaboration with our federal partners at the Office of the National
Coordinator for Health Information Technology (ONC) to monitor progress
on the 2015 Edition upgrade.
As noted in the FY 2018 Inpatient Prospective Payment Systems for
Acute Care Hospitals and the Long-Term Care Hospital Prospective
Payment System proposed rule (referred to as the FY 2018 IPPS/LTCH PPS
proposed rule) (82 FR 20136), ONC is working with health IT developers
to analyze and monitor the status of developer readiness for 2015
Edition technology. As part of these analyses, ONC also reviewed health
IT being certified to 2015 Edition by health IT developers who have
products that were certified for the 2014 Edition and were used by EHR
Incentive Program participants to attest. This analysis compared the
pace of 2014 Edition certification with the pace of 2015 Edition
certification to date. As of the beginning of the second quarter of CY
2017, ONC confirmed that at least 53 percent of eligible clinicians and
80 percent of eligible hospitals have 2015 Edition certified EHR
technology available based on previous EHR Incentive Programs
attestation data. Based on these data, and as compared to the
transition from 2011 Edition to 2014 Edition, it appears that the
transition from the 2014 Edition to the 2015 Edition is on schedule for
the CY 2018 performance period.
However, the analysis also considered market trends such as
consolidation and the number of large and small developers covering
various groups of participants and the potential impact on readiness.
The eligible hospital market is fairly concentrated, with nearly 98
percent of eligible hospital EHR Incentive Program participants using
health IT from the top ten developers (ranked by market share) with a
significant majority of that coverage by the top five developers. For
hospitals, some developers representing a smaller market share also
have certified health IT already available and are not expected to have
a release schedule much different from their larger competitors.
Considering market factors and using previous EHR Incentive Programs
attestation data, ONC estimates that at least 85 percent of eligible
hospitals would have EHR technology certified to the 2015 Edition
available for use by the end of CY 2017 for program participation in
2018. In the FY 2018 IPPS/LTCH PPS proposed rule (82 FR 20136), we
proposed to shorten the EHR reporting period to a minimum of any
continuous 90-day period within CY 2018 for eligible hospitals and
CAHs, as well as EPs who attest for a state's Medicaid EHR Incentive
Program, to allow additional time for successful implementation of EHR
technology certified to the 2015 Edition in CY 2018.
For MIPS eligible clinicians, the concern of potential impact on
participation readiness when reviewing these market factors may be more
significant. As noted in the FY 2018 IPPS/LTCH PPS proposed rule (82 FR
20136), historical data indicates eligible professionals were more
likely to use a wider range of certified health IT, including those
which individually make up a smaller segment of the overall market.
Therefore, when market factors are taken into account, there exists a
larger proportion of readiness that is unknown due to the wider range
of certified health IT which may be used by MIPS eligible clinicians.
This necessitated a more conservative approach for MIPS eligible
clinician readiness. That estimate is that 74 percent of MIPS eligible
clinicians will be ready to participate in MIPS using 2015 Edition
certified EHR technologies by January 1, 2018.
However, subsequent to the preliminary analysis, ONC has continued
to monitor readiness and to receive feedback from stakeholders on
factors influencing variations in the development and implementation
timelines for developers supporting different segments of the market,
as well as the relationship between the developer readiness timeline
and participant readiness. This continuing analysis supports a
potential need for a longer implementation timeline for MIPS eligible
clinicians. Stakeholder feedback suggests that while the estimate for
known readiness remains the same, readiness among the remaining MIPS
eligible clinicians may not be on the same timeline. About one quarter
of eligible professional EHR Incentive Program participants in prior
years used certified health IT from small developers that each has an
historical market share of 1 percent or less. Therefore, MIPS eligible
clinicians will need a significant number of smaller developers to
reach the same readiness on the same timeline as larger companies in
order to support program participants seeking to upgrade to the 2015
Edition. However, small developers generally offer a limited number or
type of products, and may have more limited resources to dedicate to
upgrade development, testing and certification, and implementation,
which may affect availability and timing. In addition, the same factors
may impact the capacity of some developers to support participants
during the process and therefore the timeline for participant readiness
would also potentially be longer. This is supported by historical
analysis as a smaller percentage of eligible professionals used 2014
Edition certified EHR technology for participation in the EHR Incentive
Programs during the 2014 calendar year than eligible hospitals and CAHs
for the same year. For this reason, we believe additional flexibility
for MIPS eligible clinicians is essential to support successful
participation in the advancing care information performance category.
We continue to believe that there are many benefits for switching
to EHR technology certified to the 2015 Edition. As noted in the FY
2018 IPPS/LTCH PPS proposed rule (82 FR 20136), the 2015 Edition health
IT certification criteria enables health information exchange through
new and enhanced certification criteria standards, and through
implementation specifications
[[Page 30065]]
for interoperability. The 2015 Edition also incorporates changes that
are designed to spur innovation and provide more choices to health care
providers and patients for the exchange of electronic health
information, including new Application Programming Interface (API)
certification criteria. APIs are required for patient engagement
measures within the advancing care information category; however, they
may also be enabled by a health care provider or organization for their
own use of third party applications with their CEHRT, such as for
quality improvement. An API can also be enabled by a health care
provider to give patients access to their health information through a
third-party application with more flexibility than is often found in
many current patient portals. From the MIPS eligible clinician
perspective, an API could complement a patient portal or could also
potentially make one unnecessary if patients are able to use software
applications designed to interact with an API that could support their
ability to view, download, and transmit their health information to a
third party. In addition, the 2015 Edition health IT transitions of
care certification criterion rigorously assesses a product's ability to
create and receive a Consolidated-Clinical Document Architecture (C-
CDA) formatted documents. The ONC also adopted certification criteria
that both support interoperability in other settings and use cases,
such as the Common Clinical Data Set summary record, data segmentation
for privacy, and care plan certification criteria (80 FR 62603).
However, in light of the conservative readiness estimates for MIPS
eligible clinicians, and in line with our commitment to supporting
small practices, solo practitioners and specialties which may be more
likely to use certified health IT offered by small developers, we are
proposing that MIPS eligible clinicians may use EHR technology
certified to either the 2014 or 2015 Edition certification criteria, or
a combination of the two for the CY 2018 performance period. We propose
to amend Sec. 414.1305 to reflect this change. We further note, that
to encourage new participants to adopt certified health IT and to
incentivize participants to upgrade their technology to 2015 Edition
products which better support interoperability across the care
continuum, we are proposing to offer a bonus of 10 percentage points
under the advancing care information performance category for MIPS
eligible clinicians who report the Advancing Care Information
Objectives and Measures for the performance period in CY 2018 using
only 2015 Edition CEHRT. We are proposing to amend Sec.
414.1380(b)(4)C)(3) to reflect this change. We are proposing this one-
time bonus for CY 2018 to support and recognize MIPS eligible
clinicians and groups that invest in implementing certified EHR
technology in their practice. Specifically, we intend this bonus to
support new participants that may be adopting health IT for the first
time in CY 2018 and do not have 2014 Edition technology available to
use or that may have no prior experience with meaningful use objectives
and measures. We believe this bonus will help recognize their
investment to adopt health IT and support their participation in the
advancing care information performance category in MIPS. In addition,
we believe this bonus will help to incentivize participants to continue
the process of upgrading from 2014 Edition to 2015 Edition, especially
small practices where the investment in updated workflows and
implementation may present unique challenges. We intend this bonus to
support and recognize their efforts to engage with the advancing care
information measures using technology certified to the 2015 Edition,
which include more robust measures using updated standards and
functions which support interoperability. We seek comment on this
proposed bonus. Specifically, we seek comment on if the percentage of
the bonus is appropriate, or whether it should be limited to new
participants in MIPS and small practices.
This bonus is not available to MIPS eligible clinicians who use a
combination of the 2014 and 2015 Editions. We note that with the
addition of the 2015 Edition CEHRT bonus of 10 percentage points, MIPS
eligible clinicians would be able to earn a bonus score of up to 25
percentage points in CY 2018 under the advancing care information
performance category, an increase from the 15 percentage point bonus
score available in CY 2017.
To facilitate readers in identifying the requirements of CEHRT for
the Advancing Care Information Objectives and Measures, we are
including Table 8 in section II.C.6.f.(6)(a) which lists the 2015
Edition and 2014 Edition certification criteria required to meet the
objectives and measures.
We invite comments on these proposals.
(5) Scoring Methodology Considerations
Section 1848(q)(5)(E)(i)(IV) of the Act states that 25 percent of
the MIPS final score shall be based on performance for the advancing
care information performance category. Further, section
1848(q)(5)(E)(ii) of the Act, provides that in any year in which the
Secretary estimates that the proportion of eligible professionals (as
defined in section 1848(o)(5) of the Act) who are meaningful EHR users
(as determined under section 1848(o)(2) of the Act) is 75 percent or
greater, the Secretary may reduce the applicable percentage weight of
the advancing care information performance category in the MIPS final
score, but not below 15 percent, and increase the weightings of the
other performance categories such that the total percentage points of
the increase equals the total percentage points of the reduction. We
note that section 1848(o)(5) of the Act defines an eligible
professional as a physician, as defined in section 1861(r) of the Act.
In CY 2017 Quality Payment Program final rule (81 FR 77226-77227),
we established a final policy, for purposes of applying section
1848(q)(5)(E)(ii) of the Act, to estimate the proportion of physicians
as defined in section 1861(r) of the Act who are meaningful EHR users
as those physician MIPS eligible clinicians who earn an advancing care
information performance category score of at least 75 percent for a
performance period. We established that we will base this estimation on
data from the relevant performance period, if we have sufficient data
available from that period. For example, if feasible, we would consider
whether to reduce the applicable percentage weight of the advancing
care information performance category in the MIPS final score for the
2019 MIPS payment year based on an estimation using the data from the
2017 performance period. We stated that we will not include in the
estimation physicians for whom the advancing care information
performance category is weighted at zero percent under section
1848(q)(5)(F) of the Act, which we relied on in the CY 2017 Quality
Payment Program final rule (81 FR 77226 through 77227) to establish
policies under which we would weigh the advancing care information
performance category at zero percent of the final score. In addition,
we are proposing not to include in the estimation physicians for whom
the advancing care information performance category would be weighted
at zero percent under our proposal in section II.C.6.f.(7) of this
proposed rule to implement certain provisions of the 21st Century Cures
Act (that is, physicians who are determined hospital-based or
ambulatory surgical center-based, or who are granted an exception based
on
[[Page 30066]]
significant hardship or decertified EHR technology.
We are considering modifications to the policy we established in
last year's rulemaking to base our estimation of physicians who are
meaningful EHR users for a MIPS payment year (for example, 2019) on
data from the relevant performance period (for example, 2017). We are
concerned that if in future rulemaking we decide to propose to change
the weight of the advancing care information performance category based
on our estimation, such a change may cause confusion to MIPS eligible
clinicians who are adjusting to the MIPS program and believe this
performance category will make up 25 percent of the final score for the
2019 MIPS payment year. The earliest we would be able to make our
estimation based on 2017 data and propose in future rulemaking to
change the weight of the advancing care information performance
category for the 2019 MIPS payment year would be in mid-2018, as the
deadline for data submission is March 31, 2018. We are requesting
public comments on whether this timeframe is sufficient, or whether a
more extended timeframe would be preferable. We are proposing to modify
our existing policy such that we would base our estimation of
physicians who are meaningful EHR users for a MIPS payment year on data
from the performance period that occurs four years before the MIPS
payment year. For example, we would use data from the 2017 performance
period to estimate the proportion of physicians who are meaningful EHR
users for purposes of reweighting the advancing care information
performance category for the 2021 MIPS payment year.
We invite comments on this proposal.
(6) Objectives and Measures
(a) Advancing Care Information Objectives and Measures Specifications
We are proposing to maintain for the CY 2018 performance period the
Advancing Care Information Objectives and Measures as finalized in the
CY 2017 Quality Payment Program final rule (81 FR 77227 through 77229)
with the modifications proposed below. As we noted (81 FR 77227), these
objectives and measures were adapted from the Stage 3 objectives and
measures finalized in the 2015 EHR Incentive Programs final rule (80 FR
62829 through 62871), however, we did not maintain the previously
established thresholds for MIPS. For a more detailed discussion of the
Stage 3 objectives and measures, including explanatory material and
defined terms, we refer readers to the 2015 EHR Incentive Programs
final rule (80 FR 62829 through 62871).
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Objective: Protect Patient Health Information.
Objective: Protect electronic protected health information (ePHI)
created or maintained by the CEHRT through the implementation of
appropriate technical, administrative, and physical safeguards.
Security Risk Analysis Measure: Conduct or review a security risk
analysis in accordance with the requirements in 45 CFR 164.308(a)(1),
including addressing the security (to include encryption) of ePHI data
created or maintained by CEHRT in accordance with requirements in 45
CFR 164.312(a)(2)(iv) and 164.306(d)(3), implement security updates as
necessary, and correct identified security deficiencies as part of the
MIPS eligible clinician's risk management process.
Objective: Electronic Prescribing.
Objective: Generate and transmit permissible prescriptions
electronically.
E-Prescribing Measure: At least one permissible prescription
written by the MIPS eligible clinician is queried for a drug formulary
and transmitted electronically using CEHRT.
Denominator: Number of prescriptions written for drugs
requiring a prescription to be dispensed other than controlled
substances during the performance period; or number of prescriptions
written for drugs requiring a prescription to be dispensed during the
performance period.
Numerator: The number of prescriptions in the denominator
generated, queried for a drug formulary, and transmitted electronically
using CEHRT.
Objective: Patient Electronic Access.
Objective: The MIPS eligible clinician provides patients (or
patient-authorized representative) with timely electronic access to
their health information and patient-specific education.
Provide Patient Access Measure: For at least one unique patient
seen by the MIPS eligible clinician: (1) The patient (or the patient-
authorized representative) is provided timely access to view online,
download, and transmit his or her health information; and (2) The MIPS
eligible clinician ensures the patient's health information is
available for the patient (or patient-authorized representative) to
access using any application of their choice that is configured to meet
the technical specifications of the Application Programing Interface
(API) in the MIPS eligible clinician's CEHRT.
Denominator: The number of unique patients seen by the
MIPS eligible clinician during the performance period.
Numerator: The number of patients in the denominator (or
patient authorized representative) who are provided timely access to
health information to view online, download, and transmit to a third
party and to access using an application of their choice that is
configured meet the technical specifications of the API in the MIPS
eligible clinician's CEHRT.
Definition of timely--Beginning with the 2018 performance period,
we are proposing to define ``timely'' as within 4 business days of the
information being available to the MIPS eligible clinician. This
definition of timely is the same as we adopted under the EHR Incentive
Programs (80 FR 62815).
Patient-Specific Education Measure: The MIPS eligible clinician
must use clinically relevant information from CEHRT to identify
patient-specific educational resources and provide electronic access to
those materials to at least one unique patient seen by the MIPS
eligible clinician.
Denominator: The number of unique patients seen by the
MIPS eligible clinician during the performance period.
Numerator: The number of patients in the denominator who
were provided electronic access to patient-specific educational
resources using clinically relevant information identified from CEHRT
during the performance period.
Objective: Coordination of Care Through Patient Engagement.
Objective: Use CEHRT to engage with patients or their authorized
representatives about the patient's care.
View, Download, Transmit (VDT) Measure: During the performance
period, at least one unique patient (or patient-authorized
representatives) seen by the MIPS eligible clinician actively engages
with the EHR made accessible by the MIPS eligible clinician. A MIPS
eligible clinician may meet the measure by either (1) view, download or
transmit to a third party their health information; or (2) access their
health information through the use of an API that can be used by
applications chosen by the patient and configured to the API in the
MIPS eligible clinician's CEHRT; or (3) a combination of (1) and (2).
Proposed change to the View, Download, Transmit (VDT) Measure:
During the performance period, at least one unique patient (or patient-
authorized representatives) seen by the MIPS eligible clinician
actively engages with the EHR made accessible by the MIPS eligible
clinician by either (1) viewing, downloading or transmitting to a third
party their health information; or (2) accessing their health
information through the use of an API that can be used by applications
chosen by the patient and configured to the API in the MIPS eligible
clinician's CEHRT; or (3) a combination of (1) and (2). We are
proposing this change because we erroneously described the actions in
the measure (viewing, downloading or transmitting; or accessing through
an API) as being taken by the MIPS eligible clinician rather than the
patient or the patient-authorized representatives. This change would
align the measure description with the requirements of the numerator
and denominator. We propose this change would apply beginning with the
performance period in 2017.
Denominator: Number of unique patients seen by the MIPS
eligible clinician during the performance period.
Numerator: The number of unique patients (or their
authorized representatives) in the denominator who have viewed online,
downloaded, or transmitted to a third party the patient's health
information during the performance period and the number of unique
patients (or their authorized representatives) in the denominator who
have accessed their health information through the use of an API during
the performance period.
Secure Messaging Measure: For at least one unique patient seen by
the MIPS eligible clinician during the performance period, a secure
message was sent using the electronic messaging function of CEHRT to
the patient (or the patient-authorized representative), or in response
to a secure message sent by the patient (or the patient-authorized
representative).
Denominator: Number of unique patients seen by the MIPS
eligible clinician during the performance period.
Numerator: The number of patients in the denominator for
whom a secure electronic message is sent to the patient (or patient-
authorized representative) or in response to a secure message sent by
the patient (or patient-authorized representative), during the
performance period.
Patient-Generated Health Data Measure: Patient-generated health
data or data from a non-clinical setting is incorporated into the CEHRT
for at least one unique patient seen by the MIPS eligible clinician
during the performance period.
Denominator: Number of unique patients seen by the MIPS
eligible clinician during the performance period.
Numerator: The number of patients in the denominator for
whom data from non-clinical settings, which may
[[Page 30069]]
include patient-generated health data, is captured through the CEHRT
into the patient record during the performance period.
Objective: Health Information Exchange
Objective: The MIPS eligible clinician provides a summary of care
record when transitioning or referring their patient to another setting
of care, receives or retrieves a summary of care record upon the
receipt of a transition or referral or upon the first patient encounter
with a new patient, and incorporates summary of care information from
other health care clinician into their EHR using the functions of
CEHRT.
Proposed Change to the Objective: The MIPS eligible clinician
provides a summary of care record when transitioning or referring their
patient to another setting of care, receives or retrieves a summary of
care record upon the receipt of a transition or referral or upon the
first patient encounter with a new patient, and incorporates summary of
care information from other health care providers into their EHR using
the functions of CEHRT.
We inadvertently used the term ``health care clinician'' and are
proposing to replace it with the more appropriate term ``health care
provider''. We are proposing this change would apply beginning with the
performance period in 2017.
Send a Summary of Care Measure: For at least one transition of care
or referral, the MIPS eligible clinician that transitions or refers
their patient to another setting of care or health care clinician (1)
creates a summary of care record using CEHRT; and (2) electronically
exchanges the summary of care record.
Proposed Change to the Send a Summary of Care Measure: For at least
one transition of care or referral, the MIPS eligible clinician that
transitions or refers their patient to another setting of care or
health care provider (1) creates a summary of care record using CEHRT;
and (2) electronically exchanges the summary of care record.
We inadvertently used the term ``health care clinician'' and are
proposing to replace it with the more appropriate term ``health care
provider''. We are proposing this change would apply beginning with the
2017 performance period.
Denominator: Number of transitions of care and referrals
during the performance period for which the MIPS eligible clinician was
the transferring or referring clinician.
Numerator: The number of transitions of care and referrals
in the denominator where a summary of care record was created using
CEHRT and exchanged electronically.
Request/Accept Summary of Care Measure: For at least one transition
of care or referral received or patient encounter in which the MIPS
eligible clinician has never before encountered the patient, the MIPS
eligible clinician receives or retrieves and incorporates into the
patient's record an electronic summary of care document.
Denominator: Number of patient encounters during the
performance period for which a MIPS eligible clinician was the
receiving party of a transition or referral or has never before
encountered the patient and for which an electronic summary of care
record is available.
Numerator: Number of patient encounters in the denominator
where an electronic summary of care record received is incorporated by
the clinician into the CEHRT.
Clinical Information Reconciliation Measure: For at least one
transition of care or referral received or patient encounter in which
the MIPS eligible clinician has never before encountered the patient,
the MIPS eligible clinician performs clinical information
reconciliation. The MIPS eligible clinician must implement clinical
information reconciliation for the following three clinical information
sets: (1) Medication. Review of the patient's medication, including the
name, dosage, frequency, and route of each medication; (2) Medication
allergy. Review of the patient's known medication allergies; (3)
Current Problem list. Review of the patient's current and active
diagnoses.
Denominator: Number of transitions of care or referrals
during the performance period for which the MIPS eligible clinician was
the recipient of the transition or referral or has never before
encountered the patient.
Numerator: The number of transitions of care or referrals
in the denominator where the following three clinical information
reconciliations were performed: Medication list; medication allergy
list; and current problem list.
Objective: Public Health and Clinical Data Registry Reporting.
Objective: The MIPS eligible clinician is in active engagement with
a public health agency or clinical data registry to submit electronic
public health data in a meaningful way using CEHRT, except where
prohibited, and in accordance with applicable law and practice.
Immunization Registry Reporting Measure: The MIPS eligible
clinician is in active engagement with a public health agency to submit
immunization data and receive immunization forecasts and histories from
the public health immunization registry/immunization information system
(IIS).
We note that the functionality to be bi-directional is part of EHR
technology certified to the 2015 Edition (80 FR 62554). It means that
in addition to sending the immunization record to the immunization
registry, the CEHRT must be able to receive and display a consolidated
immunization history and forecast.
Syndromic Surveillance Reporting Measure: The MIPS eligible
clinician is in active engagement with a public health agency to submit
syndromic surveillance data from a non-urgent care ambulatory setting
where the jurisdiction accepts syndromic data from such settings and
the standards are clearly defined.
Proposed Change to the Syndromic Surveillance Reporting Measure:
The MIPS eligible clinician is in active engagement with a public
health agency to submit syndromic surveillance data. We are proposing
this change because we inadvertently finalized the measure description
that we had proposed for Stage 3 of the EHR Incentive Program (80 FR
82866) and not the measure description that we finalized (80 FR 82970).
The proposed change aligns with the measure description finalized for
Stage 3.
Electronic Case Reporting Measure: The MIPS eligible clinician is
in active engagement with a public health agency to electronically
submit case reporting of reportable conditions.
Public Health Registry Reporting Measure: The MIPS eligible
clinician is in active engagement with a public health agency to submit
data to public health registries.
Clinical Data Registry Reporting Measure: The MIPS eligible
clinician is in active engagement to submit data to a clinical data
registry.
We note that we have split the Specialized Registry Reporting
Measure that we adopted under the 2017 Advancing Care Information
Transition Objectives and Measures into two separate measures, Public
Health Registry and Clinical Data Registry Reporting to better define
the registries available for reporting. We want to continue to
encourage those MIPS eligible clinicians who have already started down
the path of reporting to a specialized registry to continue to engage
in public health and clinical data registry reporting. Therefore, we
propose to allow MIPS eligible clinicians and groups to continue to
count active engagement in electronic
[[Page 30070]]
public health reporting with specialized registries. We propose to
allow these registries to be counted for purposes of reporting the
Public Health Registry Reporting Measure or the Clinical Data Registry
Reporting Measure beginning with the 2018 performance period. A MIPS
eligible clinician may count a specialized registry if the MIPS
eligible clinician achieved the phase of active engagement as described
under ``active engagement option 3: production'' in the 2015 EHR
Incentive Programs final rule with comment period (80 FR 62862 through
62865), meaning the clinician has completed testing and validation of
the electronic submission and is electronically submitting production
data to the public health agency or clinical data registry.
As noted previously, to facilitate readers in identifying the
requirements of CEHRT for the Advancing Care Information Objectives and
Measures, we are including the following Table 8, which includes the
2015 Edition and 2014 Edition certification criteria required to meet
the objectives and measures.
Table 8--Advancing Care Information Objectives and Measures and Certification Criteria for 2014 and 2015
Editions
----------------------------------------------------------------------------------------------------------------
Objective Measure 2015 Edition 2014 Edition
----------------------------------------------------------------------------------------------------------------
Protect Patient Health Information Security Risk The requirements are a The requirements are
Analysis. part of CEHRT specific to included in the Base EHR
each certification Definition.
criterion.
Electronic Prescribing............ e-Prescribing........ Sec. 170.315(b)(3) Sec. 170.314(b)(3)
(Electronic Prescribing). (Electronic
Sec. 170.315(a)(10) Prescribing). Sec.
(Drug-Formulary and 170.314(a)(10) (Drug-
Preferred Drug List Formulary and Preferred
checks. Drug List checks.
Patient Electronic Access......... Provide Patient Sec. 170.315(e)(1) Sec. 170.314(e)(1)
Access. (View, Download, and (View, Download, and
Transmit to 3rd Party). Transmit to 3rd Party).
Sec. 170.315(g)(7)
(Application Access--
Patient Selection). Sec.
170.315(g)(8)
(Application Access--Data
Category Request). Sec.
170.315(g)(9)
(Application Access--All
Data Request) The three
criteria combined are the
``API'' certification
criteria.
Patient Electronic Access......... Patient Specific Sec. 170.315(a)(13) Sec. 170.314(a)(13)
Education. (Patient-specific (Patient-specific
Education Resources). Education Resources).
Coordination of Care Through View, Download, or Sec. 170.315(e)(1) Sec. 170.314(e)(1)
Patient Engagement. Transmit (VDT). (View, Download, and (View, Download, and
Transmit to 3rd Party). Transmit to 3rd Party).
Sec. 170.315(g)(7)
(Application Access--
Patient Selection). Sec.
170.315(g)(8)
(Application Access--Data
Category Request). Sec.
170.315(g)(9)
(Application Access--All
Data Request) The three
criteria combined are the
``API'' certification
criteria.
Coordination of Care Through Secure Messaging..... Sec. 170.315(e)(2) Sec. 170.314(e)(3)
Patient Engagement. (Secure Messaging). (Secure Messaging).
Coordination of Care Through Patient-Generated Sec. 170.315(e)(3) N/A.
Patient Engagement. Health Data. (Patient Health
Information Capture)
Supports meeting the
measure, but is NOT
required to be used to
meet the measure. The
certification criterion
is part of the CEHRT
definition beginning in
2018.
Health Information Exchange....... Send a Summary of Sec. 170.315(b)(1) Sec. 170.314(b)(2)
Care. (Transitions of Care). (Transitions of Care-
Create and Transmit
Transition of Care/
Referral Summaries or
Sec. 170.314(b)(8)
(Optional--Transitions
of Care).
Health Information Exchange....... Request/Accept Sec. 170.315(b)(1) Sec. 170.314(b)(1)
Summary of Care. (Transitions of Care). (Transitions of Care-
Receive, Display and
Incorporate Transition
of Care/Referral
Summaries or Sec.
170.314(b)(8) (Optional-
Transitions of Care).
Health Information Exchange....... Clinical Information Sec. 170.315(b)(2) Sec. 170.314(b)(4)
Reconciliation. (Clinical Information (Clinical Information
Reconciliation and Reconciliation or Sec.
Incorporation). 170.314(b)(9) (Optional--
Clinical Information
Reconciliation and
Incorporation).
Public Health and Clinical Data Immunization Registry Sec. 170.315(f)(1) N/A.
Registry Reporting. Reporting. (Transmission to
Immunization Registries).
Public Health and Clinical Data Syndromic Sec. 170.315(f)(2) Sec. 170.314(f)(3)
Registry Reporting. Surveillance (Transmission to Public (Transmission to Public
Reporting. Health Agencies-- Health Agencies--
Syndromic Surveillance) Syndromic Surveillance)
Urgent Care Setting Only. or Sec. 170.314(f)(7)
(Optional-Ambulatory
Setting Only-
Transmission to Public
Health Agencies--
Syndromic Surveillance).
Public Health and Clinical Data Electronic Case Sec. 170.315(f)(5) N/A.
Registry Reporting. Reporting. (Transmission to Public
Health Agencies--
Electronic Case
Reporting).
[[Page 30071]]
Public Health and Clinical Data Public Health EPs may choose one or more Sec. 170.314(f)(5)
Registry Reporting. Registry Reporting. of the following: Sec. (Optional--Ambulatory
170.315(f)(4) Setting Only--Cancer
(Transmission to Cancer Case Information and
Registries). Sec. 170.314(f)(6)
Sec. 170.315(f)(7) (Optional--Ambulatory
(Transmission to Public Setting Only--
Health Agencies--Health Transmission to Cancer
Care Surveys). Registries).
Public Health and Clinical Data Clinical Data No 2015 Edition health IT N/A.
Registry Reporting. Registry Reporting. certification criteria at
this time.
----------------------------------------------------------------------------------------------------------------
We are inviting public comment on these proposals.
(b) 2017 and 2018 Advancing Care Information Transition Objectives and
Measures Specifications
Table 9--Advancing Care Information Performance Category Scoring Methodology for 2018 Advancing Care Information
Transition Objectives and Measures
----------------------------------------------------------------------------------------------------------------
2018 Advancing Care 2018 Advancing Care Required/ not
Information Transition Information required for base Performance Score Reporting
Objective Transition Measure score (50%) (up to 90%) requirement
----------------------------------------------------------------------------------------------------------------
Protect Patient Health Security Risk Required........... 0.................. Yes/No
Information. Analysis. Statement.
Electronic Prescribing....... E-Prescribing........ Required........... 0.................. Numerator/
Denominator.
Patient Electronic Access.... Provide Patient Required........... Up to 20........... Numerator/
Access. Denominator.
View, Download, or Not Required....... Up to 10........... Numerator/
Transmit (VDT). Denominator.
Patient-Specific Education... Patient-Specific Not Required....... Up to 10........... Numerator/
Education. Denominator.
Secure Messaging............. Secure Messaging..... Not Required....... Up to 10........... Numerator/
Denominator.
Health Information Exchange.. Health Information Required........... Up to 20........... Numerator/
Exchange. Denominator.
Medication Reconciliation.... Medication Not Required....... Up to 10........... Numerator/
Reconciliation. Denominator.
Public Health Reporting...... Immunization Registry Not Required....... 0 or 10............ Yes/No
Reporting. Statement.
Syndromic Not Required....... 0 or 5 *........... Yes/No
Surveillance Statement.
Reporting.
Specialized Registry Not Required....... 0 or 5 *........... Yes/No
Reporting. Statement.
----------------------------------------------------------------------------------------------------------------
Bonus up to 15%
----------------------------------------------------------------------------------------------------------------
Report to one or more additional public health agencies or clinical data 5 bonus............ Yes/No
registries beyond those identified for the performance score. Statement.
Report improvement activities using CEHRT................................ 10 bonus........... Yes/No
Statement.
----------------------------------------------------------------------------------------------------------------
* A MIPS eligible clinician who cannot fulfill the Immunization Registry Reporting measure may earn 5% for each
public health agency or clinical data registry to which the clinician reports, up to a maximum of 10% under
the performance score.
In the CY 2017 Quality Payment Program final rule (81 FR 77229
through 77237), we finalized the 2017 Advancing Care Information
Transition Objectives and Measures for MIPS eligible clinicians using
EHR technology certified to the 2014 Edition. We noted (81 FR 77229
that these objectives and measures have been adapted from the Modified
Stage 2 objectives and measures finalized in the 2015 EHR Incentive
Programs final rule (80 FR 62793 through 62825); however, we did not
maintain the previously established thresholds for MIPS. For a more
detailed discussion of the Modified Stage 2 Objectives and Measures,
including explanatory material and defined terms, we refer readers to
the 2015 EHR Incentive Programs final rule (80 FR 62793 through 62825).
We are proposing to make several modifications identified and described
below to the 2017 Advancing Care Information Transition Objectives and
Measures for the advancing care information performance category of
MIPS for the 2017 and 2018 performance periods. These modifications
would not require changes to EHR technology that has been certified to
the 2014 Edition.
We finalized the 2017 Advancing Care Information Transition
Objectives and Measures only for the 2017 performance period because
these objectives and measures are for MIPS eligible clinicians using
EHR technology certified to the 2014 Edition. Because we are proposing
in section II.C.6.f.(4) to continue to allow the use of EHR technology
certified to the 2014 Edition in the 2018 performance period, we are
also proposing to allow MIPS eligible clinicians to report the
Advancing Care Information Transition Objectives and Measures in 2018.
Objective: Protect Patient Health Information.
Objective: Protect electronic protected health information (ePHI)
created or maintained by the CEHRT through the
[[Page 30072]]
implementation of appropriate technical, administrative, and physical
safeguards.
Security Risk Analysis Measure: Conduct or review a security risk
analysis in accordance with the requirements in 45 CFR 164.308(a)(1),
including addressing the security (to include encryption) of ePHI data
created or maintained by CEHRT in accordance with requirements in 45
CFR 164.312(a)(2)(iv) and 164.306(d)(3), and implement security updates
as necessary and correct identified security deficiencies as part of
the MIPS eligible clinician's risk management process.
Objective: Electronic Prescribing.
Objective: MIPS eligible clinicians must generate and transmit
permissible prescriptions electronically.
E-Prescribing Measure: At least one permissible prescription
written by the MIPS eligible clinician is queried for a drug formulary
and transmitted electronically using CEHRT.
Denominator: Number of prescriptions written for drugs
requiring a prescription to be dispensed other than controlled
substances during the performance period; or number of prescriptions
written for drugs requiring a prescription to be dispensed during the
performance period.
Numerator: The number of prescriptions in the denominator
generated, queried for a drug formulary, and transmitted electronically
using CEHRT.
Objective: Patient Electronic Access.
Objective: The MIPS eligible clinician provides patients (or
patient-authorized representative) with timely electronic access to
their health information and patient-specific education.
Proposed Modification to the Objective: We are proposing to modify
this objective beginning with the 2017 performance period by removing
the word ``electronic'' from the description of timely access as it was
erroneously included in the final rule (81 FR 77228). It was our
intention to align the objective with the objectives for Patient
Specific Education and Patient Electronic Access adopted under modified
Stage 2 in the 2015 EHR Incentive Programs final rule (80 FR 62809 and
80 FR 62815), which do not include the word ``electronic''. The word
``electronic'' was also not included in the certification
specifications for the 2014 Edition, Sec. 170.314(a)(15) (Patient-
specific education resources) and Sec. 170.314(e)(1) (View, download,
and transmit to third party).
Provide Patient Access Measure: At least one patient seen by the
MIPS eligible clinician during the performance period is provided
timely access to view online, download, and transmit to a third party
their health information subject to the MIPS eligible clinician's
discretion to withhold certain information.
Denominator: The number of unique patients seen by the
MIPS eligible clinician during the performance period.
Numerator: The number of patients in the denominator (or
patient authorized representative) who are provided timely access to
health information to view online, download, and transmit to a third
party.
View, Download, Transmit (VDT) Measure: At least one patient seen
by the MIPS eligible clinician during the performance period (or
patient-authorized representative) views, downloads or transmits their
health information to a third party during the performance period.
Denominator: Number of unique patients seen by the MIPS
eligible clinician during the performance period.
Numerator: The number of unique patients (or their
authorized representatives) in the denominator who have viewed online,
downloaded, or transmitted to a third party the patient's health
information during the performance period.
Objective: Patient-Specific Education.
Objective: The MIPS eligible clinician provides patients (or
patient authorized representative) with timely electronic access to
their health information and patient-specific education.
Proposed Change to the Objective: The MIPS eligible clinician uses
clinically relevant information from CEHRT to identify patient-specific
educational resources and provide those resources to the patient. We
inadvertently finalized the description of the Patient Electronic
Access objective for the Patient-Specific Education Objective, so that
the Patient-Specific Education Objective had the wrong description. We
are proposing to correct this error by adopting the description of the
Patient-Specific Education Objective adopted under modified Stage 2 in
the 2015 EHR Incentive Programs final rule (80 FR 62809 and 80 FR
62815). We are proposing this change would apply beginning with the
performance period in 2017.
Patient-Specific Education Measure: The MIPS eligible clinician
must use clinically relevant information from CEHRT to identify
patient-specific educational resources and provide access to those
materials to at least one unique patient seen by the MIPS eligible
clinician.
Denominator: The number of unique patients seen by the
MIPS eligible clinician during the performance period.
Numerator: The number of patients in the denominator who
were provided access to patient-specific educational resources using
clinically relevant information identified from CEHRT during the
performance period.
Objective: Secure Messaging.
Objective: Use CEHRT to engage with patients or their authorized
representatives about the patient's care.
Secure Messaging Measure: For at least one patient seen by the MIPS
eligible clinician during the performance period, a secure message was
sent using the electronic messaging function of CEHRT to the patient
(or the patient-authorized representative), or in response to a secure
message sent by the patient (or the patient authorized representative)
during the performance period.
Denominator: Number of unique patients seen by the MIPS
eligible clinician during the performance period.
Numerator: The number of patients in the denominator for
whom a secure electronic message is sent to the patient (or patient-
authorized representative) or in response to a secure message sent by
the patient (or patient-authorized representative), during the
performance period.
Objective: Health Information Exchange.
Objective: The MIPS eligible clinician provides a summary of care
record when transitioning or referring their patient to another setting
of care, receives or retrieves a summary of care record upon the
receipt of a transition or referral or upon the first patient encounter
with a new patient, and incorporates summary of care information from
other health care clinicians into their EHR using the functions of
CEHRT.
Proposed Change to the Objective: The MIPS eligible clinician
provides a summary of care record when transitioning or referring their
patient to another setting of care, receives or retrieves a summary of
care record upon the receipt of a transition or referral or upon the
first patient encounter with a new patient, and incorporates summary of
care information from other health care providers into their EHR using
the functions of CEHRT.
We inadvertently used the term ``health care clinician'' and are
proposing to replace it with the more appropriate term ``health care
provider''. We are proposing this change would
[[Page 30073]]
apply beginning with the performance period in 2017.
Health Information Exchange Measure: The MIPS eligible clinician
that transitions or refers their patient to another setting of care or
health care clinician (1) uses CEHRT to create a summary of care
record; and (2) electronically transmits such summary to a receiving
health care clinician for at least one transition of care or referral.
Proposed Change to the Measure: The MIPS eligible clinician that
transitions or refers their patient to another setting of care or
health care provider (1) uses CEHRT to create a summary of care record;
and (2) electronically transmits such summary to a receiving health
care provider for at least one transition of care or referral.
This change reflects the change proposed to the Health Information
Exchange objective replacing ``health care clinician'' with ``health
care provider''. We are proposing this change would apply beginning
with the performance period in 2017.
Denominator: Number of transitions of care and referrals
during the performance period for which the EP was the transferring or
referring health care clinician.
Proposed Change to the Denominator: Number of transitions of care
and referrals during the performance period for which the MIPS eligible
clinician was the transferring or referring health care provider. This
change reflects the change proposed to the Health Information Exchange
Measure replacing ``health care clinician'' with ``health care
provider''. We also inadvertently referred to the EP in the description
and are replacing ``EP'' with ``MIPS eligible clinician''. We are
proposing this change would apply beginning with the performance period
in 2017.
Numerator: The number of transitions of care and referrals
in the denominator where a summary of care record was created using
CEHRT and exchanged electronically.
Medication Reconciliation
Objective: Medication Reconciliation.
Proposed Objective: We are proposing to add a description of the
Medication Reconciliation Objective beginning with the CY 2017
performance period, which we inadvertently omitted from the CY 2017
Quality Payment Program proposed and final rules, as follows:
Proposed Objective: The MIPS eligible clinician who receives a
patient from another setting of care or provider of care or believes an
encounter is relevant performs medication reconciliation. This
description aligns with the objective adopted for Modified Stage 2 at
80 FR 62811.
Medication Reconciliation Measure: The MIPS eligible clinician
performs medication reconciliation for at least one transition of care
in which the patient is transitioned into the care of the MIPS eligible
clinician.
Denominator: Number of transitions of care or referrals
during the performance period for which the MIPS eligible clinician was
the recipient of the transition or referral or has never before
encountered the patient.
Numerator: The number of transitions of care or referrals
in the denominator where the following three clinical information
reconciliations were performed: Medication list, Medication allergy
list, and current problem list.
Proposed Modification to the Numerator
Proposed Numerator: The number of transitions of care or referrals
in the denominator where medication reconciliation was performed.
We are proposing to modify the numerator by removing medication
list, medication allergy list, and current problem list. These three
criteria were adopted for Stage 3 (80 FR 62862) but not for Modified
Stage 2 (80 FR 62811). We are proposing this change would apply
beginning with the performance period in 2017.
Objective: Public Health Reporting.
Objective: The MIPS eligible clinician is in active engagement with
a public health agency or clinical data registry to submit electronic
public health data in a meaningful way using CEHRT, except where
prohibited, and in accordance with applicable law and practice.
Immunization Registry Reporting Measure: The MIPS eligible
clinician is in active engagement with a public health agency to submit
immunization data.
Syndromic Surveillance Reporting Measure: The MIPS eligible
clinician is in active engagement with a public health agency to submit
syndromic surveillance data.
Specialized Registry Reporting Measure: The MIPS eligible clinician
is in active engagement to submit data to a specialized registry.
We invite public comments on these proposals.
(c) Exclusions
We are proposing to add exclusions to the measures associated with
the Health Information Exchange and Electronic Prescribing objectives
required for the base score. We propose these exclusions would apply
beginning with the CY 2017 performance period. In the CY 2017 Quality
Payment Program final rule (81 FR 77237 through 77238), we did not
finalize any exclusions for the measures specified for the advancing
care information performance category as we believe that the MIPS
exclusion criteria and that the advancing care information performance
category scoring methodology together accomplish the same end as the
previously established exclusions for the majority of the advancing
care information performance category measures. We further noted that
it was not necessary to finalize the proposed exclusion for the
Immunization Registry Reporting Measure because MIPS eligible
clinicians have the flexibility to choose whether to report the measure
because it is part of the performance score of the advancing care
information performance category. However, we understand that many MIPS
eligible clinicians may not achieve a base score because they cannot
fulfill the measures associated with the Health Information Exchange
objective in the base score because they seldom refer or transition
patients, and we believe that the implementation burden of the
objective is too high to require of those with only a small number of
referrals or transitions. Similarly, we understand that many MIPS
eligible clinicians do not often write prescriptions in their practice
or lack prescribing authority, and thus could not meet the E-
prescribing Measure and would also fail to earn a base score. As this
was not our intention, we are proposing to establish exclusions for
these measures, as described below.
Proposed Exclusion for the E-Prescribing Objective and Measure: In
the CY 2017 Quality Payment Program final rule (81 FR 28237 through
28238), we established a policy that MIPS eligible clinicians who write
fewer than 100 permissible prescriptions in a performance period may
elect to report their numerator and denominator (if they have at least
one permissible prescription for the numerator), or they may report a
null value. This policy has confused MIPS eligible clinicians as a null
value would appear to indicate a MIPS eligible clinician has failed the
measure and thus not would not achieve a base score. We are proposing
to change this policy beginning with the CY 2017 performance period and
propose to establish an exclusion for the e-Prescribing Measure. MIPS
eligible clinicians who wish to claim this exclusion would select
``yes'' to the exclusion and submit a null value for the measure,
thereby fulfilling the requirement to report this measure as
[[Page 30074]]
part of the base score. It is important that a MIPS eligible clinician
actually claims the exclusion if they wish to exclude the measure. If a
MIPS eligible clinician does not claim the exclusion, they would fail
the measure and not earn a base score or any score in the advancing
care information performance category.
Advancing Care Information Objective and Measure.
Objective: Electronic Prescribing.
Objective: Generate and transmit permissible prescriptions
electronically.
E-Prescribing Measure: At least one permissible prescription
written by the MIPS eligible clinician is queried for a drug formulary
and transmitted electronically using CEHRT.
Denominator: Number of prescriptions written for drugs
requiring a prescription to be dispensed other than controlled
substances during the performance period; or number of prescriptions
written for drugs requiring a prescription to be dispensed during the
performance period.
Numerator: The number of prescriptions in the denominator
generated, queried for a drug formulary, and transmitted electronically
using CEHRT.
Proposed Exclusion: Any MIPS eligible clinician who writes fewer
than 100 permissible prescriptions during the performance period.
2017 and 2018 Advancing Care Information Transition Objective and
Measure
Objective: Electronic Prescribing.
Objective: MIPS eligible clinicians must generate and transmit
permissible prescriptions electronically.
E-Prescribing Measure: At least one permissible prescription
written by the MIPS eligible clinician is queried for a drug formulary
and transmitted electronically using CEHRT.
Denominator: Number of prescriptions written for drugs
requiring a prescription to be dispensed other than controlled
substances during the performance period; or number of prescriptions
written for drugs requiring a prescription to be dispensed during the
performance period.
Numerator: The number of prescriptions in the denominator
generated, queried for a drug formulary, and transmitted electronically
using CEHRT.
Proposed Exclusion: Any MIPS eligible clinician who writes fewer
than 100 permissible prescriptions during the performance period.
Proposed Exclusion for the Health Information Exchange Objective
and Measures: We are proposing to add exclusions for the measures
associated with the Health Information Exchange Objective. Stakeholders
have expressed concern through public comments on the CY 2017 Quality
Payment Program proposed rule and other inquiries to us that some MIPS
eligible clinicians are unable to meet the measures associated with the
Health Information Exchange Objective, which are required for the base
score, because they do not regularly refer or transition patients in
the normal course of their practice. As we did not intend to
disadvantage those MIPS eligible clinicians and prevent them from
earning a base score, we are proposing the exclusions.
Advancing Care Information Objective and Measures
Objective: Health Information Exchange.
Objective: The MIPS eligible clinician provides a summary of care
record when transitioning or referring their patient to another setting
of care, receives or retrieves a summary of care record upon the
receipt of a transition or referral or upon the first patient encounter
with a new patient, and incorporates summary of care information from
other health care clinician into their EHR using the functions of
CEHRT.
We note that we proposed above to replace ``health care clinician''
with ``health care provider''.
Send a Summary of Care Measure: For at least one transition of care
or referral, the MIPS eligible clinician that transitions or refers
their patient to another setting of care or health care clinician (1)
creates a summary of care record using CEHRT; and (2) electronically
exchanges the summary of care record.
We note that we proposed above to replace ``health care clinician''
with ``health care provider''.
Denominator: Number of transitions of care and referrals
during the performance period for which the MIPS eligible clinician was
the transferring or referring clinician.
Numerator: The number of transitions of care and referrals
in the denominator where a summary of care record was created using
CEHRT and exchanged electronically.
Proposed Exclusion: Any MIPS eligible clinician who transfers a
patient to another setting or refers a patient fewer than 100 times
during the performance period.
Request/Accept Summary of Care Measure: For at least one transition
of care or referral received or patient encounter in which the MIPS
eligible clinician has never before encountered the patient, the MIPS
eligible clinician receives or retrieves and incorporates into the
patient's record an electronic summary of care document.
Denominator: Number of patient encounters during the
performance period for which a MIPS eligible clinician was the
receiving party of a transition or referral or has never before
encountered the patient and for which an electronic summary of care
record is available.
Numerator: Number of patient encounters in the denominator
where an electronic summary of care record received is incorporated by
the clinician into the CEHRT.
Proposed Exclusion: Any MIPS eligible clinician who receives
transitions of care or referrals or has patient encounters in which the
MIPS eligible clinician has never before encountered the patient fewer
than 100 times during the performance period.
2017 and 2018 Advancing Care Information Transition Objective and
Measures
Objective: Health Information Exchange.
Objective: The MIPS eligible clinician provides a summary of care
record when transitioning or referring their patient to another setting
of care, receives or retrieves a summary of care record upon the
receipt of a transition or referral or upon the first patient encounter
with a new patient, and incorporates summary of care information from
other health care clinicians into their EHR using the functions of
CEHRT.
We note that we are proposing above to replace ``health care
clinician'' with ``health care provider''.
Health Information Exchange Measure: The MIPS eligible clinician
that transitions or refers their patient to another setting of care or
health care clinician (1) uses CEHRT to create a summary of care
record; and (2) electronically transmits such summary to a receiving
health care clinician for at least one transition of care or referral.
We note that we are proposing above to replace ``health care
clinician'' with ``health care provider''.
Denominator: Number of transitions of care and referrals
during the performance period for which the EP was the transferring or
referring health care clinician.
We note that we are proposing above to replace ``health care
clinician'' with ``health care provider''.
Numerator: The number of transitions of care and referrals
in the denominator where a summary of care
[[Page 30075]]
record was created using CEHRT and exchanged electronically.
Proposed Exclusion: Any MIPS eligible clinician who transfers a
patient to another setting or refers a patient fewer than 100 times
during the performance period.
We are inviting public comment on these proposals.
(7) Additional Considerations
(a) 21st Century Cures Act
As we noted in the CY 2017 Quality Payment Program final rule (81
FR 77238), section 101(b)(1)(A) of the MACRA amended section
1848(a)(7)(A) of the Act to sunset the meaningful use payment
adjustment at the end of CY 2018. Section 1848(a)(7) of the Act
includes certain statutory exceptions to the meaningful use payment
adjustment under section 1848(a)(7)(A) of the Act. Specifically,
section 1848(a)(7)(D) of the Act exempts hospital-based EPs from the
application of the payment adjustment under section 1848(a)(7)(A) of
the Act. In addition, section 1848(a)(7)(B) of the Act provides that
the Secretary may, on a case-by-case basis, exempt an EP from the
application of the payment adjustment under section 1848(a)(7)(A) of
the Act if the Secretary determines, subject to annual renewal, that
compliance with the requirement for being a meaningful EHR user would
result in a significant hardship, such as in the case of an EP who
practices in a rural area without sufficient internet access. The last
sentence of section 1848(a)(7)(B) of the Act also provides that in no
case may an exemption be granted under subparagraph (B) for more than 5
years. The MACRA did not maintain these statutory exceptions for the
advancing care information performance category of the MIPS. Thus, we
had previously stated that the provisions under sections 1848(a)(7)(B)
and (D) of the Act are limited to the meaningful use payment adjustment
under section 1848(a)(7)(A) of the Act and do not apply in the context
of the MIPS.
Following the publication of the CY 2017 Quality Payment Program
final rule, the 21st Century Cures Act (Pub. L. 114-255) was enacted on
December 13, 2016. Section 4002(b)(1)(B) of the 21st Century Cures Act
amended section 1848(o)(2)(D) of the Act to state that the provisions
of sections 1848(a)(7)(B) and (D) of the Act shall apply to assessments
of MIPS eligible clinicians under section 1848(q) of the Act with
respect to the performance category described in subsection
(q)(2)(A)(iv) (the advancing care information performance category) in
an appropriate manner which may be similar to the manner in which such
provisions apply with respect to the meaningful use payment adjustment
made under section 1848(a)(7)(A) of the Act. As a result of this
legislative change, we believe that the general exceptions described
under sections 1848(a)(7)(B) and (D) of the Act are applicable under
the MIPS program. We include below proposals to implement these
provisions as applied to assessments of MIPS eligible clinicians under
section 1848(q) of the Act with respect to the advancing care
information performance category.
(i) MIPS Eligible Clinicians Facing a Significant Hardship
In the CY 2017 Quality Payment Program final rule (81 FR 77240
through 77243), we recognized that there may not be sufficient measures
applicable and available under the advancing care information
performance category to MIPS eligible clinicians facing a significant
hardship, such as those who lack sufficient internet connectivity, face
extreme and uncontrollable circumstances, lack control over the
availability of CEHRT, or do not have face-to-face interactions with
patients. We relied on section 1848(q)(5)(F) of the Act to establish a
final policy to assign a zero percent weighting to the advancing care
information performance category in the final score if there are not
sufficient measures and activities applicable and available to MIPS
eligible clinicians within the categories of significant hardship noted
above (81 FR 77243). Additionally, under the final policy (81 FR
77243), we did not impose a limitation on the total number of MIPS
payment years for which the advancing care information performance
category could be weighted at zero percent, in contrast with the 5-year
limitation on significant hardship exceptions under the Medicare EHR
Incentive Program as required by section 1848(a)(7)(B) of the Act.
We are not proposing substantive changes to this policy; however,
as a result of the changes in the law made by the 21st Century Cures
Act discussed above, we will not rely on section 1848(q)(5)(F) of the
Act and instead are proposing to use the authority in the last sentence
of section 1848(o)(2)(D) of the Act for significant hardship exceptions
under the advancing care information performance category under MIPS.
Section 1848(o)(2)(D) of the Act, as amended by section 4002(b)(1)(B)
of the 21st Century Cures Act, states in part that the provisions of
section 1848(a)(7)(B) of the Act shall apply to assessments of MIPS
eligible clinicians with respect to the advancing care information
performance category in an appropriate manner which may be similar to
the manner in which such provisions apply with respect to the payment
adjustment made under section 1848(a)(7)(A) of the Act. We would assign
a zero percent weighting to the advancing care information performance
category in the MIPS final score for a MIPS payment year for MIPS
eligible clinicians who successfully demonstrate a significant hardship
through the application process. We would use the same categories of
significant hardship and application process as established in the CY
2017 Quality Payment Program final rule (81 FR 77240-77243). We would
automatically reweight the advancing care information performance
category to zero percent for a MIPS eligible clinician who lacks face-
to-face patient interaction and is classified as a non-patient facing
MIPS eligible clinician without requiring an application. If a MIPS
eligible clinician submits an application for a significant hardship
exception or is classified as a non-patient facing MIPS eligible
clinician, but also reports on the measures specified for the advancing
care information performance category, they would be scored on the
advancing care information performance category like all other MIPS
eligible clinicians, and the category would be given the weighting
prescribed by section 1848(q)(5)(E) of the Act regardless of the MIPS
eligible clinician's score.
We believe this policy would be an appropriate application of the
provisions of section 1848(a)(7)(B) of the Act to MIPS eligible
clinicians and is similar to the manner in which those provisions apply
with respect to the payment adjustment made under section 1848(a)(7)(A)
of the Act. Under the Medicare EHR Incentive Program an approved
hardship exception exempted an EP from the payment adjustment. We
believe that weighting the advancing care information performance
category to zero percent is similar in effect to an exemption from the
requirements of that performance category.
As required under section 1848(a)(7)(B) of the Act, eligible
professionals were not granted significant hardship exceptions for the
payment adjustments under the Medicare EHR Incentive Program for more
than 5 years. We propose not to apply the 5-year limitation under
section 1848(a)(7)(B) of the Act to significant hardship exceptions for
the advancing care information performance category under MIPS. We
believe this proposal is an appropriate application of the provisions
of section 1848(a)(7)(B)
[[Page 30076]]
of the Act to MIPS eligible clinicians due to our desire to reduce
clinician burden, promote the greatest level of participation in the
MIPS program, and maintain consistency with the policies established in
last year's final rule (81 FR 77243). In the Medicare EHR Incentive
Program, we received many applications for significant hardship
exceptions and approved most of them, which we believe indicates many
eligible professionals were unable to or would have struggled to
satisfy the requirements of meaningful use. We believe that there will
be a continued need for significant hardship exceptions in order to
provide clinicians with the necessary flexibility to participate in the
MIPS program that best matches their available resources and
circumstances, which may not change during a 5-year time period. For
example, a clinician in an area without internet connectivity may
continue to lack connectivity for more than 5 years. In addition, in
the CY 2017 Quality Payment Program final rule (81 FR 77242 through
77243), we noted that we had received comments expressing appreciation
that CMS moved away from the 5-year limitation to significant hardship
exceptions.
We solicit comments on the proposed use of the authority provided
in the 21st Century Cures Act in section 1848(o)(2)(D) of the Act as it
relates to application of significant hardship exceptions under MIPS
and the proposal not to apply a 5-year limit to such exceptions.
(ii) Significant Hardship Exception for MIPS Eligible Clinicians in
Small Practices
Section 1848(q)(2)(B)(iii) of the Act requires the Secretary to
give consideration to the circumstances of small practices (consisting
of 15 or fewer professionals) and practices located in rural areas and
geographic HPSAs in establishing improvement activities under MIPS. In
the CY 2017 Quality Payment Program final rule (81 FR 77187 through
77188), we finalized that for MIPS eligible clinicians and groups that
are in small practices or located in rural areas, or geographic health
professional shortage areas (HPSAs), to achieve full credit under the
improvement activities category, one high-weighted or two medium-
weighted improvement activities are required.
While there is no corresponding statutory provision for the
advancing care information performance category, we believe that
special consideration should also be available for MIPS eligible
clinicians located in small practices. Through comments received on the
CY 2017 Quality Payment Program proposed rule (81 FR 28161-28586), we
heard many concerns about the impact of MIPS on eligible clinicians in
small practices. Some commenters stated that there was not a meaningful
exclusion for small practices that cannot afford the upfront
investments (including investments in EHR technology) (81 FR 77066).
Many noted there are still many small practices that have not adopted
EHRs due to the administrative and financial burden. Some expressed
concern that small group and solo practices would be driven out of
business because of the potential negative payment adjustments under
MIPS (81 FR 77055). A few commenters were concerned about the impact of
MACRA on small practices and asked CMS to remain sensitive to this
concern and offer special opportunities for MIPS eligible clinicians in
areas threatened by access problems (81 FR 77055).
Based on these concerns, we are proposing a significant hardship
exception for the advancing care information performance category for
MIPS eligible clinicians who are in small practices, under the
authority in section 1848(o)(2)(D) of the Act, as amended by section
4002(b)(1)(B) of the 21st Century Cures Act (see discussion of the
statutory authority for significant hardship exceptions in section
II.C.6.f.(7)(ii). We are proposing that this hardship exception would
be available to MIPS eligible clinicians in small practices as defined
under Sec. 414.1305 (15 or fewer clinicians and solo practitioners).
We are proposing in section II.C.1.e. of this proposed rule, that CMS
would make eligibility determinations regarding the size of small
practices for performance periods occurring in 2018 and future years.
We are proposing to reweight the advancing care information performance
category to zero percent of the MIPS final score for MIPS eligible
clinicians who qualify for this hardship exception. We are proposing
this exception would be available beginning with the 2018 performance
period and 2020 MIPS payment year. We are proposing a MIPS eligible
clinician seeking to qualify for this exception would submit an
application in the form and manner specified by us by December 31st of
the performance period or a later date specified by us. We are also
proposing MIPS eligible clinicians seeking this exception must
demonstrate in the application that there are overwhelming barriers
that prevent the MIPS eligible clinician from complying with the
requirements for the advancing care information performance category.
In accordance with section 1848(a)(7)(B) of the Act, the exception
would be subject to annual renewal. Under our proposal in section
II.C.6.f.(7)(a), the 5-year limitation under section 1848(a)(7)(B) of
the Act would not apply to this significant hardship exception for MIPS
eligible clinicians in small practices.
We believe that applying the significant hardship exception in this
way would be appropriate given the challenges small practices face as
described by the commenters. In addition, we believe this application
would be similar to the manner in which the exception applies with
respect to the payment adjustment made under section 1848(a)(7)(A) of
the Act because weighting the advancing care information performance
category to zero percent is similar in effect to an exemption from the
requirements of that performance category.
While we would be making this significant hardship exception
available to small practices in particular, we are considering whether
other categories or types of clinicians might similarly require an
exception. We solicit comment on what those categories or types are,
why such an exception is required, and any data available to support
the necessity of the exception. We note that supporting data would be
particularly helpful to our consideration of whether any additional
exceptions would be appropriate.
We are seeking comments on these proposals.
(iii) Hospital-Based MIPS Eligible Clinicians
In the CY 2017 Quality Payment Program final rule (81 FR 77238
through 77240), we defined a hospital-based MIPS eligible clinician
under Sec. 414.1305 as a MIPS eligible clinician who furnishes 75
percent or more of his or her covered professional services in sites of
service identified by the Place of Service (POS) codes used in the
HIPAA standard transaction as an inpatient hospital (POS 21), on-campus
outpatient hospital (POS 22), or emergency room (POS 23) setting, based
on claims for a period prior to the performance period as specified by
CMS. We intend to use claims with dates of service between September 1
of the calendar year 2 years preceding the performance period through
August 31 of the calendar year preceding the performance period, but in
the event it is not operationally feasible to use claims from this time
period, we will use a 12-month period as close as practicable to this
time period. We discussed our assumption that MIPS eligible clinicians
who are determined hospital-based do not have
[[Page 30077]]
sufficient advancing care information measures applicable to them, and
we established a policy to reweight the advancing care information
performance category to zero percent of the MIPS final score for the
MIPS payment year in accordance with section 1848(q)(5)(F) of the Act
(81 FR 77240).
We are not proposing substantive changes to this policy; however,
as a result of the changes in the law made by the 21st Century Cures
Act discussed above, we will not rely on section 1848(q)(5)(F) of the
Act and instead are proposing to use the authority in the last sentence
of section 1848(o)(2)(D) of the Act for exceptions for hospital-based
MIPS eligible clinicians under the advancing care information
performance category. Section 1848(o)(2)(D) of the Act, as amended by
section 4002(b)(1)(B) of the 21st Century Cures Act, states in part
that the provisions of section 1848(a)(7)(D) of the Act shall apply to
assessments of MIPS eligible clinicians with respect to the advancing
care information performance category in an appropriate manner which
may be similar to the manner in which such provisions apply with
respect to the payment adjustment made under section 1848(a)(7)(A) of
the Act. We would assign a zero percent weighting to the advancing care
information performance category in the MIPS final score for a MIPS
payment year for hospital-based MIPS eligible clinicians as previously
defined. A hospital-based MIPS eligible clinician would have the option
to report the advancing care information measures for the performance
period for the MIPS payment year for which they are determined
hospital-based. However, if a MIPS eligible clinician who is determined
hospital-based chooses to report on the advancing care information
measures, they would be scored on the advancing care information
performance category like all other MIPS eligible clinicians, and the
category would be given the weighting prescribed by section
1848(q)(5)(E) of the Act regardless of their score.
We believe this policy would be an appropriate application of the
provisions of section 1848(a)(7)(D) of the Act to MIPS eligible
clinicians and is similar to the manner in which those provisions apply
with respect to the payment adjustment made under section 1848(a)(7)(A)
of the Act. Under the Medicare EHR Incentive Program an approved
hardship exception exempted an EP from the payment adjustment. We
believe that weighting the advancing care information performance
category to zero percent is similar in effect to an exemption from the
requirements of that performance category.
We propose to amend Sec. 414.1380(c)(1) and (2) of the regulation
text to reflect this proposal.
We request comments on the proposed use of the authority provided
in the 21st Century Cures Act in section 1848(o)(2)(D) of the Act as it
relates to hospital-based MIPS eligible clinicians.
(iv) Ambulatory Surgical Center (ASC)--Based MIPS Eligible Clinicians
Section 16003 of the 21st Century Cures Act amended section
1848(a)(7)(D) of the Act to provide that no payment adjustment may be
made under section 1848(a)(7)(A) of the Act for 2017 and 2018 in the
case of an eligible professional who furnishes substantially all of his
or her covered professional services in an ambulatory surgical center
(ASC). Section 1848(a)(7)(D)(iii) of the Act provides that
determinations of whether an eligible professional is ASC-based may be
made based on the site of service as defined by the Secretary or an
attestation, but shall be made without regard to any employment or
billing arrangement between the eligible professional and any other
supplier or provider of services. Section 1848(a)(7)(D)(iv) of the Act
provides that the ASC-based exception shall no longer apply as of the
first year that begins more than 3 years after the date on which the
Secretary determines, through notice and comment rulemaking, that CEHRT
applicable to the ASC setting is available.
Under section 1848(o)(2)(D) of the Act, as amended by section
4002(b)(1)(B) of the 21st Century Cures Act, the ASC-based provisions
of section 1848(a)(7)(D) of the Act shall apply to assessments of MIPS
eligible clinicians under section 1848(q) of the Act with respect to
the advancing care information performance category in an appropriate
manner which may be similar to the manner in which such provisions
apply with respect to the payment adjustment made under section
1848(a)(7)(A) of the Act. We believe our proposals set forth below for
ASC-based MIPS eligible clinicians are an appropriate application of
the provisions of section 1848(a)(7)(D) of the Act to MIPS eligible
clinicians. Under the Medicare EHR Incentive Program an approved
hardship exception exempted an EP from the payment adjustment. We
believe that weighting the advancing care information performance
category to zero percent is similar in effect to an exemption from the
requirements of that performance category.
To align with our hospital-based MIPS eligible clinician policy, we
are proposing to define at Sec. 414.1305 an ASC-based MIPS eligible
clinician as a MIPS eligible clinician who furnishes 75 percent or more
of his or her covered professional services in sites of service
identified by the Place of Service (POS) code 24 used in the HIPAA
standard transaction based on claims for a period prior to the
performance period as specified by us. We request comments on this
proposal and solicit comments as to whether other POS codes should be
used to identify a MIPS eligible clinician's ASC-based status or if an
alternative methodology should be used. We note that the ASC-based
determination will be made independent of the hospital-based
determination.
To determine a MIPS eligible clinician's ASC-based status, we are
proposing to use claims with dates of service between September 1 of
the calendar year 2 years preceding the performance period through
August 31 of the calendar year preceding the performance period, but in
the event it is not operationally feasible to use claims from this time
period, we would use a 12-month period as close as practicable to this
time period. For example, for the 2018 performance period (2020 MIPS
payment year), we would use the data available at the end of October
2017 for Medicare claims with dates of service between September 1,
2016 through August 31, 2017, to determine whether a MIPS eligible
clinician is considered ASC-based under our proposed definition. We are
proposing this timeline to allow us to notify MIPS eligible clinicians
of their ASC-based status prior to the start of the performance period
and to align with the hospital-based MIPS eligible clinician
determination period. For the 2019 MIPS payment year, we would not be
able to notify MIPS eligible clinicians of their ASC-based status until
after the final rule is published, which we anticipate would be later
in 2017. We expect that we would provide this notification through
QPP.cms.gov.
For MIPS eligible clinicians who we determine are ASC-based, we
propose to assign a zero percent weighting to the advancing care
information performance category in the MIPS final score for the MIPS
payment year. However, if a MIPS eligible clinician who is determined
ASC-based chooses to report on the advancing care information measures
for the performance period for the MIPS payment year for which they are
determined ASC-based, we propose they would be scored on the advancing
care information performance category like
[[Page 30078]]
all other MIPS eligible clinicians, and the performance category would
be given the weighting prescribed by section 1848(q)(5)(E) of the Act
regardless of their advancing care information performance category
score.
We are proposing these ASC-based policies would apply beginning
with the 2017 performance period/2019 MIPS payment year.
We propose to amend Sec. 414.1380(c)(1) and (2) of the regulation
text to reflect these proposals.
We request comments on these proposals.
(v) Exception for MIPS Eligible Clinicians Using Decertified EHR
Technology
Section 4002(b)(1)(A) of the 21st Century Cures Act amended section
1848(a)(7)(B) of the Act to provide that the Secretary shall exempt an
eligible professional from the application of the payment adjustment
under section 1848(a)(7)(A) of the Act with respect to a year, subject
to annual renewal, if the Secretary determines that compliance with the
requirement for being a meaningful EHR user is not possible because the
CEHRT used by such professional has been decertified under ONC's Health
IT Certification Program. Section 1848(o)(2)(D) of the Act, as amended
by section 4002(b)(1)(B) of the 21st Century Cures Act, states in part
that the provisions of section 1848(a)(7)(B) of the Act shall apply to
assessments of MIPS eligible clinicians with respect to the advancing
care information performance category in an appropriate manner which
may be similar to the manner in which such provisions apply with
respect to the payment adjustment made under section 1848(a)(7)(A) of
the Act.
We are proposing that a MIPS eligible clinician may demonstrate
through an application process that reporting on the measures specified
for the advancing care information performance category is not possible
because the CEHRT used by the MIPS eligible clinician has been
decertified under ONC's Health IT Certification Program. We are
proposing that if the MIPS eligible clinician's demonstration is
successful and an exception is granted, we would assign a zero percent
weighting to the advancing care information performance category in the
MIPS final score for the MIPS payment year. In accordance with section
1848(a)(7)(B) of the Act, the exception would be subject to annual
renewal, and in no case may a MIPS eligible clinician be granted an
exception for more than 5 years. We are proposing this exception would
be available beginning with the CY 2018 performance period and the 2020
MIPS payment year.
We are proposing that a MIPS eligible clinician may qualify for
this exception if their CEHRT was decertified either during the
performance period for the MIPS payment year or during the calendar
year preceding the performance period for the MIPS payment year. We
believe that this timeframe is appropriate because the loss of
certification may prevent a MIPS eligible clinician from reporting for
the advancing care information performance category because it will
require that the MIPS eligible clinician switch to an alternate CEHRT,
a process that we believe may take up to 2 years. For example, for the
2020 MIPS payment year, if the MIPS eligible clinician's EHR technology
was decertified during the CY 2018 performance period or during CY
2017, the MIPS eligible clinician may qualify for this exception. In
addition, we are proposing that the MIPS eligible clinician must
demonstrate in their application and through supporting documentation
if available that the MIPS eligible clinician made a good faith effort
to adopt and implement another CEHRT in advance of the performance
period. We are proposing a MIPS eligible clinician seeking to qualify
for this exception would submit an application in the form and manner
specified by us by December 31st of the performance period, or a later
date specified by us.
We believe that applying the exception in this way is an
appropriate application of the provisions of section 1848(a)(7)(B) of
the Act to MIPS eligible clinicians given that weighting the advancing
care information performance category to zero percent is similar in
effect to an exemption from the requirements of that performance
category. Under the Medicare EHR Incentive Program an approved hardship
exception exempted an EP from the payment adjustment. We believe that
weighting the advancing care information performance category to zero
percent is similar in effect to an exemption from the requirements of
that performance category.
The ONC Health IT Certification Program: Enhanced Oversight and
Accountability final rule (``EOA final rule'') (81 FR 72404), effective
December 19, 2016, created a regulatory framework for the ONC's direct
review of health information technology (health IT) certified under the
ONC Health IT Certification Program, including, when necessary,
requiring the correction of non-conformities found in health IT
certified under the Program and/or terminating certifications issued to
certified health IT. Prior to the EOA final rule, ONC-Authorized
Certification Bodies (ONC-ACBs) had the only authority to terminate or
revoke certification of health IT under the program, which they used on
previous occasions. On September 23, 2015, we posted an FAQ discussing
the requirements for using a decertified CEHRT.\3\
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\3\ https://questions.cms.gov/faq.php?isDept=0&search=decertify&searchType=keyword&submitSearch=1&id=5005.
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Once all administrative processes, if any, are complete, then
notice of a ``termination of certification'' is listed on the of the
Certified Health IT Product List (CPHL) Web page.\4\ As appropriate,
ONC will also publicize the termination of certification of health IT
through other communication channels (for example, ONC list serv(s)).
Further, when ONC terminates the certification of a health IT product,
the health IT developer is required to notify all potentially affected
customers in a timely manner.
---------------------------------------------------------------------------
\4\ The list is available at https://chpl.healthit.gov/#/decertifications/products.
---------------------------------------------------------------------------
We further note that in comparison to termination actions taken by
ONC and ONC-ACBs, a health IT developer may voluntarily withdraw a
certification that is in good standing under the ONC Health IT
Certification Program. A voluntary withdrawal may be the result of the
health IT developer going out of business, the developer no longer
supporting the product, or for other reasons that are not in response
to ONC-ACB surveillance, ONC direct review, or a finding of non-
conformity by ONC or an ONC-ACB.\5\ In such instances, ONC will list
these products on the ``Inactive Certificates'' \6\ Web page of the
CHPL.
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\5\ For further descriptions of certification statuses, please
consult the CHPL Public User Guide.
\6\ The ``Inactive Certificates'' Web page is available at
https://chpl.healthit.gov/#/decertifications/inactive.
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We propose to amend Sec. 414.1380(c)(1) and (2) of the regulation
text to reflect these proposals. We are seeking comments on these
proposals.
(b) Hospital-Based MIPS Eligible Clinicians
In the CY 2017 Quality Payment Program final rule (81 FR 77238
through 77240, we defined a hospital-based MIPS eligible clinician as a
MIPS eligible clinician who furnishes 75 percent or more of his or her
covered professional services in sites of services identified by the
Place of Service (POS) codes used in the HIPAA standard transaction as
an inpatient hospital (POS 21), on campus outpatient hospital
[[Page 30079]]
(POS 22) or emergency room (POS 23) setting, based on claims for a
period prior to the performance period as specified by CMS.
We are proposing to modify our policy to include covered
professional services furnished by MIPS eligible clinicians in an off-
campus-outpatient hospital (POS 19) in the definition of hospital-based
MIPS eligible clinician. POS 19 was developed in 2015 in order to
capture the numerous physicians that are paid for a portion of their
services in an ``off campus-outpatient hospital'' versus an on campus-
outpatient hospital, (POS 22). We also believe that these MIPS eligible
clinicians would not typically have control of the development and
maintenance of their EHR systems, just like those who bill using POS
22. We propose to add POS 19 to our existing definition of a hospital-
based MIPS eligible clinician beginning with the performance period in
2018.
We invite comment on this proposal.
(c) Nurse Practitioners, Physician Assistants, Clinical Nurse
Specialists, and Certified Registered Nurse Anesthetists
In the CY 2017 Quality Payment Program final rule (81 FR 77243-
77244), we discussed our belief that certain types of MIPS eligible
clinicians (NPs, PAs, CNSs, and CRNAs) may lack experience with the
adoption and use of CEHRT. Because many of these non-physician
clinicians are not eligible to participate in the Medicare or Medicaid
EHR Incentive Program, we stated that we have little evidence as to
whether there are sufficient measures applicable and available to these
types of MIPS eligible clinicians under the advancing care information
performance category. We established a policy under section
1848(q)(5)(F) of the Act to assign a weight of zero to the advancing
care information performance category in the MIPS final score if there
are not sufficient measures applicable and available to NPs, PAs,
CRNAs, and CNSs. We will assign a weight of zero only in the event that
an NP, PA, CRNA, or CNS does not submit any data for any of the
measures specified for the advancing care information performance
category. We encouraged all NPs, PAs, CRNAs, and CNSs to report on
these measures to the extent they are applicable and available,
however, we understand that some NPs, PAs, CRNAs, and CNSs may choose
to accept a weight of zero for this performance category if they are
unable to fully report the advancing care information measures. These
MIPS eligible clinicians may choose to submit advancing care
information measures should they determine that these measures are
applicable and available to them; however, we noted that if they choose
to report, they will be scored on the advancing care information
performance category like all other MIPS eligible clinicians and the
performance category will be given the weighting prescribed by section
1848(q)(5)(E) of the Act regardless of their advancing care information
performance category score.
We stated that this approach is appropriate for the first MIPS
performance period based on the payment consequences associated with
reporting, the fact that many of these types of MIPS eligible
clinicians may lack experience with EHR use, and our current
uncertainty as to whether we have adopted sufficient measures that are
applicable and available to these types of MIPS eligible clinicians. We
noted that we would use the first MIPS performance period to further
evaluate the participation of these MIPS eligible clinicians in the
advancing care information performance category and would consider for
subsequent years whether the measures specified for this category are
applicable and available to these MIPS eligible clinicians. At this
time we have no additional information because the first MIPS
performance period is currently underway, and thus we propose the same
policy for NPs, PAs, CRNAs, and CNSs for the 2018 performance period as
well. We still intend to evaluate the participation of these MIPS
eligible clinicians in the advancing care information performance
category for 2017 and expect to adopt measures applicable and available
to them in subsequent years.
We are seeking comment on how the advancing care information
performance category could be applied to NPs, PAs, CRNAs, and CNSs in
future years of MIPS, and the types of measures that would be
applicable and available to these types of MIPS eligible clinicians. In
addition, through the Call for Measures Process we are seeking new
measures that may be more broadly applicable to these additional types
of MIPS eligible clinicians in future program years. For more
information on the Call for Measures, see https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallForMeasures.html.
We are inviting public comment on these proposals.
(d) Scoring for MIPS Eligible Clinicians in Group Practices
In any of the situations described in the sections above, we would
assign a zero percent weighting to the advancing care information
performance category in the MIPS final score for the MIPS payment year
if the MIPS eligible clinician meets certain specified requirements for
this weighting. We noted that these MIPS eligible clinicians may choose
to submit advancing care information measures; however, if they choose
to report, they will be scored on the advancing care information
performance category like all other MIPS eligible clinicians and the
performance category will be given the weighting prescribed by section
1848(q)(5)(E) of the Act regardless of their advancing care information
performance category score. This policy includes MIPS eligible
clinicians choosing to report as part of a group practice or part of a
virtual group.
Group practices as defined at Sec. 414.1310(e)(1) are required to
aggregate their performance data across the TIN in order for their
performance to be assessed as a group (81 FR 77058). Additionally,
groups that elect to have their performance assessed as a group will be
assessed as a group across all four MIPS performance categories. By
reporting as part of a group practice, MIPS eligible clinicians are
subscribing to the data reporting and scoring requirements of the group
practice. We note that the data submission criteria for groups
reporting advancing care information performance category described in
the CY 2017 Quality Payment Program final rule (81 FR 77215) state that
group data should be aggregated for all MIPS eligible clinicians within
the group practice. This includes those MIPS eligible clinicians who
may qualify for a zero percent weighting of the advancing care
information performance category due to the circumstances as described
above, such as a significant hardship or other type of exception,
hospital-based or ASC-based status, or certain types of non-physician
practitioners (NPs, PAs, CNSs, and CRNAs). If these MIPS eligible
clinicians report as part of a group practice or virtual group, they
will be scored on the advancing care information performance category
like all other MIPS eligible clinicians and the performance category
will be given the weighting prescribed by section 1848(q)(5)(E) of the
Act regardless of the group practice's advancing care information
performance category score.
[[Page 30080]]
(e) Timeline for Submission of Reweighting Applications
In the CY 2017 Quality Payment Program final rule (81 FR77240-
77243), we established the timeline for the submission of applications
to reweight the advancing care information performance category in the
MIPS final score to align with the data submission timeline for MIPS.
We established that all applications for reweighting the advancing care
information performance category be submitted by the MIPS eligible
clinician or designated group representative in the form and manner
specified by us. All applications may be submitted on a rolling basis,
but must be received by us no later than the close of the submission
period for the relevant performance period, or a later date specified
by us. An application would need to be submitted annually to be
considered for reweighting each year.
The Quality Payment Program Exception Application will be used to
apply for the following exceptions: Insufficient Internet Connectivity;
Extreme and Uncontrollable Circumstances; Lack of Control over the
Availability of CEHRT; Decertification of CEHRT; and Small Practice.
We are proposing to change the submission deadline for the
application as we believe that aligning the data submission deadline
with the reweighting application deadline could disadvantages MIPS
eligible clinicians. We are proposing to change the submission deadline
for the CY 2017 performance period to December 31, 2017, or a later
date specified by us. We believe this change would help MIPS eligible
clinicians by allowing them to learn whether their application is
approved prior to the data submission deadline for the CY 2017
performance period, March 31, 2018. We plan to have the application
available in mid-2017. We encourage MIPS eligible clinicians to apply
early as we expect to process the applications on a rolling basis. We
note that if a MIPS eligible clinician submits data for the advancing
care information category after an application has been submitted, the
data would be scored, the application would be considered voided and
the advancing care information performance category would not be
reweighted.
We further propose that the submission deadline for the 2018
performance period will be December 31, 2018, or a later date as
specified by us. We believe this would help MIPS eligible clinicians by
allowing them to learn whether their application is approved prior to
the data submission deadline for the CY 2018 performance period, March
31, 2019.
We request comments on these proposals.
g. APM Scoring Standard for MIPS Eligible Clinicians in MIPS APMs
(1) Overview
Under section 1848(q)(1)(C)(ii)(1) of the Act, Qualifying APM
Participants (QPs) are not MIPS eligible clinicians and are thus
excluded from MIPS reporting requirements and payment adjustments.
Similarly, under section 1848(q)(1)(c)(ii)(II) of the Act, Partial
Qualifying APM Participants (Partial QPs) are also not MIPS eligible
clinicians unless they opt to report and be scored under MIPS. All
other eligible clinicians, including those participating in MIPS APMs,
are MIPS eligible clinicians and subject to MIPS reporting requirements
and payment adjustments unless they are excluded on another basis such
as being newly enrolled in Medicare or not exceeding the low volume
threshold.
In the CY 2017 Quality Payment Program final rule (81 FR 77246-
77269, 77543), we finalized the APM scoring standard, which is designed
to reduce reporting burden for participants in certain APMs by
minimizing the need for them to make duplicative data submissions for
both MIPS and their respective APMs. We also sought to ensure that
eligible clinicians in APM Entities that participate in certain types
of APMs that assess their participants on quality and cost are assessed
as consistently as possible across MIPS and their respective APMs.
Given that many APMs already assess their participants on cost and
quality of care and require engagement in certain improvement
activities, we believe that without the APM scoring standard,
misalignments could be quite common between the evaluation of
performance under the terms of the APM and evaluation of performance on
measures and activities under MIPS.
In the CY 2017 Quality Payment Program final rule (81 FR 77249), we
identified the types of APMs for which the APM scoring standard would
apply as MIPS APMs. We finalized that to be a MIPS APM, an APM must
satisfy the following criteria: (1) APM Entities participate in the APM
under an agreement with CMS or by law or regulation; (2) the APM
requires that APM Entities include at least one MIPS eligible clinician
on a Participation List; and (3) the APM bases payment incentives on
performance (either at the APM Entity or eligible clinician level) on
cost/utilization and quality measures. We specified that we will post
the list of MIPS APMs prior to the first day of the MIPS performance
year for each year (81 FR 77250). We finalized in the regulation at
Sec. 414.1370(b) that for a new APM to be a MIPS APM, its first
performance year must start on or before the first day of the MIPS
performance year. A list of MIPS APMs is available at www.qpp.cms.gov.
We established in the regulation at Sec. 414.1370(c) that the MIPS
performance year under Sec. 414.1320 of the regulations applies for
the APM scoring standard.
We finalized that under section Sec. 414.1370(f) of our
regulations on the APM scoring standard, MIPS eligible clinicians will
be scored at the APM Entity group level and each eligible clinician
will receive the APM Entity group's final score. The MIPS payment
adjustment is applied at the TIN/NPI level for each of the MIPS
eligible clinicians in the APM Entity. The MIPS final score is
comprised of the four MIPS performance category scores, as described in
our regulation at Sec. 414.1370(g): quality, cost, improvement
activities, and advancing care information. Both the Medicare Shared
Savings Program and Next Generation ACO Model are MIPS APMs for the CY
2017 performance year. For these two MIPS APMs, in accordance with our
regulation at Sec. 414.1370(h), the MIPS performance category scores
are weighted as follows: Quality at 50 percent; cost at zero percent;
improvement activities at 20 percent; and advancing care information at
30 percent of the final score. For all other MIPS APMs for the CY 2017
performance year, quality and cost are each weighted at zero percent,
improvement activities at 25 percent, and advancing care information at
75 percent of the final score.
As explained in the following sections, we propose to: Add an APM
participant assessment date for full TIN APMs; add the CAHPS for ACOs
survey to the Shared Savings Program and Next Generation ACO quality
measures included for scoring under the MIPS APM quality performance
category; define Other MIPS APMs; and add scoring for quality
improvement to the MIPS APM quality performance category for MIPS APMs
beginning in 2018. We also propose a Quality Payment Program 2018
performance year quality scoring methodology for Other MIPS APMs, and
describe the scoring methodology for quality improvement for Other MIPS
APMs as applicable.
In reviewing these proposals, we remind readers that the APM
scoring
[[Page 30081]]
standard is built upon the generally applicable MIPS scoring standard,
but provides for special policies to address the unique circumstances
of MIPS eligible clinicians who are in APM Entities participating in
MIPS APMs. For the cost, improvement activities, and advancing care
information performance categories, unless a separate policy has been
established or is being proposed for the APM scoring standard, the
generally applicable MIPS policies would be applicable. Additionally,
unless we include a proposal to adopt a unique policy for the APM
scoring standard, we propose to adopt the same generally applicable
MIPS policies proposed elsewhere in this proposed rule, and would treat
the APM Entity group as the group for purposes of MIPS. For the quality
performance category, however, the APM scoring standard we propose is
presented as a separate, unique standard, and therefore generally
applicable MIPS policies would not be applied to the quality
performance category under the APM scoring standard unless specifically
stated. We seek comment on whether there may be potential conflicts or
inconsistencies between the generally applicable MIPS policies and
those under the APM scoring standard, particularly where these could
impact our goals to reduce duplicative and potentially incongruous
reporting requirements and performance evaluations that could undermine
our ability to test or evaluate MIPS APMs, or whether certain generally
applicable MIPS policies should be made explicitly applicable to the
APM scoring standard.
(2) Assessment Dates for Inclusion of MIPS Eligible Clinicians in APM
Entity Groups Under the APM Scoring Standard
In the CY 2017 Quality Payment Program final rule, we specified in
the regulation at Sec. 414.1370(e) that the APM Entity group for
purposes of scoring under the APM scoring standard is determined in the
manner prescribed at Sec. 414.1425(b)(1), which provides that eligible
clinicians who are on a Participation List on at least one of three
dates (March 31, June 30, and August 31) would be considered part of
the APM Entity group. Under these regulations, MIPS eligible clinicians
who are not on a Participation List on one of these three assessment
dates are not scored under the APM scoring standard. Instead, they
would need to submit data to MIPS through one of the MIPS data
submission mechanisms and their performance would be assessed either as
individual MIPS eligible clinicians or as a group according to the
generally applicable MIPS reporting and scoring criteria.
We will continue to use the three assessment dates of March 31,
June 30, and August 31 to identify MIPS eligible clinicians who are on
an APM Entity's Participation List and determine the APM Entity group
that is used for purposes of the APM scoring standard. Beginning in the
2018 performance year, we propose to add a fourth assessment date of
December 31 to identify those MIPS eligible clinicians who participate
in a full TIN APM. We propose to define full TIN APM at Sec. 414.1305
to mean an APM where participation is determined at the TIN level, and
all eligible clinicians who have assigned their billing rights to a
participating TIN are therefore participating in the APM. An example of
a full TIN APM is the Shared Savings Program which requires all
individuals and entities that have reassigned their right to receive
Medicare payment to the TIN of an ACO participant to participate in the
ACO and comply with the requirements of the Shared Savings Program.
If an eligible clinician elects to reassign their billing rights to
a TIN participating in a full TIN APM, the eligible clinician is
necessarily participating in the full TIN APM. We propose to add this
fourth date of December 31 only for eligible clinicians in a full TIN
APM, and only for purposes of applying the APM scoring standard. We are
not proposing to use this additional assessment date of December 31 for
purposes of QP determinations. Therefore, we propose to amend Sec.
414.1370(e) to identify the four assessment dates that would be used to
identify the APM Entity group for purposes of the APM scoring standard,
and to specify that the December 31 date would be used only to identify
eligible clinicians on the APM Entity's Participation List for a MIPS
APM that is a full TIN APM in order to add them to the APM Entity group
that is scored under the APM scoring standard.
We propose to use this fourth assessment date of December 31 to
extend the APM scoring standard to only those MIPS eligible clinicians
participating in MIPS APMs that are full TIN APMs, ensuring that an
eligible clinician who joins the full TIN APM late in the performance
year would be scored under the APM scoring standard. We considered
proposing to use the fourth assessment date more broadly for all MIPS
APMs. However, we believe that this approach would have allowed MIPS
eligible clinicians to inappropriately leverage the fourth assessment
date to avoid reporting and scoring under the generally applicable MIPS
scoring standard when they were part of the MIPS APM for only a very
limited portion of the performance year. That is, for MIPS APMs that
allow split TIN participation, it would be possible for eligible
clinicians to briefly join a MIPS APM principally in order to benefit
from the APM scoring standard, despite having limited opportunity to
contribute to the APM Entity's performance in the MIPS APM. In
contrast, we believe MIPS eligible clinicians would be less likely to
join a full TIN APM principally to avail themselves of the APM scoring
standard, since doing so would require either that the entire TIN join
the MIPS APM or the administratively burdensome act of the eligible
clinician reassigning their billing rights to the TIN of an entity
participating in the full TIN APM.
We will continue to use only the three dates of March 31, June 30,
and August 31 to determine, based on Participation Lists, the MIPS
eligible clinicians who participate in MIPS APMs that are not full TIN
APMs. We seek comment on the proposed addition of the fourth date of
December 31 to assess Participation Lists to identify MIPS eligible
clinicians who participate in MIPS APMs that are full TIN APMs for
purposes of the APM scoring standard.
(3) Calculating MIPS APM Performance Category Scores
In the CY 2017 Quality Payment Program final rule, we established a
scoring standard for MIPS eligible clinicians participating in MIPS
APMs to reduce participant reporting burden by reducing the need for
eligible clinicians participating in these types of APMs to make
duplicative data submissions for both MIPS and their respective APMs
(81 FR 77246 through 77271). In accordance with section
1848(q)(1)(D)(i) of the Act, we proposed to assess the performance of a
group of MIPS eligible clinicians in an APM Entity that participates in
one or more MIPS APMs based on their collective performance as an APM
Entity group, as defined at Sec. 414.1305.
In addition to reducing reporting burden, we sought to ensure that
eligible clinicians in MIPS APMs are not assessed in multiple ways on
the same performance activities. Depending on the terms of the
particular MIPS APM, we believe that misalignments could be common
between the evaluation of performance on quality and cost under MIPS
versus under the terms of the APM. We believe requiring eligible
clinicians in MIPS APMs to submit data, be scored on measures, and be
subject
[[Page 30082]]
to payment adjustments that are not aligned between MIPS and an APM
could potentially undermine the validity of testing or performance
evaluation under the APM. We also believe imposition of MIPS reporting
requirements would result in reporting activity that provides little or
no added value to the assessment of eligible clinicians, and could
confuse eligible clinicians as to which CMS incentives should take
priority over others in designing and implementing care improvement
activities.
(a) Cost Performance Category
In the CY 2017 Quality Payment Program final rule, for MIPS
eligible clinicians participating in MIPS APMs, we used our authority
to waive requirements under the Medicare statute to reduce the scoring
weight for the cost performance category to zero (81 FR 77258, 77262,
and 77266). We did this for MIPS APMs authorized under section 1115A of
the Act using our authority under section 1115A(d)(1) of the Act to
waive the requirement under section 1848(q)(5)(E)(i)(II) of the Act
that specifies the scoring weight for the cost performance category.
Having reduced the cost performance category weight to zero, we further
used our authority under section 1115A(d)(1) of the Act to waive the
requirements under sections 1848(q)(2)(B)(ii) and 1848(q)(2)(A)(ii) of
the Act to specify and use, respectively, cost measures in calculating
the MIPS final score for MIPS eligible clinicians participating in
Other MIPS APMs (81 FR 77261 through 77262 and 77265 through 77266).
Similarly, for MIPS eligible clinicians participating in the Medicare
Shared Savings Program, we used our authority under section 1899(f) of
the Act to waive the same requirements of section 1848 of the Act for
the MIPS cost performance category (81 FR 77257 through 77258). We
finalized this policy because: (1) APM Entity groups are already
subject to cost and utilization performance assessment under the MIPS
APMs; (2) MIPS APMs usually measure cost in terms of total cost of
care, which is a broader accountability standard that inherently
encompasses the purpose of the claims-based measures that have
relatively narrow clinical scopes, and MIPS APMs that do not measure
cost in terms of total cost of care may depart entirely from MIPS
measures; and (3) the beneficiary attribution methodologies differ for
measuring cost under APMs and MIPS, leading to an unpredictable degree
of overlap (for eligible clinicians and for CMS) between the sets of
beneficiaries for which eligible clinicians would be responsible that
would vary based on the unique APM Entity characteristics such as which
and how many eligible clinicians comprise an APM Entity group. We
believe that with an APM Entity's finite resources for engaging in
efforts to improve quality and lower costs for a specified beneficiary
population, measurement of the population identified through the APM
must take priority in order to ensure that the goals and the model
evaluation associated with the APM are as clear and free of confounding
factors as possible. The potential for different, conflicting results
across APMs and MIPS assessments may create uncertainty for MIPS
eligible clinicians who are attempting to strategically transform their
respective practices and succeed under the terms of the APM. We are not
proposing changes to these policies.
We welcome comment on our proposal to continue to waive the
weighting of the cost performance category for the 2020 payment year
forward.
(i) Measuring Improvement in the Cost Performance Category
In setting performance standards with respect to measures and
activities in each MIPS performance category, section 1848(q)(3)(B) of
the Act requires us to consider, historical performance standards,
improvement, and the opportunity for continued improvement. Section
1848(q)(5)(D)(i)(I) requires us to introduce the measurement of
improvement into performance scores in the cost performance category
for MIPS eligible clinicians for the 2020 MIPS Payment Year if data
sufficient to measure improvement are available. Section
1848(q)(5)(D)(i)(II) permits us to take into account improvement in the
case of performance scores in other performance categories. Given that
we have in effect waivers of the scoring weight for the cost
performance category, and of the requirement to specify and use cost
measures in calculating the MIPS final score for MIPS eligible
clinicians participating in MIPS APMs, and for the same reasons that we
initially waived those requirements, we propose to use our authority
under section 1115A(d)(1) of the Act for MIPS APMs authorized under
section 1115A of the Act and under section 1899(f) of the Act for MIPS
APMs under the Medicare Shared Savings Program, to waive the
requirement under section 1848(q)(5)(D)(i)(I) of the Act to take
improvement into account for performance scores in the cost performance
category beginning with the 2018 MIPS performance year.
We seek comment on this proposal.
(b) Quality Performance Category
(i) Web Interface Reporters: Shared Savings Program and Next Generation
ACO Model
(A) Quality Measures
We finalized in the CY 2017 Quality Payment Program final rule that
under the APM scoring standard, participants in the Shared Savings
Program and Next Generation ACO Model would be assessed for the
purposes of generating a MIPS APM quality performance category score
based exclusively on quality measures submitted using the CMS Web
Interface (81 FR 77256 and 77261). In the CY 2017 Quality Payment
Program final rule, we recognized that ACOs in both the Shared Savings
Program and Next Generation ACO Model use the CMS Web Interface to
submit data on quality measures, and that the measures they would
report were also MIPS measures for 2017. For the Shared Savings Program
and the Next Generation ACO Model, we finalized a policy to use quality
measures and data submitted by the participant ACOs to the CMS Web
Interface (as required under the rules for these initiatives) and MIPS
benchmarks for these measures to score quality for MIPS eligible
clinicians in these MIPS APMs at the APM Entity level (81 FR 77256,
77261). For these MIPS APMs, which we refer to as Web Interface
reporters going forward, we established that quality performance data
that are not submitted to the CMS Web Interface, for example the CAHPS
for ACOs survey and claims-based measures, will not be included in the
MIPS APM quality performance category score for 2017.
(aa) Addition of New Measures
For the Shared Savings Program and Next Generation ACO Model, we
propose to score the CAHPS for ACOs survey, in addition to the CMS Web
Interface measures that are used to calculate the MIPS APM quality
performance category score for the Shared Savings Program and Next
Generation ACO Model, beginning in the 2018 performance year. The CAHPS
for ACOs survey is already required in the Shared Savings Program and
Next Generation ACO Model, and including the CAHPS for ACOs survey
would better align the measures on which participants in these MIPS
APMs are assessed under the APM scoring standard with the measures used
to
[[Page 30083]]
assess participants' quality performance under the APM.
We did not initially propose to include the CAHPS for ACOs survey
as part of the MIPS APM quality performance category scoring for the
Shared Savings Program and Next Generation ACO Model because we
believed that the CAHPS for ACOs survey would not be collected and
scored in time to produce a MIPS quality performance category score.
However, operational efficiencies have recently been introduced that
have made it possible to score the CAHPS for ACOs survey on the same
timeline as the CAHPS for MIPS survey. Under our proposal, the CAHPS
for ACOs survey would be added to the total number of quality
performance category measures available for scoring in these MIPS APMs.
While the CAHPS for ACOs survey is new to MIPS APM scoring, the CG-
CAHPS survey upon which it is based is also the basis for the CAHPS for
MIPS survey, which was included on the MIPS final list for the 2017
performance year. For a further discussion of the CAHPS for ACOs
survey, and the way it will be scored, we refer readers to
II.C.6.b.(3)(a)(ii) of this proposed rule, which describes the
identical CAHPS for MIPS survey and its scoring method that will be
used for MIPS in the 2018 performance year. We note that although each
question in the CAHPS for ACOs survey can also be found in the CAHPS
for MIPS survey, the CAHPS for ACOs survey will have one fewer survey
question the SSM entitled ``Between Visit Communication'', which has
never been a scored measure with the Medicare Shared Savings Program
CAHPS for ACOs Survey and which we believe to be inappropriate for use
by ACOs.
Table 10--Web Interface Reporters: Shared Savings Program and Next Generation ACO Model New Measure
----------------------------------------------------------------------------------------------------------------
NQF/quality National
Measure name number (if quality Measure description Primary measure
applicable) strategy domain steward
----------------------------------------------------------------------------------------------------------------
CAHPS for ACOs............... N/A............ Patient/ Consumer Assessment of Agency for
Caregiver Healthcare Providers and Healthcare
Experience. Systems (CAHPS) surveys for Research and
Accountable Care Quality (AHRQ)
Organizations (ACOs) in the
Medicare Shared Savings
Program (SSP) and Next
Generation ACOs ask consumers
about their experiences with
health care. The CAHPS for
ACOs Survey is collected from
a sample of beneficiaries who
get the majority of their
care from an ACO, and the
questions address care
received from a named
clinician within the ACO.
Survey measures include:
--Getting Timely Care,
Appointments, and
Information.
--How Well Your Providers
Communicate.
--Patients' Rating of
Providers.
--Access to Specialists....
--Health Promotion and
Education.
--Shared Decision Making...
--Health Status/Functional
Status.
--Stewardship of Patient
Resources.
----------------------------------------------------------------------------------------------------------------
(B) Calculating Quality Scores
We refer readers to section II.C.7.a.(1)(h)(ii) of this proposed
rule for our summary of finalized policies and proposed changes related
to calculating the MIPS quality performance category percent score for
MIPS eligible clinicians, including APM Entity groups reporting through
the CMS Web Interface. Those policies and proposed changes in section
II.C.7.a.(1)(h)(ii) of this proposed rule would apply in the same
manner under the APM scoring standard except as otherwise noted in this
section of the proposed rule. However, we propose not to subject MIPS
APM Web Interface reporters to a 3 point floor because we do not
believe it is necessary to apply this transition year policy to
eligible clinicians participating in previously established MIPS APMs.
(C) Incentives to Report High Priority Measures
In the CY 2017 Quality Payment Program final rule, we finalized
that for CMS Web Interface reporters, we will apply bonus points based
on the finalized set of measures reportable through the CMS Web
Interface. (81 FR 77291 through 77294). We will assign two bonus points
for reporting two or more outcome or patient experience measures and
one bonus point for reporting any other high priority measure, beyond
the first high priority measure. We note that in addition to the
measures required by the APM to be submitted through the CMS Web
Interface, APM Entities in the Shared Savings Program and Next
Generation ACO Models must also report the CAHPS for ACOs survey and we
propose that beginning for the 2020 payment year forward they may
receive bonus points under the APM scoring standard for submitting that
measure. Participants in MIPS APMs, like all MIPS eligible clinicians,
are also subject to the 10 percent cap on bonus points for reporting
high priority measures. APM Entities reporting through the CMS Web
Interface will only receive bonus points if they submit a high priority
measure with a performance rate that is greater than zero, provided
that the measure meets the case minimum requirements.
(D) Scoring Quality Improvement
Beginning in the CY 2018 performance year, section
1848(q)(5)(D)(i)(I) of the Act requires us to score improvement for the
MIPS quality performance category for MIPS eligible clinicians,
including those participating in MIPS APMs, if data sufficient to
measure quality improvement are available. We propose to calculate the
quality improvement score using the methodology described in section
II.C.7.a.(1)(i) for scoring quality improvement for eligible clinicians
submitting quality measures via the CMS Web Interface. We believe
aligning the scoring methodology used for all CMS Web Interface
submissions will minimize confusion among MIPS eligible clinicians
receiving a MIPS score, including those participating in MIPS APMs.
(E) Total Quality Performance Category Score for CMS Web Interface
Reporters
We propose to calculate the total quality percent score for MIPS
eligible clinicians using the CMS Web Interface according to the
methodology described
[[Page 30084]]
in section II.C.7.a.(1)(h)(2) of this proposed rule.
We seek comment on our proposed quality performance category
scoring methodology for CMS Web Interface reporters.
(ii) Other MIPS APMs
We propose to define the term Other MIPS APM at Sec. 414.1305 as a
MIPS APM that does not require reporting through the CMS Web Interface.
We propose to add this definition as we believe it will be useful in
discussing our policies for the APM scoring standard. In the 2018 MIPS
performance period, Other MIPS APMs will include the Comprehensive ESRD
Care Model, the Comprehensive Primary Care Plus Model (CPC+), and the
Oncology Care Model.
(A) Quality Measures
In the CY 2017 Quality Payment Program final rule, we explained
that current MIPS APMs have requirements regarding the number of
quality measures, measure specifications, as well as the measure
reporting method(s) and frequency of reporting, and have an established
mechanism for submission of these measures to us within the structure
of the specific MIPS APM. We explained that operational considerations
and constraints interfered with our ability to use the quality measure
data from some MIPS APMs for the purpose of satisfying MIPS data
submission requirements for the quality performance category for the
first performance year. We concluded that there was insufficient time
to adequately implement changes to the current MIPS APM quality measure
data collection timelines and infrastructure in the first performance
year to conduct a smooth hand-off to the MIPS system that would enable
use of APM quality measure data to satisfy the MIPS quality performance
category requirements in the first MIPS performance year (81 FR 77264).
Out of concern that subjecting MIPS eligible clinicians who participate
in MIPS APMs to multiple, potentially duplicative or inconsistent
performance assessments could undermine the validity of testing or
performance evaluation under the MIPS APMs; and that there was
insufficient time to make adjustments in operationally complex systems
and processes related to the alignment, submission and collection of
APM quality measures for purposes of MIPS, we used our authority under
section 1115A(d)(1) to waive certain requirements of section 1848(q).
We finalized that for the first MIPS performance year only, for
MIPS eligible clinicians participating in APM Entities in Other MIPS
APMs, the weight for the quality performance category is zero (81 FR
77268). To avoid risking adverse operational or program evaluation
consequences for MIPS APMs while we worked toward incorporating MIPS
APM quality measures into scoring for future performance years, we used
the authority provided by section 1115A(d)(1) of the Act to waive the
quality performance category weight required under section
1848(q)(5)(E)(i)(I) of the Act, and we indicated that with the
reduction of the quality performance category weight to zero, it was
unnecessary to establish for MIPS APMs a final list of quality measures
as required under section 1848(q)(2)(D) of the Act or to specify and
use quality measures in determining the MIPS final score for these MIPS
eligible clinicians. As such, we further waived the requirements under
sections 1848(q)(2)(D), 1848(q)(2)(B)(i) and 1848(q)(2)(A)(i) of the
Act to establish a final list of quality measures (using certain
criteria and processes); and to specify and use, respectively, quality
measures in calculating the MIPS final score for the first MIPS
performance year.
In the CY 2017 Quality Payment Program final rule, we anticipated
that beginning with the second MIPS performance year, the APM quality
measure data submitted to us during the MIPS performance year would be
used to derive a MIPS quality performance score for APM Entities in all
MIPS APMs.
We also anticipated that it may be necessary to propose policies
and waivers of requirements of the statute, such as section
1848(q)(2)(D) of the Act, to enable the use of non-MIPS quality
measures in the quality performance category score. We anticipated that
by the second performance year we would have had sufficient time to
resolve operational constraints related to use of separate quality
measure systems and to adjust quality measure data submission
timelines. Accordingly, we stated our intention to, in future
rulemaking, use our section 1115A(d)(1) waiver authority to establish
that the quality measures and data that are used to evaluate
performance for APM Entities in MIPS APMs would be used to calculate a
MIPS quality performance score under the APM scoring standard.
We have since designed the means to overcome the operational
constraints that prevented us from scoring quality under the APM
scoring standard in the first performance year, and we propose to adopt
quality measures for use under the APM scoring standard, and begin
collecting MIPS APM quality measure performance data in order to
generate a MIPS quality performance category score for APM Entities
participating in MIPS APMs beginning with the 2018 performance year.
(aa) APM Measures for MIPS
In the CY 2017 Quality Payment Program final rule, we explained the
concerns that led us to express our intent to use the quality measures
and data that apply in the MIPS APM for purposes of the APM scoring
standard, including concerns about the application of multiple,
potentially duplicative or inconsistent performance assessments that
could negatively impact our ability to evaluate MIPS APMs (81 FR
77246). Additionally, the quality and cost/utilization measures that
are used to calculate performance-based payments in MIPS APMs may vary
from one MIPS APM to another. Factors such as the type and quantity of
measures required, the MIPS APM's particular measure specifications,
how frequently the measures must be reported, and the mechanisms used
to collect or submit the measures all add to the diversity in the
quality and cost/utilization measures used to evaluate performance
among MIPS APMs. Given these concerns and the differences between and
among the quality measures used to evaluate performance within MIPS
APMs as opposed to those used more generally under MIPS, we propose to
use our authority under section 1115A(d)(1) of the Act to waive
requirements under section 1848(q)(2)(D) of the Act, which requires the
Secretary to use certain criteria and processes to establish an annual
MIPS final list of quality measures from which all MIPS eligible
clinicians may choose measures for purposes of assessment, and instead
to establish a MIPS APM quality measure list for purposes of the APM
scoring standard. The MIPS APM quality measure list would be adopted as
the final list of MIPS quality measures under the APM scoring standard,
and would reflect the quality measures that are used to evaluate
performance on quality within each MIPS APM.
The MIPS APM quality measure list we propose in Table 13, would
define distinct measure sets for participants in each MIPS APM for
purposes of the APM scoring standard, based on the measures that are
used by the APM, and for which data will be collected by the close of
the MIPS submission period. The measure sets on the MIPS APM measure
list would represent all possible measures which may contribute to an
APM Entity's MIPS score for the MIPS quality performance
[[Page 30085]]
category, and may include measures that are the same as or similar to
those used by MIPS. However, measures may ultimately not be used for
scoring if a measure's data becomes inappropriate or unavailable for
scoring; for example, if a measure's clinical guidelines are changed or
the measure is otherwise modified by the APM during the performance
year, the data collected during that performance year would not be
uniform, and as such may be rendered unusable for purposes of the APM
scoring standard (See Tables 14, 15, and 16).
(B) Measure Requirements for Other MIPS APMs
Because the quality measure sets for each Other MIPS APM are
unique, we propose to calculate the MIPS quality performance category
score using APM-specific quality measures. For purposes of the APM
scoring standard, we will score only measures that: (1) Are tied to
payment as described under the terms of the APM, (2) are available for
scoring near the close of the MIPS submission period, (3) have a
minimum of 20 cases available for reporting, and (4) have an available
benchmark. We discuss each of these requirements for Other MIPS APM
quality measures below.
(aa) Tied to Payment
For purposes of the APM scoring standard, we will consider a
measure to be tied to payment if an APM Entity group will receive a
payment adjustment or other incentive payment under the terms of the
APM, based on the APM Entity's performance on the measure.
(bb) Available for Scoring
Some MIPS APM quality measure results are not available until late
in the calendar year subsequent to the MIPS performance year, which
would prevent us from including them in the MIPS APM quality
performance category score due to the larger programmatic timelines for
providing MIPS eligible clinician performance feedback by July and
issuing budget-neutral MIPS payment adjustments. Consequently, we
propose to only use the MIPS APM quality measure data that are
submitted by the close of the MIPS submission period and are available
for scoring in time for inclusion to calculate a MIPS quality
performance category score. Measures are to be submitted according to
requirements under the terms of the APM; the measure data will then be
aggregated and prepared for submission to MIPS for the purpose of
creating a MIPS quality performance category score.
We believe using the Other MIPS APMs' quality measure data that
have been submitted no later than the close of the MIPS submission
period and have been processed and made available to MIPS for scoring
in time to calculate a MIPS quality performance category score is
consistent with our intent to decrease duplicative reporting for MIPS
eligible clinicians who would otherwise need to report quality measures
to both MIPS and their APM. Going forward, these are the measures to
which we are referring when we limit scoring to measures that are
available near the close of the MIPS submission period.
(cc) 20 Case Minimum
We also believe that a 20 case minimum, in alignment with the one
finalized generally under MIPS in the CY 2017 Quality Payment Program
final rule (81 FR 77288), is necessary to ensure the reliability of the
measure data submitted, as explained the CY 2017 Quality Payment
Program final rule.
As under the general policy for MIPS, when an APM Entity reports a
quality measure that includes less than 20 cases, that measure would
receive a null score for that measure's achievement points, and the
measure would be removed from both the numerator and the denominator of
the MIPS quality performance category percentage. We propose to apply
this policy under the APM scoring standard.
(dd) Available Benchmark
An APM Entity's score on each quality measure would be calculated
in part by comparing the APM Entity's performance on the measure with a
benchmark performance score. Therefore, we would need all scored
measures to have a benchmark available by the time that the MIPS
quality performance category score is calculated, in order to make that
comparison.
We propose that, for the APM scoring standard, the benchmark score
used for a quality measure would be the benchmark used in the MIPS APM
for calculation of the performance based payments, where such a
benchmark is available. If the APM does not produce a benchmark score
for a reportable measure that is included on the APM measures list, we
would use the benchmark score for the measure that is used for the MIPS
quality performance category generally (outside of the APM scoring
standard) for that performance year, provided the measure
specifications for the measure are the same under both the MIPS final
list and the APM measures list. If neither the APM nor MIPS has a
benchmark available for a reported measure, the APM Entity that
reported that measure would receive a null score for that measure's
achievement points, and the measure would be removed from both the
numerator and the denominator of the quality performance category
percentage.
(C) Calculating the Quality Performance Category Percent Score
Eligible clinicians who participate in Other MIPS APMs are subject
to specific quality measure reporting requirements within these APMs.
To best align with APM design and objectives, we propose that the
minimum number of required measures to be reported for the APM scoring
standard would be the minimum number of quality measures that are
required by the MIPS APM and are collected and available in time to be
included in the calculation for the APM Entity score under the APM
scoring standard. For example, if an Other MIPS APM requires
participating APM Entities to report nine of 14 quality measures by a
specific date and the APM Entity misses the MIPS submission deadline,
then for the purposes of calculating an APM Entity quality performance
category score, the APM Entity would receive a zero for those measures.
An APM Entity that does not submit any APM quality measures by the MIPS
submission deadline would receive a zero for its MIPS APM quality
performance category percent score for the performance year.
We propose that if an APM Entity submits some, but not all of the
measures required by the MIPS APM by the close of the MIPS submission
period, the APM Entity would receive points for the measures that were
submitted, but would receive a score of zero for each remaining measure
between the number of measures reported and the number of measures
required by the APM that were available for scoring.
For example, if an APM Entity in the above hypothetical MIPS APM
submits quality performance data on three of the APM's measures,
instead of the required nine, the APM Entity would receive quality
points in the APM scoring standard quality performance category percent
score for the three measures it submitted, but would receive zero
points for each of the six remaining measures that were required under
the terms of the MIPS APM. On the other hand, if an APM Entity reports
on more than the minimum number of measures required to be reported
under the MIPS APM and the measures meet the other
[[Page 30086]]
criteria for scoring, only the measures with the highest scores, up to
the number of measures required to be reported under the MIPS APM,
would be counted; however, any bonus points earned by reporting on
measures beyond the minimum number of required measures would be
awarded.
If a measure is reported but fails to meet the 20 case minimum or
does not have a benchmark available, there would be a null score for
that measure, and it would be removed from both the numerator and the
denominator, so as not to negatively affect the APM Entity's quality
performance category score.
We propose to assign bonus points for reporting high priority
measures or measures with end-to-end CEHRT reporting as described for
general MIPS scoring in the CY 2017 Quality Payment Program final rule
(81 FR 77297 through 77299).
(aa) Quality Measure Benchmarks
An APM Entity's MIPS quality measure score will be calculated by
comparing the APM Entity's performance on a given measure with a
benchmark performance score. We propose that the benchmark score used
for a quality measure would be the benchmark used by the MIPS APM for
calculation of the performance based payments within the APM, if
possible, in order to best align the measure performance outcomes
between the APM and MIPS programs. If the MIPS APM does not produce a
benchmark score for a reportable measure that will be available at the
close of the MIPS submission period, the benchmark score for the
measure that is used for the MIPS quality performance category
generally for that performance year would be used, provided the measure
specifications are the same for both. If neither the APM nor MIPS has a
benchmark available for a reported measure, the APM Entity that
reported that measure will receive a null score for that measure's
achievement points, and the measure will be removed from both the
numerator and the denominator of the quality performance category
percentage.
We are proposing that for measures that are pay for reporting or
which do not measure performance on a continuum of performance, we will
consider these measures to be lacking a benchmark and they will be
treated as such. For example, if a model only requires that an APM
Entity must surpass a threshold and does not measure APM Entities on
performance beyond surpassing a threshold, we would not consider such a
measure to measure performance on a continuum.
We propose to score quality measure performance under the APM
scoring standard using a percentile distribution, separated by decile
categories, as described in the finalized MIPS quality scoring
methodology (81 FR 77282 through 77284). For each benchmark, we will
calculate the decile breaks for measure performance and assign points
based on the benchmark decile range into which the APM Entity's measure
performance falls.
We propose to use a graduated points-assignment approach, where a
measure is assigned a continuum of points out to one decimal place,
based on its place in the decile. For example, a raw score of 55
percent would fall within the sixth decile of 41.0 percent to 61.9
percent and would receive between 6.0 and 6.9 points.
We seek comment on this proposed method.
Table 11--Benchmark Decile Distribution
------------------------------------------------------------------------
Graduated
Sample benchmark decile Sample quality points (with
measure (%) no floor)
------------------------------------------------------------------------
Example Benchmark Decile 1.............. 0-9.9 1.0-1.9
Example Benchmark Decile 2.............. 10.0-17.9 2.0-2.9
Example Benchmark Decile 3.............. 18.0-22.9 3.0-3.9
Example Benchmark Decile 4.............. 23.0-35.9 4.0-4.9
Example Benchmark Decile 5.............. 36.0-40.9 5.0-5.9
Example Benchmark Decile 6.............. 41.0-61.9 6.0-6.9
Example Benchmark Decile 7.............. 62.0-68.9 7.0-7.9
Example Benchmark Decile 8.............. 69.0-78.9 8.0-8.9
Example Benchmark Decile 9.............. 79.0-84.9 9.0-9.9
Example Benchmark Decile 10............. 85.0-100 10.0
------------------------------------------------------------------------
(bb) Assigning Quality Measure Points Based on Achievement
For the APM scoring standard quality performance category, we
propose that each APM Entity that reports on quality measures would
receive between 1 and 10 achievement points for each measure reported
that can be reliably scored against a benchmark, up to the number of
measures that are required to be reported by the APM. Because measures
that lack benchmarks or 20 reported cases are removed from the
numerator and denominator of the quality performance category
percentage, it is unnecessary to include a point-floor for scoring of
Other MIPS APMs. Similarly, because the quality measures reported by
the MIPS APM for MIPS eligible clinicians under the APM scoring
standard are required to be submitted to the APM under the terms of
participation in the APM, and the MIPS eligible clinicians do not
select their APM measures, there will be no cap on topped out measures
for MIPS APM participants being scored under the APM scoring standard,
which differs from the policy for other MIPS eligible clinicians
proposed at section II.C.7.a.(2)(c) of this proposed rule.
Beginning in the 2018 MIPS performance year, we propose that APM
Entities in MIPS APMs, like other MIPS eligible clinicians, would be
eligible to receive bonus points for the MIPS quality performance
category for reporting on high priority measures or measures submitted
via CEHRT (for example, end-to-end submission) according to the
criteria described in section II.C.7.a.(1) of this proposed rule. For
each Other MIPS APM, we propose to identify whether any of their
available measures meets the criteria to receive a bonus, and add the
bonus points to the quality achievement points. Further, we propose
that the total number of awarded bonus points may not exceed 10 percent
of the APM Entity's total available achievement points for the MIPS
quality performance category score.
To generate the APM Entity's quality performance category
percentage, achievement points would be added to any applicable bonus
points, and then divided by the total number of available achievement
points, with a cap of 100
[[Page 30087]]
percent. For more detail on the MIPS quality performance category
percentage score calculation, we refer readers to section II.C.7.a.(1)
of this proposed rule.
Under the APM scoring standard for Other MIPS APMs, the number of
available achievement points would be the number of measures required
under the terms of the APM and available for scoring multiplied by ten.
If, however, an APM Entity reports on a required measure that fails the
20 case minimum requirement, or which has no available benchmark for
that performance year, the measure would receive a null score and all
points from that measure would be removed from both the numerator and
the denominator.
For example, if an APM Entity reports on four out of four measures
required to be reported by the MIPS APM, and receives an achievement
score of five on each and no bonus points, the APM Entity's quality
performance category percentage would be [(5 points x 4 measures) + 0
bonus points]/(4 measures x 10 max available points), or 50 percent.
If, however, one of those measures failed the 20 case minimum
requirement or had no benchmark available, that measure would have a
null value and would be removed from both the numerator and denominator
to create a quality performance category percentage of [(5 points x 3
measures) + 0 bonus points]/(3measures x 10 max available points), or
50 percent.
If an APM Entity fails to meet the 20 case minimum on all available
APM measures, that APM Entity would have its quality performance
category score reweighted to zero, as described below.
We request comment on the above proposals for calculating the
quality category percent score.
(D) Quality Improvement Scoring
Beginning in the 2018 performance year, we propose to score
improvement as well as achievement in the quality performance category.
For the APM scoring standard, we propose that the quality
improvement percentage points would be awarded based on the following
formula:
Quality Improvement Score = (Absolute Improvement/Previous Year Quality
Performance Category Percent Score Prior to Bonus Points)/10
For a more detailed discussion of improvement scoring for the
quality performance category under the APM scoring standard, we refer
readers to the discussion on calculating improvement at the quality
performance category level for MIPS at section II.C.7.a.(1)(i) of this
proposed rule.
(E) Calculating Total Quality Performance Category Score
We propose that the APM Entity's total quality performance category
score would be equal to [(achievement points + bonus points)/total
available achievement points] + quality improvement score. The APM
Entity's total quality performance category score may not exceed 100
percent. We request comment on the above proposed quality scoring
methodology.
We seek comment on the proposed quality performance category
scoring methodology for APM Entities participating in Other MIPS APMs.
(c) Improvement Activities Performance Category
As finalized in the CY 2017 Quality Payment Program final rule, for
all MIPS APMs we will assign the same improvement activities score to
each APM Entity based on the activities involved in participation in a
MIPS APM. APM Entities will receive a minimum of one half of the total
possible points. This policy is in accordance with section
1848(q)(5)(C)(ii) of the Act. In the event that the assigned score does
not represent the maximum improvement activities score, the APM Entity
group will have the opportunity to report additional improvement
activities to add points to the APM Entity level score.
(d) Advancing Care Information Performance Category
In the CY 2017 Quality Payment Program final rule, we finalized our
policy to attribute one score to each MIPS eligible clinician in an APM
Entity group by looking for both individual and group TIN level data
submitted for a MIPS eligible clinician, and using the highest
available score (81 FR 77268). We will then use these scores to create
an APM Entity's score based on the average of the highest scores
available for all MIPS eligible clinicians in the APM Entity group. If
an individual or TIN did not report on the advancing care information
performance category, they will contribute a zero to the APM Entity's
aggregate score. Each MIPS eligible clinician in an APM Entity group
will receive one score, weighted equally with the scores of every other
MIPS eligible clinician in the APM Entity group, and we will use these
to calculate a single APM Entity-level advancing care information
performance category score.
We refer readers to section II.C.6.f.(6) of this proposed rule for
our summary of proposed changes related to scoring the advancing care
information performance category.
(i) Special Circumstances
As described in the CY 2017 Quality Payment Program final rule (81
FR 77238-77245), under the generally applicable MIPS scoring standard,
we will assign a weight of zero percent to the advancing care
information performance category in the final score for MIPS eligible
clinicians who meet specific criteria: hospital-based MIPS eligible
clinicians, MIPS eligible clinicians who are facing a significant
hardship, and certain types of non-physician practitioners (NPs, PAs,
CRNAs, CNSs) who are MIPS eligible clinicians. In section II.C.7.a.(6)
of this proposed rule, we are also proposing to include in this
weighting policy ASC-based MIPS eligible clinicians and MIPS eligible
clinicians who are using decertified EHR technology.
Under the APM scoring standard, we propose that if a MIPS eligible
clinician who qualifies for a zero percent weighting of the advancing
care information performance category in the final score is part of a
TIN that includes one or more MIPS eligible clinicians who do not
qualify for a zero percent weighting, we would not apply the zero
percent weighting to the qualifying MIPS eligible clinician, and the
TIN would still be required to report on behalf of the group, although
the TIN would not need to report data for the qualifying MIPS eligible
clinician. All MIPS eligible clinicians in the TIN would count towards
the TIN's weight when calculating an aggregated APM Entity score for
the advancing care information performance category.
If, however, the MIPS eligible clinician is a solo practitioner and
qualifies for a zero percent weighting, or if all MIPS eligible
clinicians in a TIN qualify for the zero percent weighting, the TIN
would not be required to report on the advancing care information
performance category, and if the TIN chooses not to report that TIN
would be assigned a weight of 0 when calculating the APM Entity's
advancing care information performance category score.
If advancing care information data are reported by one or more TINs
in an APM Entity, an advancing care information performance category
score will be calculated for, and will be applicable to, all MIPS
eligible clinicians in the APM Entity group. If all MIPS eligible
clinicians in all TINs in an APM Entity group qualify for a zero
percent weighting of have the advancing care information performance
category, or in the case of a solo practitioner who comprises an entire
[[Page 30088]]
APM Entity and qualifies for zero percent weighting, the advancing care
information performance category would be weighted at zero percent of
the final score, and the advancing care information performance
category's weight would be redistributed to the quality performance
category.
(4) Calculating Total APM Entity Score
(a) Performance Category Weighting
As discussed in section II.C.6.g.(3)(a) of this proposed rule, we
propose to continue to use our authority to waive sections
1848(q)(2)(B)(ii) and 1848(q)(2)(A)(ii) of the Act to specify and use,
respectively, cost measures; and to maintain the cost performance
category weight of zero under the APM scoring standard for the 2018
performance period and subsequent MIPS performance periods. Because the
cost performance category would be reweighted to zero that weight would
need to be redistributed to other performance categories. We propose to
use our authority under section 1115A(d)(1) to waive requirements under
sections 1848(q)(5)(E)(i)(I)(bb), 1848(q)(5)(E)(i)(III) and
1848(q)(5)(E)(i)(IV) of the Act that prescribe the weights,
respectively, for the quality, improvement activities, and ACI
performance categories. We propose to weight the quality performance
category score to 50 percent, the improvement activities performance
category to 20 percent, and the advancing care information performance
category to 30 percent of the final score for all APM Entities in Other
MIPS APMs. We propose these weights to align the Other MIPS APM
performance category weights with those assigned to the Web Interface
reporters, which we adopted as explained in the CY 2017 Quality Payment
Program final rule at 81 FR 77262 through 77263. We believe it is
appropriate to align the performance category weights for APM Entities
in MIPS APMs that require reporting through the Web Interface with
those in Other MIPS APMs. By aligning the performance category weights
among all MIPS APMs, we would create greater scoring parity among the
MIPS eligible clinicians in MIPS APMs who are being scored under the
APM scoring standard. These proposals are summarized in Table 12.
Table 12--APM Scoring Standard Performance Category Weights--Beginning for the 2018 Performance Period
----------------------------------------------------------------------------------------------------------------
Performance
MIPS performance category APM entity submission Performance category score category
requirement weight (%)
----------------------------------------------------------------------------------------------------------------
Quality............................. The APM Entity will be CMS will assign the same 50
required to submit quality quality category
measures to CMS as required performance score to each
by the MIPS APM. Measures TIN/NPI in an APM Entity
available at the close of group based on the APM
the MIPS submission period Entity's total quality
will be used to calculate score, derived from
the MIPS quality available APM quality
performance category score. measures.
If the APM Entity does not
submit any APM required
measures by the MIPS
submission deadline, the
APM Entity will be assigned
a zero.
Cost................................ The APM Entity group will N/A......................... 0
not be assessed on cost
under MIPS.
Improvement Activities.............. MIPS eligible clinicians do CMS will assign the same 20
not need to report improvement activities
improvement activities score to each APM Entity
data; if the CMS-assigned based on the activities
improvement activities involved in participation
score is below the maximum in the MIPS APM. APM
improvement activities Entities will receive a
score APM Entities will minimum of one half of the
have the opportunity to total possible points. In
submit additional the event that the assigned
improvement activities to score does not represent
raise the APM Entity the maximum improvement
improvement activity score. activities score, the APM
Entity will have the
opportunity to report
additional improvement
activities to add points to
the APM Entity level score.
Advancing Care Information.......... Each MIPS eligible clinician We will attribute the same 30
in the APM Entity group is score to each MIPS eligible
required to report clinician in the APM Entity
advancing care information group. This score will be
to MIPS through either the highest score
group TIN or individual attributable to the TIN/NPI
reporting. combination of each MIPS
eligible clinician, which
may be derived from either
group or individual
reporting. The scores
attributed to each MIPS
eligible clinicians will be
averaged for a single APM
Entity score.
----------------------------------------------------------------------------------------------------------------
It is possible that there could be instances where an Other MIPS
APM has no measures available to score for the quality performance
category for a MIPS performance period; for example, it is possible
that none of the Other MIPS APM's measures would be available for
calculating a quality performance category score by or shortly after
the close of the MIPS submission period because the measures were
removed due to changes in clinical practice guidelines. In addition, as
explained in section II.C.6.g.(3)(d)(i) of this proposed rule, the MIPS
eligible clinicians in an APM Entity may qualify for a zero percent
weighting for the advancing care information performance category. In
such instances, under the APM scoring standard, we propose to reweight
the affected performance category to zero, in accordance with section
1848(q)(5)(F) of the Act.
If the quality performance category is reweighted to zero, we
propose to reweight the improvement activities and advancing care
information performance categories to 25 and 75 percent, respectively.
If the advancing care information performance category is reweighted to
zero, the quality performance category weight would be
[[Page 30089]]
increased to 80 percent. These proposals are summarized in Table 13.
Table 13--APM Scoring Standard Performance Category Weights for Other MIPS APMs With Performance Categories
Weighted to 0--Beginning for the 2018 Performance Period
----------------------------------------------------------------------------------------------------------------
Performance
Performance category
APM entity submission Performance category category weight (no
MIPS performance category requirement score weight (no advancing care
quality) (%) information)
(%)
----------------------------------------------------------------------------------------------------------------
Quality........................ The APM Entity would CMS will assign the 0 80
not be assessed on same quality category
quality under MIPS if performance score to
no quality data are each TIN/NPI in an
available at the close APM Entity group
of the MIPS submission based on the APM
period. The APM Entity Entity's total
will submit quality quality score,
measures to CMS as derived from
required by the MIPS available APM quality
APM. measures.
Cost........................... The APM Entity group N/A................... 0 0
will not be assessed
on cost under MIPS.
Improvement Activities......... MIPS eligible CMS will assign the 25 20
clinicians do not need same improvement
to report improvement activities score to
activities data unless each APM Entity group
the CMS-assigned based on the
improvement activities activities involved
scores is below the in participation in
maximum improvement the MIPS APM.
activities score. APM Entities will
receive a minimum of
one half of the total
possible points. In
the event that the
assigned score does
not represent the
maximum improvement
activities score, the
APM Entity will have
the opportunity to
report additional
improvement
activities to add
points to the APM
Entity level score.
Advancing Care Information..... Each MIPS eligible We will attribute the 75 0
clinician in the APM same score to each
Entity group reports MIPS eligible
advancing care clinician in the APM
information to MIPS Entity group. This
through either group score will be the
TIN or individual highest score
reporting. attributable to the
TIN/NPI combination
of each MIPS eligible
clinician, which may
be derived from
either group or
individual reporting.
The scores attributed
to each MIPS eligible
clinicians will be
averaged for a single
APM Entity score.
----------------------------------------------------------------------------------------------------------------
We seek comment on the proposed reweighting for APM Entities
participating in MIPS APMs.
(b) Risk Factor Score
Section 1848(q)(1)(G) of the Act requires us to consider risk
factors in our scoring methodology. Specifically, that section provides
that the Secretary, on an ongoing basis, shall, as the Secretary
determines appropriate and based on individuals' health status and
other risk factors, assess appropriate adjustments to quality measures,
cost measures, and other measures used under MIPS and assess and
implement appropriate adjustments to payment adjustments, final scores,
scores for performance categories, or scores for measures or activities
under the MIPS.
We refer readers to II.C.7.b.(1) of this proposed rule for a
description of the risk factor adjustment and its application to APM
Entities.
(c) Small Practice Bonus
We believe an adjustment for eligible clinicians in small practices
(referred to herein as the small practice bonus) is appropriate to
recognize barriers faced by small practices, such as unique challenges
related to financial and other resources, environmental factors, and
access to health information technology, and to incentivize eligible
clinicians in small practices to participate in the Quality Payment
Program and to overcome any performance discrepancy due to practice
size.
We refer readers to section II.C.7.b.(2) of this proposed rule for
a discussion of the small practice adjustment and its application to
APM Entities.
(d) Final Score Methodology
In the CY 2017 Quality Payment Program final rule, we finalized the
methodology for calculating a final score of 0-100 based on the four
performance categories (81 FR 77320). We refer readers to section
II.C.7.c. of this proposed rule for a discussion of the changes we are
proposing for the final score methodology.
(5) MIPS APM Performance Feedback
In the CY 2017 Quality Payment Program final rule (81 FR 77270), we
finalized that all MIPS eligible clinicians scored under the APM
scoring standard will receive performance feedback as specified under
section 1848(q)(12) of the Act on the quality and cost performance
categories to the extent applicable, based on data collected in the
September 2016 QRUR, unless they did not have data included in the
September 2016 QRUR. Those eligible clinicians without data included in
the September 2016 QRUR will not receive any performance feedback until
performance data is available for feedback.
Beginning with the 2018 performance year, we propose that MIPS
eligible clinicians whose MIPS payment adjustment is based on their
score under the APM scoring standard will receive performance feedback
as specified
[[Page 30090]]
under section 1848(q)(12) of the Act for the quality, advancing care
information, and improvement activities performance categories to the
extent data are available for the MIPS performance year. Further, we
propose that in cases where performance data are not available for a
MIPS APM performance category because the MIPS APM performance category
has been weighted to zero for that performance year, we would not
provide performance feedback on that MIPS performance category.
We believe that with an APM Entity's finite resources for engaging
in efforts to improve quality and lower costs for a specified
beneficiary population, the incentives of the APM must take priority
over those offered by MIPS in order to ensure that the goals and
evaluation associated with the APM are as clear and free of confounding
factors as possible. The potential for different, conflicting messages
in performance feedback provided by the APMs and that provided by MIPS
may create uncertainty for MIPS eligible clinicians who are attempting
to strategically transform their respective practices and succeed under
the terms of the APM. Accordingly, under section 1115A(d)(1) and
section 1899(f), for all performance years we propose to waive--for
MIPS eligible clinicians participating in MIPS APMs--the requirement
under section 1848(q)(12)(A)(i)(I) of the Act to provide performance
feedback for the cost performance category.
We request comment on these proposals to waive requirements for
performance feedback on the cost performance category indefinitely, and
for the other performance categories in years for which the weight for
those categories has been reweighted to zero.
(6) Summary of Proposals
In summary, we have proposed the following in this section:
We propose to amend the regulation at Sec. 414.1370(e) to
identify the four assessment dates that would be used to identify the
APM Entity group for purposes of the APM scoring standard, and to
specify that the December 31 date will be used only to identify
eligible clinicians on the APM Entity's Participation List for a MIPS
APM that is a full TIN APM in order to add them to the APM Entity group
that is scored under the APM scoring standard. We propose to use this
fourth assessment date of December 31 to extend the APM scoring
standard to only those MIPS eligible clinicians participating in MIPS
APMs that are full TIN APMs, ensuring that an eligible clinician who
joins the full TIN APM late in the performance year would be scored
under the APM scoring standard.
We propose to continue to weight the cost performance
category under the APM scoring standard for Web Interface reporters at
zero percent for the 2020 payment year forward.
Aligned with our proposal to weight the cost performance
category at zero percent, we propose not to take improvement into
account for performance scores in the cost performance category for Web
Interface reporters beginning with the 2020 MIPS Payment Year.
We propose to score the CAHPS for ACOs survey, in addition
to the CMS Web Interface measures that are used to calculate the MIPS
APM quality performance category score for Web Interface reporters
including the Shared Savings Program and Next Generation ACO Model),
beginning in the 2018 performance year.
We propose that, beginning for the 2018 performance year,
eligible clinicians in MIPS APMs that are Web Interface reporters may
receive bonus points under the APM scoring standard for submitting the
CAHPS for ACOs survey.
We propose to calculate the quality improvement score for
MIPS eligible clinicians submitting quality measures via the CMS Web
Interface using the methodology described in section II.C.7.a.(1)(i).
We propose to calculate the total quality percent score
for MIPS eligible clinicians using the CMS Web Interface according to
the methodology described in section II.C.7.a.(1)(h)(2) of this
proposed rule.
We propose to establish a separate MIPS final list of
quality measures for each Other MIPS APM that would be the quality
measure list used for purposes of the APM scoring standard.
We propose to calculate the MIPS quality performance
category score for Other MIPS APMs using MIPS APM-specific quality
measures. For purposes of the APM scoring standard, we would score only
measures that: (1) Are tied to payment as described under the terms of
the APM, (2) are available for scoring near the close of the MIPS
submission period, (3) have a minimum of 20 cases available for
reporting, and (4) have an available benchmark.
We propose to only use the MIPS APM quality measure data
that are submitted by the close of the MIPS submission period and are
available for scoring in time for inclusion to calculate a MIPS quality
performance category score.
We propose that, for the APM scoring standard, the
benchmark score used for a quality measure would be the benchmark used
in the MIPS APM for calculation of the performance based payments,
where such a benchmark is available. If the APM does not produce a
benchmark score for a reportable measure that is included on the APM
measures list, we would use the benchmark score for the measure that is
used for the MIPS quality performance category generally (outside of
the APM scoring standard) for that performance year, provided the
measure specifications for the measure are the same under both the MIPS
final list and the APM measures list.
We propose that the minimum number of quality measures
required to be reported for the APM scoring standard would be the
minimum number of quality measures that are required within the MIPS
APM and are collected and available in time to be included in the
calculation for the APM Entity score under the APM scoring standard. We
propose that if an APM Entity submits some, but not all of the measures
required by the MIPS APM by the close of the MIPS submission period,
the APM Entity would receive points for the measures that were
submitted, but would receive a score of zero for each remaining measure
between the number of measures reported and the number of measures
required by the APM that were available for scoring.
We propose that the benchmark score used for a quality
measure would be the benchmark used by the MIPS APM for calculation of
the performance based payments within the APM, if possible, in order to
best align the measure performance outcomes between the two programs.
We are proposing that for measures that are pay for reporting or which
do not measure performance on a continuum of performance, we will
consider these measures to be lacking a benchmark and they will be
treated as such.
We propose to score quality measure performance under the
APM scoring standard using a percentile distribution, separated by
decile categories, as described in the finalized MIPS quality scoring
methodology. We propose to use a graduated points-assignment approach,
where a measure is assigned a continuum of points out to one decimal
place, based on its place in the decile.
We propose that each APM Entity that reports on quality
measures would receive between 1 and 10 achievement points for each
measure reported that can be reliably scored against a benchmark, up to
the number of
[[Page 30091]]
measures that are required to be reported by the APM.
We propose that APM Entities in MIPS APMs, like other MIPS
eligible clinicians, would be eligible to receive bonus points for the
MIPS quality performance category for reporting on high priority
measures or measures submitted via CEHRT. For each Other MIPS APM, we
propose to identify whether any of their available measures meets the
criteria to receive a bonus, and add the bonus points to the quality
achievement points.
Beginning in the 2018 performance year, we propose to
score improvement as well as achievement in the quality performance
category. For the APM scoring standard, we propose that the improvement
percentage points would be awarded based on the following formula:
Quality Improvement Score = (Absolute Improvement/Previous Year Quality
Performance Category Percent Score Prior to Bonus Points)/10.
We propose that the APM Entity's total quality performance
category score would be equal to [(achievement points + bonus points)/
total available achievement points] + quality improvement score.
Under the APM scoring standard, we propose that if a MIPS
eligible clinician who qualifies for a zero percent weighting of the
advancing care information performance category in the final score is
part of a TIN that includes one or more MIPS eligible clinicians who do
not qualify for a zero percent weighting, we would not apply the zero
percent weighting to the qualifying MIPS eligible clinician, and the
TIN would still be required to report on behalf of the group, although
the TIN would not need to report data for the qualifying MIPS eligible
clinician.
We propose to maintain the cost performance category
weight of zero for Other MIPS APMs under the APM scoring standard for
the 2020 MIPS payment year and subsequent MIPS payment years. Because
the cost performance category would be reweighted to zero that weight
would need to be redistributed to other performance categories. We
propose to align the Other MIPS APM performance category weights with
those proposed for Web Interface reporters and weight the quality
performance category to 50 percent, the improvement activities
performance category to 20 percent, and the advancing care information
performance category to 30 percent of the APM Entity final score.
It is possible that none of the Other MIPS APM's measures
would be available for calculating a quality performance category score
by or shortly after the close of the MIPS submission period, for
example, due to changes in clinical practice guidelines. In addition,
the MIPS eligible clinicians in an APM Entity may qualify for a zero
percent weighting for the advancing care information performance
category. In such instances, under the APM scoring standard, we propose
to reweight the affected performance category to zero.
Beginning with the 2018 performance year, we propose that
MIPS eligible clinicians whose MIPS payment adjustment is based on
their score under the APM scoring standard will receive performance
feedback as specified under section 1848(q)(12) of the Act for the
quality, advancing care information, and improvement activities
performance categories to the extent data are available for the MIPS
performance year. Further, we propose that in cases where the MIPS APM
performance category has been weighted to zero for that performance
year, we would not provide performance feedback on that MIPS
performance category.
The following tables represent the measures being introduced for
notice and comment, and would serve as the measure set used by
participants in the identified MIPS APMs in order to create a MIPS
score under the APM scoring standard, as described in section
II.C.6.g.(3)(b)(ii)(A) of this proposed rule. Once this list is
finalized, no measures may be added to this list.
Table 14--MIPS APM Measures List--Oncology Care Model
----------------------------------------------------------------------------------------------------------------
NQF/Quality
Measure name number (if National quality Measure description Primary measure
applicable) strategy domain steward
----------------------------------------------------------------------------------------------------------------
Risk-adjusted proportion of NA............... Effective Percentage of OCM- NA
patients with all-cause Clinical Care. attributed FFS
hospital admissions within the beneficiaries who
6-month episode. were had an acute-
care hospital stay
during the
measurement period.
Risk-adjusted proportion of NA............... Effective Percentage of OCM- .................
patients with all-cause ED Clinical Care. attributed FFS
visits or observation stays beneficiaries who had
that did not result in a an ER visit that did
hospital admission within the not result in a
6-month episode. hospital stay during
the measurement
period.
Proportion of patients who died NA............... Effective Percentage of OCM- NA
who were admitted to hospice Clinical Care. attributed FFS
for 3 days or more. beneficiaries who
died and spent at
least 3 days in
hospice during the
measurement time
period.
Oncology: Medical and 0384/143......... Person and Percentage of patient Physician
Radiation--Pain Intensity Caregiver visits, regardless of Consortium for
Quantified. Centered patient age, with a Performance
Experience. diagnosis of cancer Improvement
currently receiving Foundations
chemotherapy or (PCPI).
radiation therapy in
which pain intensity
is quantified.
Oncology: Medical and 0383/144......... Person and Percentage of visits American Society
Radiation--Plan of Care for Caregiver for patients, of Clinical
Pain. Centered regardless of age, Oncology.
Experience. with a diagnosis of
cancer currently
receiving
chemotherapy or
radiation therapy who
report having pain
with a documented
plan of care to
address pain.
Preventive Care and Screening: 0418/134......... Community/ Percentage of patients Centers for
Screening for Depression and Population aged 12 and older Medicare &
Follow-Up Plan. Health. screened for Medicaid
depression on the Services.
date of the encounter
using an age
appropriate
standardized
depression screening
tool AND if positive,
a follow-up plan is
documented on the
date of the positive
screen.
[[Page 30092]]
Patient-Reported Experience of NA............... Person and Summary/Survey NA
Care. Caregiver Measures may include:
Centered --Overall measure of
Experience. patient experience.
--Exchanging
Information with
Patients.
--Access..............
--Shared Decision
Making.
--Enabling Self-
Management.
--Affective
Communication.
Prostate Cancer: Adjuvant 0390/104......... Effective Percentage of American
Hormonal Therapy for High or Clinical Care. patients, regardless Urological
Very High Risk Prostate Cancer. of age, with a Association
diagnosis of prostate Education and
cancer at high or Research.
very high risk of
recurrence receiving
external beam and
radiotherapy to the
prostate who were
prescribed adjuvant
hormonal therapy
(GnRH [gonadotropin
releasing hormone]
agonist or
antagonist).
Adjuvant chemotherapy is 0223............. Communication and Percentage of patients Commission on
recommended or administered Care under the age of 80 Cancer, American
within 4 months (120 days) of Coordination. with AJCC III (lymph College of
diagnosis to patients under node positive) colon Surgeons.
the age of 80 with AJCC III cancer for whom
(lymph node positive) colon adjuvant chemotherapy
cancer. is recommended and
not received or
administered within 4
months (120 days) of
diagnosis.
Combination chemotherapy is 0559............. Communication and Percentage of female Commission on
recommended or administered Care patients, age >18 at Cancer, American
within 4 months (120 days) of Coordination. diagnosis, who have College of
diagnosis for women under 70 their first diagnosis Surgeons.
with AJCC T1cN0M0, or Stage of breast cancer
IB--III hormone receptor (epithelial
negative breast cancer. malignancy), at AJCC
stage T1cN0M0 (tumor
greater than 1 cm),
or Stage IB--III,
whose primary tumor
is progesterone and
estrogen receptor
negative recommended
for multiagent
chemotherapy
(recommended or
administered) within
4 months (120 days)
of diagnosis.
Trastuzumab administered to 1858/450......... Efficiency and Proportion of female American Society
patients with AJCC stage I Cost Reduction. patients (aged 18 of Clinical
(T1c)--III and human epidermal years and older) with Oncology.
growth factor receptor 2 AJCC stage I (Tlc)--
(HER2) positive breast cancer Ill, human epidermal
who receive adjuvant growth factor
chemotherapy. receptor 2 (HER2)
positive breast
cancer receiving
adjuvant chemotherapy.
Breast Cancer: Hormonal Therapy 0387............. Communication and Percentage of female AMA-convened
for Stage I (T1b)--IIIC Care patients aged 18 Physician
Estrogen Receptor/Progesterone Coordination. years and older with Consortium for
Receptor (ER/PR) Positive Stage I (T1b) through Performance
Breast Cancer. IIIC, ER or PR Improvement.
positive breast
cancer who were
prescribed tamoxifen
or aromatase
inhibitor (AI) during
the 12-month
reporting period.
Documentation of Current 0419/130......... Patient Safety... Percentage of visits Centers for
Medications in the Medical for patients aged 18 Medicare &
Record. years and older for Medicaid
which the eligible Services.
clinician attests to
documenting a list of
current medications
using all immediate
resources available
on the date of the
encounter. This list
must include ALL
known prescriptions,
over-the counters,
herbals, and vitamin/
mineral/dietary AND
must contain the
medications' name,
dosage, frequency and
route of
administration.
----------------------------------------------------------------------------------------------------------------
Table 15--MIPS APM Measures List--Comprehensive ESRD Care
----------------------------------------------------------------------------------------------------------------
NQF/Quality
Measure name number (if National quality Measure description Primary measure
applicable) strategy domain steward
----------------------------------------------------------------------------------------------------------------
ESCO Standardized Mortality 0101/154......... Patient Safety... Falls: Risk National
Ratio. Assessment: Committee for
Percentage of Quality
patients aged 65 Assurance.
years and older with
a history of falIs
who had a risk
assessment for falls
completed within for
Quality 12 months.
Falls: Screening, Risk 0101/154......... Communication and Falls: Risk National
Assessment and Plan of Care to Coordination. Assessment: Committee for
Prevent Future Falls. Percentage of Quality
patients aged 65 Assurance.
years and older with
a history of falIs
who had a risk
assessment for falls
completed within for
Quality 12 months.
Advance Care Plan.............. 0326/47.......... Patient Safety... Percentage of patients National
aged 65 years and Committee for
older who have an Quality
advance care plan or Assurance.
surrogate decision
maker documented in
the medical record or
documentation in the
medical record that
an advance care plan
was discussed but the
patient did not wish
or was not able to
name a surrogate
decision maker or
provide an advance
care plan.
[[Page 30093]]
ICH-CAHPS: Nephrologists' 0258............. Person and Summary/Survey Agency for
Communication and Caring. Caregiver Measures may include: Healthcare
Centered --Getting timely care, Research and
Experience and appointments, and Quality.
Outcome. information.
--How well providers
communicate.
--Patients' rating of
provider.
--Access to
specialists.
--Health promotion and
education.
--Shared decision-
making.
--Health status and
functional status.
--Courteous and
helpful office staff.
--Care coordination...
--Between visit
communication.
--Helping you to take
medications as
directed, and.
--Stewardship of
patient resources.
ICH-CAHPS: ICH-CAHPS: Rating of 0258............. Person and Comparison of services Agency for
Dialysis Center. Caregiver and quality of care Healthcare
Centered that dialysis Research and
Experience and facilities provide Quality.
Outcome. from the perspective
of ESRD patients
receiving in-center
hemodialysis care.
Patients will assess
their dialysis
providers, including
nephrologists and
medical and non-
medical staff, the
quality of dialysis
care they receive,
and information
sharing about their
disease.
ICH-CAHPS: Quality of Dialysis 0258............. ................. Comparison of services Agency for
Center Care and Operations. and quality of care Healthcare
that dialysis Research and
facilities provide Quality.
from the perspective
of ESRD patients
receiving in-center
hemodialysis care.
Patients will assess
their dialysis
providers, including
nephrologists and
medical and non-
medical staff, the
quality of dialysis
care they receive,
and information
sharing about their
disease.
ICH-CAHPS: Providing 0258............. ................. Comparison of services Agency for
Information to Patients. and quality of care Healthcare
that dialysis Research and
facilities provide Quality.
from the perspective
of ESRD patients
receiving in-center
hemodialysis care.
Patients will assess
their dialysis
providers, including
nephrologists and
medical and non-
medical staff, the
quality of dialysis
care they receive,
and information
sharing about their
disease.
ICH-CAHPS: Rating of Kidney 0258............. ................. Comparison of services Agency for
Doctors. and quality of care Healthcare
that dialysis Research and
facilities provide Quality.
from the perspective
of ESRD patients
receiving in-center
hemodialysis care.
Patients will assess
their dialysis
providers, including
nephrologists and
medical and non-
medical staff, the
quality of dialysis
care they receive,
and information
sharing about their
disease.
ICH-CAHPS: Rating of Dialysis 0258............. ................. Comparison of services Agency for
Center Staff. and quality of care Healthcare
ICH-CAHPS: Rating of Dialysis that dialysis Research and
Center. facilities provide Quality.
from the perspective
of ESRD patients
receiving in-center
hemodialysis care.
Patients will assess
their dialysis
providers, including
nephrologists and
medical and non-
medical staff, the
quality of dialysis
care they receive,
and information
sharing about their
disease.
Medication Reconciliation Post 0554............. Communication and The percentage of National
Discharge. Care discharges from any Committee for
Coordination. inpatient facility Quality
(e.g. hospital, Assurance.
skilled nursing
facility, or
rehabilitation
facility) for
patients 18 years of
age and older seen
within 30 days
following the
discharge in the
office by the
physicians,
prescribing
practitioner,
registered nurse, or
clinical pharmacist
providing on-going
care for whom the
discharge medication
list was reconciled
with the current
medication list in
the outpatient
medical record. This
measure is reported
as three rates
stratified by age
group:
Reporting
Criteria 1: 18-64
years of age.
Reporting
Criteria 2: 65
years and older.
Total
Rate: All patients
18 years of age
and Older.
Diabetes Care: Eye Exam........ 0055/117......... Effective Percentage of patients National
Clinical Care. 18-75 years of age Committee for
with diabetes who had Quality
a retinal or dilated Assurance.
eye exam by an eye
care professional
during the
measurement period or
a negative retinal
exam (no evidence of
retinopathy) in the
12 months prior to
the measurement
period.
Diabetes Care: Foot Exam....... 0056/163......... Effective Percentage of patients National
Clinical Care. 18-75 years of age Committee for
with diabetes (type 1 Quality
and type 2) who Assurance.
received a foot exam
(visual inspection
and sensory exam with
mono filament and a
pulse exam) during
the previous
measurement year.
Influenza Immunization for the 0041/110, 0226... Community/ Percentage of patients Kidney Care
ESRD Population. Population aged 6 months and Quality Alliance
Health. older seen for a (KCQA).
visit between October
1 and March 31 who
received an influenza
immunization OR who
reported previous
receipt of an
influenza
immunization.
Pneumococcal Vaccination Status 0043/111......... Community/ Percentage of patients National
Population 65 years of age and Committee for
Health. older who have ever Quality
received a Assurance.
pneumococcal vaccine.
[[Page 30094]]
Screening for Clinical 0418/134......... Community/ Percentage of patients Centers for
Depression and Follow-Up Plan. Population aged 12 and older Medicare and
Health. screened for Medicaid
depression on the Services.
date of the encounter
and using an age
appropriate
standardized
depression screening
tool AND if positive,
a follow-up plan is
documented on the
date of the positive
screen.
Tobacco Use: Screening and 0028/226......... Community/ Percentage of patients Physician
Cessation Intervention. Population aged 18 years and Consortium for
Health. older who were Performance
screened for tobacco Improvement
use one or more times Foundations
within 24 months AND (PCPI).
who received
cessation counseling
intervention if
identified as a
tobacco user.
----------------------------------------------------------------------------------------------------------------
Table 16--MIPS APM Measures List--Comprehensive Primary Care Plus (CPC+)
----------------------------------------------------------------------------------------------------------------
NQF/Quality
Measure name number (if National quality Measure description Primary measure
applicable) strategy domain steward
----------------------------------------------------------------------------------------------------------------
Depression Remission at Twelve 0710/370......... Effective Patients age 18 and Minnesota
Months. Clinical Care. older with major Community
depression or Measurement
dysthymia and an
initial Patient
Health Questionnaire
(PHQ-9) score greater
than nine who
demonstrate remission
at twelve months (+/-
30 days after an
index visit) defined
as a PHQ-9 score less
than five. This
measure applies to
both patients with
newly diagnosed and
existing depression
whose current PHQ-9
score indicates a
need for treatment.
Controlling High Blood Pressure 0018/236......... Effective Percentage of patients National
Clinical Care. 18-85 years of age Committee for
who had a diagnosis Quality
of hypertension and Assurance
whose blood pressure
was adequately
controlled (<140/90
mmHg) during the
measurement period.
Diabetes: Eye Exam............. 0055/117......... Effective Percentage of patients National
Clinical Care. 18-75 years of age Committee for
with diabetes who had Quality
a retinal or dilated Assurance
eye exam by an eye
care professional
during the
measurement period or
a negative retinal
exam (no evidence of
retinopathy) in the
12 months prior to
the measurement
period.
Diabetes: Hemoglobin A1c 0059/001......... Effective Percentage of patients National
(HbA1c) Poor Control (>9%). Clinical Care. 18-75 years of age Committee for
with diabetes who had Quality
hemoglobin A1c >9.0% Assurance
during the
measurement period.
Use of High-Risk Medications in 0022/238......... Patient Safety... Percentage of patients National
the Elderly. 66 years of age and Committee for
older who were Quality
ordered high-risk Assurance
medications. Two
rates are reported.
a. Percentage of
patients who were
ordered at least
one high-risk
medication.
b. Percentage of
patients who were
ordered at least
two different high-
risk medications.
Dementia: Cognitive Assessment. NA/281........... Effective Percentage of Physician
Clinical Care. patients, regardless Consortium for
of age, with a Performance
diagnosis of dementia Improvement
for whom an Foundation
assessment of (PCPI)
cognition is
performed and the
results reviewed at
least once within a
12-month period.
Falls: Screening for Future 0101/318......... Patient Safety... Percentage of patients National
Fall Risk. 65 years of age and Committee for
older who were Quality
screened for future Assurance
fall risk at least
once during the
measurement period.
Initiation and Engagement of 0004/305......... Effective Percentage of patients National
Alcohol and Other Drug Clinical Care. 13 years of age and Committee for
Dependence Treatment. older with a new Quality
episode of alcohol Assurance
and other drug (AOD)
dependence who
received the
following. Two rates
are reported.
a. Percentage of
patients who
initiated treatment
within 14 days of the
diagnosis.
b. Percentage of
patients who
initiated
treatment and who
had two or more
additional
services with an
AOD diagnosis
within 30 days of
the initiation
visit.
Closing the Referral Loop: NA/374........... Communication and Percentage of Patients Centers for
Receipt of Specialist Report. Care with referrals, Medicare and
Coordination. regardless of age, Medicaid
for which the Services
referring provider
receives a report
from the provider to
whom the patient was
referred.
Cervical Cancer Screening...... 0032/309......... Effective Percentage of women 21- National
Clinical Care. 64 years of age, who Committee for
were screened for Quality
cervical cancer using Assurance
either of the
following criteria.
Women age
21-64 who had
cervical cytology
performed every 3
years.
Women age
30-64 who had
cervical cytology/
human
papillomavirus
(HPV) co-testing
performed every 5
years.
Colorectal Cancer Screening.... 0034/113......... Effective Percentage of National
Clinical Care. patients, 50-75 years Committee for
of age who had Quality
appropriate screening Assurance
for colorectal cancer.
Preventive Care and Screening: 0028/226......... Community/ Percentage of patients Physician
Tobacco Use: Screening and Population aged 18 years and Consortium for
Cessation Intervention. Health. older who were Performance
screened for tobacco Improvement
use one or more times Foundations
within 24 months AND (PCPI)
who received
cessation counseling
intervention if
identified as a
tobacco user.
[[Page 30095]]
Breast Cancer Screening........ 2372/112......... Effective Percentage of women 50- National
Clinical Care. 74 years of age who Committee for
had a mammogram to Quality
screen for breast Assurance
cancer.
Preventive Care and Screening: 0041/110......... Community/ Percentage of patients PCPI(R)
Influenza Immunization. Population aged 6 months and Foundation
Health. older seen for a (PCPI[R])
visit between October
1 and March 31 who
received an influenza
immunization OR who
reported previous
receipt of an
influenza
immunization.
Pneumonia Vaccination Status 0043/111......... Community/ Percentage of patients National
for Older Adults. Population 65 years of age and Committee for
Health. older who have ever Quality
received a Assurance
pneumococcal vaccine.
Diabetes: Medical Attention for 0062/119......... Effective The percentage of National
Nephropathy. Clinical Care. patients 18-75 years Committee for
of age with diabetes Quality
who had a nephropathy Assurance
screening test or
evidence of
nephropathy during
the measurement
period.
Ischemic Vascular Disease 0068/204......... Effective Percentage of patients National
(IVD): Use of Aspirin or Clinical Care. 18 years of age and Committee
Another. older who were Quality
diagnosed with acute Assurance
myocardial infarction
(AMI), coronary
artery bypass graft
(CABG) or
percutaneous coronary
interventions (PCI)
in the 12 months
prior to the
measurement period,
or who had an active
diagnosis of ischemic
vascular disease
(IVD) during the
measurement period,
and who had
documentation of use
of aspirin or another
antiplatelet during
the measurement
period.
Hypertension: Improvement in NA/373........... Effective Percentage of patients Centers for
Blood Pressure. Clinical Care. aged 18-85 years of Medicare &
age with a diagnosis Medicaid
of hypertension whose Services (CMS)
blood pressure
improved during the
measurement period.
Preventive Care and Screening: 0418/134......... Community/ Percentage of patients Centers for
Screening for Depression and Population aged 12 years and Medicare &
Follow-Up Plan. Health. older screened for Medicaid
depression on the Services (CMS)
date of the encounter
using an age
appropriate
standardized
depression screening
tool AND if positive,
a follow-up plan is
documented on the
date of the positive
screen.
Diabetes: Foot Exam............ 0056/163......... Effective The percentage of National
Clinical Care. patients 18-75 years Committee for
of age with diabetes Quality
(type 1 and type 2) Assurance
who received a foot
exam (visual
inspection and
sensory exam with
mono filament and a
pulse exam) during
the measurement year.
Statin Therapy for the NA/438........... Not provided in Percentage of the Quality Insights
Prevention and Treatment of the measure. following patients--
Cardiovascular Disease. all considered at
high risk of
cardiovascular
events--who were
prescribed or were on
statin therapy during
the measurement
period:
* Adults aged >=21
years who were
previously diagnosed
with or currently
have an active
diagnosis of clinical
atherosclerotic
cardiovascular
disease (ASCVD); OR.
* Adults aged >=21
years who have ever
had a fasting or
direct low-density
lipoprotein
cholesterol (LDL-C)
level >=190 mg/dL or
were previously
diagnosed with or
currently have an
active diagnosis of
familial or pure
hypercholesterolemia;
OR
* Adults aged 40-75
years with a
diagnosis of
diabetes with a
fasting or direct
LDL-C level of 70-
189 mg/dL.
Inpatient Hospital Utilization NA............... ................. For members 18 years National
(IHU). of age and older, the Committee for
risk-adjusted ratio Quality
of observed to Assurance
expected acute
inpatient discharges
during the
measurement year
reported by Surgery,
Medicine, and Total.
Emergency Department NA............... ................. For members 18 years National
Utilization (EDU). of age and older, the Committee for
risk-adjusted ratio Quality
of observed to Assurance
expected emergency
department (ED)
visits during the
measurement year.
Preventive Care and Screening: 0421............. Community/ Percentage of patients Centers for
Body Mass Index (BMI) Population aged 18 years and Medicare &
Screening and Follow-Up Plan. Health. older with a BMI Medicaid
documented during the Services (CMS)
current encounter or
during the previous
six months AND with a
BMI outside of normal
parameters, a follow-
up plan is documented
during the encounter
or during the
previous six months
of the current
encounter. Normal
Parameters: Age 18
years and older BMI
[gteqt]18.5 and <25
kg/m2.
CAHPS.......................... CPC+ specific; ................. CG-CAHPS Survey 3.0... AHRQ
different than
CAHPS for MIPS.
----------------------------------------------------------------------------------------------------------------
7. MIPS Final Score Methodology
For the 2020 MIPS payment year, we intend to build on the scoring
methodology we finalized for the transition year, which allows for
accountability and alignment across the performance categories and
minimizes burden on MIPS eligible clinicians, while continuing to
prepare MIPS eligible clinicians for the performance threshold required
for the 2021 MIPS payment year. Our rationale for our scoring
methodology continues to be grounded in the understanding that the MIPS
scoring system has many components and numerous moving parts.
As we continue to move forward in implementing the MIPS program, we
strive to balance the statutory requirements and programmatic goals
[[Page 30096]]
with the ease of use, stability, and meaningfulness for MIPS eligible
clinicians, while also emphasizing simplicity and scoring that is
understandable for MIPS eligible clinicians. In this section, we
propose refinements to the performance standards, the methodology for
determining a score for each of the four performance categories (the
``performance category score''), and the methodology for determining a
final score based on the performance category scores.
We intend to continue the transition of MIPS by proposing the
following policies:
Continuation of many transition year scoring policies in
the quality performance category, with an adjustment to the number of
achievement points available for measures that fail to meet the data
completeness criteria, to encourage MIPS eligible clinician to meet
data completeness while providing an exception for small practices;
An improvement scoring methodology that rewards MIPS
eligible clinicians who improve their performance in the quality and
cost performance categories;
A new scoring option for the quality and cost performance
categories that allows facility-based MIPS eligible clinicians to be
scored based on their facility's performance;
Special considerations for MIPS eligible clinicians in
small practices or those who care for complex patients; and
Policies that allow multiple pathways for MIPS eligible
clinicians to receive a neutral to positive MIPS payment adjustment.
We believe these sets of proposed policies will help clinicians
smoothly transition from the transition year to the 2021 MIPS payment
year, for which the performance threshold (which represents the final
score that would earn a neutral MIPS adjustment) will be either the
mean or median (as selected by the Secretary) of the MIPS final scores
for all MIPS eligible clinicians from a previous period specified by
the Secretary.
Unless otherwise noted, for purposes of this section II.C.7. on
scoring, the term ``MIPS eligible clinician'' will refer to MIPS
eligible clinicians that submit data and are scored at either the
individual- or group-level, including virtual groups, but will not
refer to MIPS eligible clinicians who elect facility-based scoring. The
scoring rules for facility-based measurement are discussed in section
II.C.7.a.(4). of this proposed rule. We also note that the APM scoring
standard applies to APM Entities in MIPS APMs, and those policies take
precedence where applicable; however, where those policies do not
apply, scoring for MIPS eligible clinicians as described in this
section II.C.7. on scoring will apply. We refer readers to section
II.C.6.g. of this proposed rule for additional information about the
APM scoring standard.
a. Converting Measures and Activities Into Performance Category Scores
(1) Policies That Apply Across Multiple Performance Categories
The detailed policies and proposals for scoring the four
performance categories are described in detail in section II.C.7.a. of
this proposed rule. However, as the four performance categories
collectively create a single MIPS final score, there are several
policies that apply across categories, which we discuss in section
II.C.7.a.(1) of this proposed rule.
(a) Performance Standards
In accordance with section 1848(q)(3) of the Act, in the CY 2017
Quality Payment Program final rule, we finalized performance standards
for the four performance categories. We refer readers to the CY 2017
Quality Payment Program final rule for a description of the performance
standards against which measures and activities in the four performance
categories are scored (81 FR 77271 through 77272).
As discussed in section II.C.7.a.(1)(b)(i) of this proposed rule,
we are proposing to add an improvement scoring standard to the quality
and cost performance categories starting for the 2020 MIPS payment
year.
(b) Policies Related to Scoring Improvement
(i) Background
In accordance with section 1848(q)(5)(D)(i) of the Act, beginning
with the 2020 MIPS payment year, if data sufficient to measure
improvement are available, the final score methodology shall take into
account improvement of the MIPS eligible clinician in calculating the
performance score for the quality and cost performance categories and
may take into account improvement for the improvement activities and
advancing care information performance categories. In addition, section
1848(q)(3)(B) of the Act provides that the Secretary, in establishing
performance standards for measures and activities for the MIPS
performance categories, shall consider: Historical performance
standards; improvement; and the opportunity for continued improvement.
Section 1848(q)(5)(D)(ii) of the Act also provides that achievement may
be weighted higher than improvement.
In the CY 2017 Quality Payment Program final rule, we summarized
public comments received on the proposed rule regarding potential ways
to incorporate improvement into the scoring methodology moving forward,
including approaches based on methodologies used in the Hospital VBP
Program, the Shared Savings Program, and Medicare Advantage 5-star
Ratings Program (81 FR 77306 through 77308). We did not finalize a
policy at that time on this topic and indicated we would take comments
into account in developing a proposal for future rulemaking.
When considering the applicability of these programs to MIPS, we
looked at the approach that was used to measure improvement for each of
the programs and how improvement was incorporated into the overall
scoring system. An approach that focuses on measure-level comparison
enables a more granular assessment of improvement because performance
on a specific measure can be considered and compared from year to year.
All options that we considered last year use a standard set of measures
that do not provide for choice of measures to assess performance;
therefore, they are better structured to compare changes in performance
based on the same measure from year to year. The aforementioned
programs do not use a category-level approach; however, we believe that
a category-level approach would provide a broader perspective,
particularly in the absence of a standard set of measures, because it
would allow for a more flexible approach that enables MIPS eligible
clinicians to select measures and data submission mechanisms that can
change from year to year and be more appropriate to their practice in a
given year.
We believe that both approaches are viable options for measuring
improvement. Accordingly, we believe that an appropriate approach for
measuring improvement for the quality performance category and the cost
performance category should consider the unique characteristics of each
performance category rather than necessarily applying a uniform
approach across both performance categories. For the quality
performance category, clinicians are offered a variety of different
measures which can be submitted by different mechanisms, rather than a
standard set of measures or a single data submission mechanism.
[[Page 30097]]
For the cost performance category, however, clinicians are scored on
the same set of cost measures to the extent each measure is applicable
and available to them; clinicians cannot choose which cost measures
they will be scored on. In addition, all of the cost measures are
derived from administrative claims data with no additional submission
required by the clinician.
When considering the applicability of these programs to MIPS, we
also considered how scoring improvement is incorporated into the
overall scoring system, including when only achievement or improvement
is incorporated into a final score or when improvement and achievement
are both incorporated into a final score.
We considered whether we could adapt the Hospital VBP Program's
general approach for assessing improvement to MIPS and note that many
commenters, in response to the CY 2017 Quality Payment Program proposed
rule, recommended this methodology for MIPS because it is familiar to
the health care community. However, we decided that the Hospital VBP
Program's improvement scoring methodology, which compares changes in
performance based on the same measure from year to year, is not fully
translatable to MIPS for the quality performance category and the cost
performance category. The scoring methodology used to assess
achievement in the Hospital VBP Program, as required by section
1886(o)(5)(B)(ii) of the Act, does not reward points for achievement in
the same method as MIPS, because hospitals that fall below the
achievement threshold (the median performance during the benchmark
period) are not awarded achievement points. We refer readers to the
Hospital Inpatient VBP Program Final Rule (76 FR 26516 through 26525)
for additional discussion of the Hospital VBP Program's scoring
methodology. In addition, the Hospital VBP Program requires the use of
either the achievement score or the improvement points, but not both,
for the Program's performance scoring calculation. Adopting the
Hospital VBP Program method for MIPS would require significant changes
to the scoring methodology used for the quality and cost performance
categories. For the quality performance category, there are a wide
variety of measures available in MIPS, and clinicians have flexibility
in selecting measures and submission mechanisms, with the potential for
clinicians to select different measures from year to year, which would
affect our ability to capture performance changes at the measure level.
We continue to believe that flexibility for clinicians to select
meaningful measures is appropriate for MIPS, especially for the quality
performance category. The Hospital VBP Program methodology, which
relies on consistent measures from year to year in order to track
improvement, would limit our ability to measure improvement in MIPS.
We also considered adopting the Shared Savings Program's approach
for assessing improvement, where participants can receive bonus points
for improving on quality measures over time. The Shared Savings Program
methodology could be adopted without an underlying change to the
scoring of achievement in the quality and cost performance categories
with an approach that considers both achievement and improvement in its
overall scoring calculation and would align MIPS and the Shared Savings
Program. However, we believe that the Shared Savings Program's
improvement methodology would not be appropriate for the MIPS quality
performance category because we are again concerned about the wide
variety of quality measures available in MIPS and the flexibility
clinicians have in selecting measures and submission mechanisms that
could affect our ability to capture performance changes at the measure
level. We seek to balance a system that allows for meaningful
measurement to clinicians and accommodates the various practice types
by allowing for a choice of measures and submission mechanisms that may
differ from year to year for the quality performance category. However,
as we discuss in section II.C.7.a.(3)(a) of this proposed rule, we do
believe the Shared Savings Program measure level methodology could be
translated for cost measures in the cost performance category.
Finally, we also considered adopting the Medicare Advantage
Program's 5-Star Rating approach for assessing improvement, where
Medicare Advantage contracts are rated on quality and performance
measures. Under this approach, we would identify an overall
``improvement measure score'' by comparing the underlying numeric data
for measures from the prior year with the data from measures for the
performance period. To obtain an ``improvement measure score'' MIPS
eligible clinicians would need to have data for both years in at least
half of the required measures for the quality performance category (81
FR 77307). We are again concerned that the wide variety of measures
available in MIPS and the flexibility clinicians have in selecting
different measures and submission mechanisms from year to year could
affect our ability to capture performance changes at the measure level,
particularly for the quality performance category. Accordingly, we do
not believe this is an appropriate approach for the quality performance
category. Although this approach could be considered for the cost
performance category, we believe that the Shared Savings Program is
more analogous to MIPS and that the improvement methodology used in
that program is one with which more stakeholders in MIPS would be
familiar.
After taking all of this into consideration, we are proposing two
different approaches for scoring improvement from year to year. As
described in section II.C.7.a.(2)(i)(i) of this proposed rule, we are
proposing to measure improvement at the performance category level for
the quality performance category score. Because clinicians can elect
the submission mechanisms and quality measures that are most meaningful
to their practice, and these choices can change from year to year, we
want a flexible methodology that allows for improvement scoring even
when the quality measures change. This is particularly important as we
encourage MIPS eligible clinicians to move away from topped out
measures and toward more outcome measures. We do not want the
flexibility that is offered to MIPS eligible clinicians in the quality
performance category to limit clinicians' ability to move towards
outcome measures, or limit our ability to measure improvement. Our
proposal for taking improvement into account as part of the quality
performance category score is addressed in detail in sections
II.C.7.a.(2)(i) through II.C.7.a.(2)(j) of this proposed rule.
We believe that there is reason to adopt a different methodology
for scoring improvement for the cost performance category from that
used for the quality performance category. In contrast to the quality
performance category, for the cost performance category, MIPS eligible
clinicians do not have a choice in measures or submission mechanisms;
rather, all MIPS eligible clinicians are assessed on all measures based
on the availability and applicability of the measure to their practice,
and all measures are derived from administrative claims data.
Therefore, for the cost performance category, we propose in section
II.C.7.a.(3)(a)(i) of this proposed rule to measure improvement at the
measure
[[Page 30098]]
level. We also note, that while we are statutorily required to measure
improvement for the cost performance category beginning with the second
MIPS payment year if data sufficient to measure improvement is
available, we are also proposing at II.C.6.d.(2) of this proposed rule
to weight the cost performance category at zero percent for the 2018
MIPS performance period/2020 MIPS payment year. Therefore, the
improvement score for the cost performance category would not affect
the MIPS final score for the 2018 MIPS performance period/2020 MIPS
payment year and would be for informational purposes only.
We are not proposing to score improvement in the improvement
activities performance category or the advancing care information
performance category at this time, though we may address improvement
scoring for these performance categories in future rulemaking.
We propose to amend Sec. 414.1380(a)(1)(i) to add that improvement
scoring is available for performance in the quality performance
category and for the cost performance category at Sec.
414.1380(a)(1)(ii) beginning with the 2020 MIPS payment year.
We invite public comment on our proposals to score improvement for
the quality and cost performance categories starting with the 2020 MIPS
payment year.
(ii) Data Sufficiency Standard To Measure Improvement
Section 1848(q)(5)(D)(i) of the Act requires us to measure
improvement for the quality and cost performance categories of MIPS if
data sufficient to measure improvement are available, which we
interpret to mean that we would measure improvement when we can
identify data from a current performance period that can be compared to
data from a prior performance period or data that compares performance
from year to year. In section II.C.7.a.(2)(i)(ii) of this proposed
rule, we propose for the quality performance category that we would
measure improvement when data are available because there is a
performance category score for the prior performance period. In section
II.C.7.a.(3)(a)(i) of this proposed rule, we propose for the cost
performance category that we would measure improvement when data are
available which is when there is sufficient case volume to provide
measurable data on measures in subsequent years with the same
identifier. We refer readers to the noted sections for details on these
proposals.
(c) Scoring Flexibility for ICD-10 Measure Specification Changes During
the Performance Period
The quality and cost performance categories rely on measures that
use detailed measure specifications that include ICD-10-CM/PCS (``ICD-
10'') code sets. We annually issue new ICD-10 coding updates, which are
effective from October 1, through September 30 (https://www.cms.gov/Medicare/Coding/ICD10/ICD10OmbudsmanandICD10CoordinationCenterICC.html). As part of this
update, codes are added as well as removed from the ICD-10 code set.
To provide scoring flexibility for MIPS eligible clinicians and
groups for measures impacted by ICD-10 coding changes in the final
quarter of the Quality Payment Program performance period--which may
render the measures no longer comparable to the historical benchmark--
we propose at Sec. 414.1380(b)(1)(xviii) and Sec. 414.1320(c)(2) to
provide that we will assess performance on measures considered
significantly impacted by ICD-10 updates based only on the first 9
months of the 12-month performance period (for example, January 1, 2018
through September 30, 2018, for the 2018 MIPS performance period). We
believe it would be appropriate to assess performance for significantly
impacted measures based on the first 9 months of the performance
period, rather than the full 12 months, because the indicated
performance for the last quarter could be affected by the coding
changes rather than actual differences in performance. Performance on
measures that are not significantly impacted by changes to ICD-10 codes
would continue to be assessed on the full 12-month performance period
(January 1 through December 31).
Any measure that relies on an ICD-10 code which is added, modified,
or removed, such as in the measure numerator, denominator, exclusions,
or exceptions, could have an impact on the indicated performance on the
measure, although the impact may not always be significant. We propose
an annual review process to analyze the measures that have a code
impact and assess the subset of measures significantly impacted by ICD-
10 coding changes during the performance period. Depending on the data
available, we anticipate that our determination as to whether a measure
is significantly impacted by ICD-10 coding changes would include these
factors: A more than 10 percent change in codes in the measure
numerator, denominator, exclusions, and exceptions; guideline changes
or new products or procedures reflected in ICD-10 code changes; and
feedback on a measure received from measure developers and stewards. We
considered an approach where we would consider any change in ICD-10
coding to impact performance on a measure and thus only rely on the
first 9 months of the 12-month performance period for such measures.
However, we believe such an approach would be too broad and truncate
measurement for too many measures where performance may not be
significantly affected. We believe that our proposed approach ensures
the measures on which individual MIPS eligible clinicians and groups
will have their performance assessed are accurate for the performance
period and are consistent with the benchmark set for the performance
period.
We propose to publish on the CMS Web site which measures are
significantly impacted by ICD-10 coding changes and would require the
9-month assessment. We propose to publish this information by October
1st of the performance period if technically feasible, but by no later
than the beginning of the data submission period, which is January 1,
2019 for the 2018 performance period.
We request comment on the proposal to address ICD-10 measures
specification changes during the performance period by relying on the
first 9 months of the 12-month performance period. We also request
comment on potential alternate approaches to address measures that are
significantly impacted due to ICD-10 changes during the performance
period, including the factors we might use to determine whether a
measure is significantly impacted.
(2) Scoring the Quality Performance Category for Data Submission via
Claims, Data Submissions via EHR, Third Party Data Submission Options,
CMS Web Interface, and Administrative Claims
Many comments submitted in response to the CY 2017 Quality Payment
Program final rule requested additional clarification on our finalized
scoring methodology for the 2019 MIPS payment year. To provide further
clarity to MIPS eligible clinicians about the transition year scoring
policies, before describing our proposed scoring policies for the 2020
MIPS payment year, we provide a summary of the scoring policies
finalized in the CY 2017 Quality Payment Program final rule along with
examples of how they apply under several scenarios.
In the CY 2017 Quality Payment Program final rule (81 FR 77286
through
[[Page 30099]]
77287), we finalized that the quality performance category would be
scored by assigning achievement points to each submitted measure, which
we refer to in this section of the proposed rule as ``measure
achievement points'' and we propose to amend various paragraphs in
Sec. 414.1380(b)(1) to use this term in place of ``achievement
points''. MIPS eligible clinicians can also earn bonus points for
certain measures (81 FR 77293 through 77294; 81 FR 77297 through
77299), which we refer to as ``measure bonus points'', and we propose
to amend Sec. 414.1380(b)(1)(xiii) (which we propose to redesignate as
Sec. 414.1380(b)(1)(xiv) in this proposed rule),\7\ Sec.
414.1380(b)(1)(xiv) (which we propose to redesignate as Sec.
414.1380(b)(1)(xv) in this proposed rule), and Sec. 414.1380(b)(1)(xv)
(which we propose to redesignate as Sec. 414.1380(b)(1)(xvii) in this
proposed rule) to use this term in place of ``bonus points''. The
measure achievement points assigned to each measure would be added with
any measure bonus points and then divided by the total possible points
(Sec. 414.1380(b)(1)(xv) (which we propose to redesignate as Sec.
414.1380(b)(1)(xvii)). In this section of the proposed rule we refer to
the total possible points as ``total available measure achievement
points'', and we propose to amend Sec. 414.1380(b)(1)(xv) to use this
term in place of ``total possible points''. We also propose to amend
these terms in Sec. 414.1380(b)(1)(xiii)(D) (which we propose to
redesignate as Sec. 414.1380(b)(1)(xiv)(D) in this proposed rule), and
Sec. 414.1380(b)(1)(xiv) (which we propose to redesignate as Sec.
414.1380(b)(1)(xv) in this proposed rule).
---------------------------------------------------------------------------
\7\ In section II.C.7.a.(2)(c) of this proposed rule, we propose
a new provision to be codified at Sec. 414.1380(b)(1)(xiii), and in
section II.C.7.a.(2)(i) of this proposed rule, we propose a new
provision to be codified at Sec. 414.1380(b)(1)(xvi). As a result,
we propose as well that the remaining paragraphs be redesignated in
order following the new provisions.
---------------------------------------------------------------------------
This resulting quality performance category score is a fraction
from zero to 1, which can be formatted as a percent; therefore, for
this section, we will present the quality performance category score as
a percent and refer to it as ``quality performance category percent
score.'' We also propose to amend Sec. 414.1380(b)(1)(xv) (which we
propose to redesignate as Sec. 414.1380(b)(1)(xvii) in this proposed
rule) to use this term in place of ``quality performance category
score''. Thus, the formula for the quality performance category percent
score that we will use in this section is as follows:
(total measure achievement points + total measure bonus points)/total
available measure achievement points = quality performance category
percent score.
In the CY 2017 Quality Payment Program final rule, we finalized
that for the quality performance category, an individual MIPS eligible
clinician or group that submits data on quality measures via EHR, QCDR,
qualified registry, claims, or a CMS-approved survey vendor for the
CAHPS for MIPS survey will be assigned measure achievement points for 6
measures (1 outcome or, if an outcome measure is not available, other
high priority measure and the next 5 highest scoring measures) as
available and applicable, and will receive applicable measure bonus
points for all measures submitted that meet the bonus criteria (81 FR
77282 through 77301).
In addition, for groups of 16 or more clinicians who meet the case
minimum of 200, we will also automatically score the administrative
claims-based all-cause hospital readmission measure as a seventh
measure (81 FR 77287). For individual MIPS eligible clinicians and
groups for whom the readmission measure does not apply, the denominator
is generally 60 (10 available measure achievement points multiplied by
6 available measures). For groups for whom the readmission measure
applies, the denominator is generally 70 points.
If we determined that a MIPS eligible clinician has fewer than 6
measures available and applicable, we will score only the number of
measures that are available and adjust the denominator accordingly to
the total available measure achievement points (81 FR 77291). We refer
readers to section II.C.7.a.(2)(e) of this proposed rule, for a
description of the validation process to determine measure
availability.
For the 2019 MIPS payment year, a MIPS eligible clinician that
submits quality measure data via claims, EHR, or third party data
submission options (that is, QCDR, qualified registry, EHR, or CMS-
approved survey vendor for the CAHPS for MIPS survey), can earn between
3 and 10 measure achievement points for quality measures submitted for
the performance period of greater than or equal to 90 continuous days
during CY 2017. A MIPS eligible clinician can earn measure bonus points
(subject to a cap) if they submit additional high priority measures
with a performance rate that is greater than zero, and that meet the
case minimum and data completeness requirements, or submit a measure
using an end-to-end electronic pathway. An individual MIPS eligible
clinician that has 6 or more quality measures available and applicable
will have 60 total available measure achievement points. For example,
as shown in Table 17, if an individual MIPS eligible clinician submits
7 measures, including one required outcome measure and 2 additional
high priority measures, the MIPS eligible clinician will be assigned
points based on achievement for the required outcome measure and the
next 5 measures with the highest number of measure achievement points.
In this example, the second high priority measure has the lowest number
of measure achievement points and therefore is not included in the
total measure achievement points calculated (81 FR 77300), but the MIPS
eligible clinician will still receive a bonus point for submitting a
high priority measure (81 FR 77291 through 77294). We note that in the
CY 2017 Quality Payment Program proposed rule, we proposed that bonus
points would be available for high priority measures that are not
scored (not included in the top 6 measures for the quality performance
category score) as long as the measure has the required case minimum,
data completeness, and has a performance rate greater than zero,
because we believed these qualities would allow us to include the
measure in future benchmark development (81 FR 28255). Although we
received public comments on this policy, responded to those comments,
and reiterated this proposal in the CY 2017 Quality Payment Program
final rule (81 FR 77292), we would like to clarify that our policy to
assign measure bonus points for high priority measures, even if the
measure's achievement points are not included in the total measure
achievement points for calculating the quality performance category
percent score, as long as the measure has the required case minimum,
data completeness, and has a performance rate greater than zero,
applies beginning with the transition year. We propose to amend Sec.
414.1380(b)(1)(xiii)(A) (which we propose to redesignate as Sec.
414.1380(b)(1)(xiv)(A)) to state that measure bonus points may be
included in the calculation of the quality performance category percent
score regardless of whether the measure is included in the calculation
of the total measure achievement points. We also propose a technical
correction to the second sentence of that paragraph to state that to
qualify for measure bonus points, each measure must be reported with
sufficient case volume to meet the required case minimum, meet the
required data completeness criteria, and
[[Page 30100]]
not have a zero percent performance rate.
Table 17--Example Calculation of the Quality Performance Category Percent Score for an Individual for the
Transition Year
----------------------------------------------------------------------------------------------------------------
Total
available
Measure achievement Measure bonus measure Performance category
points points * achievement percent score
points
----------------------------------------------------------------------------------------------------------------
Measure 1 (Outcome--required).... 3.................. n/a 10 (measure achievement
Measure 2........................ 6.................. n/a 10 points from 6 measures
+ measure bonus points)/
total available measure
achievement points.
Measure 3........................ 6.................. n/a 10
Measure 4........................ 6.................. n/a 10
Measure 5........................ 6.................. n/a 10
Measure 6 (High priority)........ 4.................. 1 10
Measure 7 (High priority)........ 3 (not included for 1 n/a ........................
achievement).
------------------------------------------------------------------------------
Total........................ 31................. 2 60 (31+2)/60 = 55%
----------------------------------------------------------------------------------------------------------------
* Assumes the measures meet the required case minimum, data completeness, and has performance greater than zero.
Assumes no bonus points for end-to-end electronic submission. This example does not apply to CMS Web Interface
Reporters because individuals are not able to submit data via that mechanism.
A group of 16 or more clinicians will also be automatically scored
on the hospital readmission measure if they meet the case minimum.
Table 18 illustrates an example of a group that submitted the 6
required quality measures, including an additional high priority
measure, and received 3 measure achievement points for each submitted
measure and the all-cause readmission measure.
Table 18--Example Calculation of the Quality Performance Category Percent Score for a Group of 16 or More
Clinicians, Non-CMS Web Interface Reporter for the Transition Year
----------------------------------------------------------------------------------------------------------------
Total
Measure available
achievement Measure bonus measure Performance category
points points * achievement percent score
points
----------------------------------------------------------------------------------------------------------------
Measure 1 (Outcome--required)...... 3 n/a 10 (measure achievement points
from 7 measures + measure
bonus points)/total
available measure
achievement points.
Measure 2 (High priority).......... 3 1 10
Measure 3.......................... 3 n/a 10
Measure 4.......................... 3 n/a 10
Measure 5.......................... 3 n/a 10
Measure 6.......................... 3 n/a 10
Measure 7--(readmission measure 3 n/a 10
with 200+ cases).
----------------------------------------------------------------------------
Total.......................... 21 1 70 (21+1)/70 = 31.4%
----------------------------------------------------------------------------------------------------------------
* Assumes the measures meet the required case minimum, data completeness, and has performance greater than zero.
Assumes no bonus points for end-to-end electronic submission.
In the CY 2017 Quality Payment Program final rule, we also
finalized scoring policies specific to groups of 25 or more that submit
their quality performance measures using the CMS Web Interface (81 FR
77278 through 77306).
Although we are not proposing to change the basic scoring system
that we finalized in the CY 2017 Quality Payment Program final rule for
the 2020 MIPS payment year, we are proposing several modifications to
scoring the quality performance category, including adjusting scoring
for measures that do not meet the data completeness criteria, adding a
method for scoring measures submitted via multiple mechanisms, adding a
method for scoring selected topped out measures, and adding a method
for scoring improvement. We also note that in section II.C.7.a.(4) of
this proposed rule, we are also proposing an additional option for
facility-based scoring for the quality performance category.
(a) Quality Measure Benchmarks
We are not proposing to change the policies on benchmarking
finalized in the CY 2017 Quality Payment Program final rule and
codified at paragraphs (b)(1)(i) through (iii) of Sec. 414.1380;
however, we are proposing a technical correction to paragraphs (i) and
(ii) to clarify that measure benchmark data are separated into decile
categories based on percentile distribution, and that, other than using
performance period data, performance period benchmarks are created in
the same manner as historical benchmarks using decile categories based
on a percentile distribution and that each benchmark must have a
minimum of 20 individual clinicians or groups who reported on the
measure meeting the data completeness requirement and case minimum case
size criteria and performance greater than zero. We refer
[[Page 30101]]
readers to the discussion at 81 FR 77282 for more details on that
policy.
We note that in section II.C.2.c. of this proposed rule, we are
proposing to increase the low-volume threshold which, because we
include MIPS eligible clinicians and comparable APMs that meet our
benchmark criteria in our measure benchmarks, could have an impact on
our MIPS benchmarks, specifically by reducing the number of individual
eligible clinicians and groups that meet the definition of a MIPS
eligible clinician and contribute to our benchmarks. Therefore, we seek
feedback on whether we should broaden the criteria for creating our
MIPS benchmarks to include PQRS and any data from MIPS, including
voluntary reporters, that meet our benchmark performance, case minimum
and data completeness criteria when creating our benchmarks.
In the CY 2017 Quality Payment Program final rule, we did not
stratify benchmarks by practice characteristics, such as practice size,
because we did not believe there was a compelling rationale for such an
approach, and we believed that stratifying could have unintended
negative consequences for the stability of the benchmarks, equity
across practices, and quality of care for beneficiaries (81 FR 77282).
However, we sought comment on any rationales for or against stratifying
by practice size we may not have considered. We note that we do create
separate benchmarks for each of the following submission mechanisms:
EHR submission options; QCDR and qualified registry submission options;
claims submission options; CMS Web Interface submission options; CMS-
approved survey vendor for CAHPS for MIPS submission options; and
administrative claims submission options (for measures derived from
claims data, such as the all-cause hospital readmission measure) (81 FR
77282).
Several commenters who responded to our solicitation of comment in
the final rule supported stratifying measure benchmarks by practice
size because the commenters believed it would help small practices,
which have limited resources compared to larger practices, and because
quality measures may have characteristics that are less favorable to
small groups. One commenter recommended that we stratify by practice
size during the 5 years in which technical assistance is available. One
commenter recommended that we develop criteria for determining when a
benchmark should be stratified by group size, and another commenter
recommended if we do not stratify benchmarks by practice size, we
adjust MIPS payment adjustments for practice size. Several commenters
recommended that we stratify benchmarks beyond practice size and
include adjustments for disease severity and socioeconomic status of
patients, specialty or sub-specialty, geographic region, and/or site of
service. One commenter specifically suggested that we use peer
comparison groups when establishing measure benchmarks.
After consideration of the comments we received, we are not
proposing to change our policies related to stratifying benchmarks by
practice size for the 2020 MIPS payment year. For many measures, the
benchmarks may not need stratification as they are only meaningful to
certain specialties and only expected to be submitted by those certain
specialists. We would like to further clarify that in the majority of
instances our current benchmarking approach only compares like
clinicians to like clinicians. We continue to believe that stratifying
by practice size could have unintended negative consequences for the
stability of the benchmarks, equity across practices, and quality of
care for beneficiaries. However, we seek comment on methods by which we
could stratify benchmarks, while maintaining reliability and stability
of the benchmarks, to use in developing future rulemaking for future
performance and payment years. Specifically, we seek comment on methods
for stratifying benchmarks by specialty or by place of service. We also
request comment on specific criteria to consider for stratifying
measures, such as how we should stratify submissions by multi-specialty
practices or by practices that operate in multiple places of service.
(b) Assigning Points Based on Achievement
In the CY 2017 Quality Payment Program final rule, we finalized at
Sec. 414.1380(b)(1) that a MIPS quality measure must have a measure
benchmark to be scored based on performance. MIPS quality measures that
do not have a benchmark (for example, because fewer than 20 MIPS
eligible clinicians or groups submitted data that met our criteria to
create a reliable benchmark) will not be scored based on performance
(81 FR 77286). We are not proposing any changes to this policy, but we
are proposing a technical correction to the regulatory text at Sec.
414.1380(b)(1) to delete the term ``MIPS'' before ``quality measure''
in third sentence of that paragraph and to delete the term MIPS before
``quality measures'' in the fourth sentence of that paragraph because
this policy applies to all quality measures, including the measures
finalized for the MIPS program and the quality measures submitted
through a QCDR that have been approved for MIPS.
We are also not proposing to change the policies to score quality
measure performance using a percentile distribution, separated by
decile categories and assign partial points based on the percentile
distribution finalized in the CY 2017 Quality Payment Program final
rule and codified at paragraphs (b)(1)(ix), (x), and (xi) of Sec.
414.1380; however, we propose a technical correction to paragraph (ix)
to clarify that measures are scored against measure benchmarks. We
refer readers to the discussion at 81 FR 77286 for more details on
those policies.
For illustration, Table 19 provides an example of assigning points
for performance based on benchmarks using a percentile distribution,
separated by decile categories. The example is of the benchmarks for
Measure 130 Documentation of Current Medications in the Medical Record,
which is based on our 2015 benchmark file for the 2017 MIPS performance
period.
Table 19--Example of Assigning Points for Performance Based on a Benchmark, Separated by Deciles
----------------------------------------------------------------------------------------------------------------
Measure ID #130 (documentation of current medications
in the medical record) *
--------------------------------------------------------
Submission mechanism Claims
performance EHR performance Registry/QCDR
benchmark benchmark benchmark
----------------------------------------------------------------------------------------------------------------
Decile 1 or 2 (3 points)............................... <96.11 <76.59 <61.27
Decile 3 (3.0-3.9 points).............................. 96.11-98.73 76.59-87.88 61.27-82.11
Decile 4 (4.0-4.9 points).............................. 98.74-99.64 87.89-92.73 82.12-91.71
Decile 5 (5.0-5.9 points).............................. 99.65-99.99 92.74-95.35 91.72-96.86
[[Page 30102]]
Decile 6 (6.0-6.9 points).............................. -- 95.36 -97.08 96.87-99.30
Decile 7 (7.0-7.9 points).............................. -- 97.09-98.27 99.31 -99.99
Decile 8 (8.0-8.9 points).............................. -- 98.28-99.12 --
Decile 9 (9.0-9.9 points).............................. -- 99.13-99.75 --
Decile 10 (10 points).................................. 100 >= 99.76 100
----------------------------------------------------------------------------------------------------------------
* Based on our historical benchmark file for the 2017 MIPS performance period.
In Table 19, the cells with ``--'' represent where there is a
cluster at the top of benchmark distribution. For example, for the
claims benchmark, over 50 percent of the MIPS eligible clinicians
submitting that measure had a performance rate of 100 percent based on
2015 PQRS data. Because of the cluster, clinicians who are at the 6, 7,
8, and 9th decile all would have performance rates of 100 percent and
would all receive a score of 10 points, indicated by dashes for those
deciles. Based on this clustered distribution, those clinicians with
performance of 99.99 percent fall into decile 5 and receive points in
the range from 5.0 to 5.9 points. For this measure, the benchmark for
each submission mechanism is topped out.
We note that for quality measures for which baseline period data is
available, we will publish the numerical baseline period benchmarks
with deciles prior to the start of the performance period (or as soon
as possible thereafter) (81 FR 77282). For quality measures for which
there is no comparable data from the baseline period, we will publish
the numerical performance period benchmarks after the end of the
performance period (81 FR 77282). We will also publish further
explanation of how we calculate partial points at qpp.cms.gov.
(i) Floor for Scored Quality Measures
For the 2017 MIPS performance period, we also finalized at Sec.
414.1380(b)(1) a global 3-point floor for each scored quality measure,
as well as for the hospital readmission measure (if applicable), such
that MIPS eligible clinicians would receive between 3 and 10 measure
achievement points for each submitted measure that can be reliably
scored against a benchmark, which requires meeting the case minimum and
data completeness requirements (81 FR 77286 through 77287). Likewise,
for measures without a benchmark based on the baseline period, we
stated that we would continue to assign between 3 and 10 measure
achievement points for performance years after the first transition
year because it would help to ensure that the MIPS eligible clinicians
are protected from a poor performance score that they would not be able
to anticipate (81 FR 77282; 81 FR 77287). For measures with benchmarks
based on the baseline period, we stated the 3-point floor was for the
transition year and that we would revisit the 3-point floor in future
years (81 FR 77286 through 77287).
For the 2018 MIPS performance period, we propose to again apply a
3-point floor for each measure that can be reliably scored against a
benchmark based on the baseline period, and to amend Sec.
414.1380(b)(1) accordingly. We refer readers to section
II.C.7.a.(2)(h)(ii) of this rule, for our proposal to score measures in
the CMS Web Interface for the Quality Payment Program for which
performance is below the 30th percentile. We will revisit the 3-point
floor for such measures again in future rulemaking.
We invite public comment on this proposal to again apply this 3-
point floor for quality measures that can be reliably scored against a
baseline benchmark in the 2018 MIPS performance period.
(ii) Additional Policies for the CAHPS for MIPS Measure Score
In the CY 2017 Quality Payment Program final rule, we finalized a
policy for the CAHPS for MIPS measure, such that each Summary Survey
Measure (SSM) will have an individual benchmark, that we will score
each SSM individually and compare it against the benchmark to establish
the number of points, and the CAHPS score will be the average number of
points across SSMs (81 FR 77284).
As described in section II.C.6.b.(3)(a)(iii) of this proposed rule,
we are proposing to remove two SSMs from the CAHPS for MIPS survey,
which would result in the collection of 10 SSMs in the CAHPS for MIPS
survey. Eight of those 10 SSMs have had high reliability for scoring in
prior years, or reliability is expected to improve for the revised
version of the measure, and they also represent elements of patient
experience for which we can measure the effect one practice has
compared to other practices participating in MIPS. The ``Health Status
and Functional Status'' SSM, however, assesses underlying
characteristics of a group's patient population characteristics and is
less of a reflection of patient experience of care with the group.
Moreover, to the extent that health and functional status reflects
experience with the practice, case-mix adjustment is not sufficient to
separate how much of the score is due to patient experience versus due
to aspects of the underlying health of patients. The ``Access to
Specialists'' SSM has low reliability; historically it has had small
sample sizes, and therefore, the majority of groups do not achieve
adequate reliability, which means there is limited ability to
distinguish between practices' performance.
For these reasons, we propose not to score the ``Health Status and
Functional Status'' SSM and the ``Access to Specialists'' SSM beginning
with the 2018 MIPS performance period. Despite not being suitable for
scoring, both SSMs provide important information about patient care.
Qualitative work suggests that ``Access to Specialists'' is a critical
issue for Medicare FFS beneficiaries. The survey is also a useful tool
for assessing beneficiaries' self-reported health status and functional
status, even if this measure is not used for scoring practices' care
experiences. Therefore, we believe that continued collection of the
data for these two SSMs is appropriate even though we do not propose to
score them.
Other than these two SSMs, we propose to score the remaining 8 SSMs
because they have had high reliability for scoring in prior years, or
reliability is expected to improve for the revised version of the
measure, and they also
[[Page 30103]]
represent elements of patient experience for which we can measure the
effect one practice has compared to other practices participating in
MIPS. Table 20 summarizes the proposed SSMs included in the CAHPS for
MIPS survey and illustrates application of our proposal to score only 8
measures.
Table 20--Proposed SSM for CAHPS for MIPS Scoring
----------------------------------------------------------------------------------------------------------------
Proposed for inclusion in Proposed for inclusion in
Summary survey measure the CAHPS for MIPS survey? CAHPS for MIPS scoring?
----------------------------------------------------------------------------------------------------------------
Getting Timely Care, Appointments, and Information... Yes......................... Yes.
How Well Providers Communicate....................... Yes......................... Yes.
Patient's Rating of Provider......................... Yes......................... Yes.
Health Promotion & Education......................... Yes......................... Yes.
Shared Decision Making............................... Yes......................... Yes.
Stewardship of Patient Resources..................... Yes......................... Yes.
Courteous and Helpful Office Staff................... Yes......................... Yes.
Care Coordination.................................... Yes......................... Yes.
Health Status and Functional Status.................. Yes......................... No.
Access to Specialists................................ Yes......................... No.
----------------------------------------------------------------------------------------------------------------
We invite comment on our proposal not to score the ``Health Status
and Functional Status'' and ``Access to Specialists'' SSMs beginning
with the 2018 MIPS performance period.
We note that in section II.C.6.g.(3)(b)(i)(A) of this proposed
rule, we are proposing to add the CAHPS for ACOs survey as an available
measure for calculating the MIPS APM score for the Shared Savings
Program and Next Generation ACO Model. We refer readers participating
in ACOs to section II.C.6.g.(3)(b) of this proposed rule for the CAHPS
for ACOs scoring methodology.
(c) Identifying and Assigning Measure Achievement Points for Topped Out
Measures
Section 1848(q)(3)(B) of the Act requires that, in establishing
performance standards with respect to measures and activities, we
consider, among other things, the opportunity for continued
improvement. We finalized in the CY 2017 Quality Payment Program final
rule that we would identify topped out process measures as those with a
median performance rate of 95 percent or higher (81 FR 77286). For non-
process measures we finalized a topped out definition similar to the
definition used in the Hospital VBP Program: Truncated Coefficient of
Variation is less than 0.10 and the 75th and 90th percentiles are
within 2 standard errors (81 FR 77286). When a measure is topped out, a
large majority of clinicians submitting the measure performs at or very
near the top of the distribution; therefore, there is little or no room
for the majority of MIPS eligible clinicians who submit the measure to
improve. We understand that every measure we have identified as topped
out may offer room for improvement for some MIPS eligible clinicians;
however, we believe asking clinicians to submit measures that we have
identified as topped out and measures for which they already excel is
an unnecessary burden that does not add value or improve beneficiary
outcomes.
Based on 2015 historic benchmark data,\8\ approximately 45 percent
of the quality measure benchmarks currently meet the definition of
topped out, with some submission mechanisms having a higher percent of
topped out measures than others. Approximately 70 percent of claims
measures are topped out, 10 percent of EHR measures are topped out, and
45 percent of registry/QCDR measures are topped out.
---------------------------------------------------------------------------
\8\ The topped out determination is calculated on historic
performance data and the percentage of topped out measures may
change when evaluated for the most applicable annual period.
---------------------------------------------------------------------------
In the CY 2017 Quality Payment Program final rule, we finalized
that for the 2019 MIPS payment year, we would score topped out quality
measures in the same manner as other measures (81 FR 77286). We
finalized that we would not modify the benchmark methodology for topped
out measures for the first year that the measure has been identified as
topped out, but that we would modify the benchmark methodology for
topped out measures beginning with the 2020 MIPS payment year, provided
that it is the second year the measure has been identified as topped
out. As described in detail later in this section, we are proposing a
phased in approach to apply special scoring to topped out measures,
beginning with the 2018 MIPS performance period (2020 MIPS payment
year), rather than modifying the benchmark methodology for topped out
measures as indicated in the CY 2017 Quality Payment Program final
rule.
In the CY 2017 Quality Payment Program final rule, we sought
comment on how topped out measures should be scored provided that it is
the second year the measure has been identified as topped out (81 FR
77286). We suggested three possible options: (1) Score the measures
using a mid-cluster approach; (2) remove topped out measures; or (3)
apply a flat percentage in building the benchmarks for topped out
measures. Flat percentages assign points based directly on the
percentage of performance rather than by a percentile distribution by
decile. Flat-rate would provide high scores to virtually all clinicians
submitting the measure because performance rates tend to be high.
Cluster-based benchmarks for topped out measures are based on a
percentile distribution, but because many submitters are clustered at
the top of performance, there can be large drops in points assigned for
relatively small differences in performance. The current top of the
cluster approach can result in many clinicians receiving 10 points. A
mid-cluster approach would limit the maximum number of points a topped
out measure can achieve based on how clustered the score are, and could
still result in large drops, although less than with the top of the
cluster approach, in points assigned for relatively small differences
in performance. We also noted in the CY 2017 Quality Payment Program
final rule that we anticipate removing topped out measures over time
and sought comment on what point in time we should remove topped out
measures from MIPS (81 FR 77286). The comments and our proposed policy
for removing topped out measures are described in section II.C.6.c.(2)
of this proposed rule.
In response to our request for comment in the CY 2017 Quality
Payment Program final rule, a few
[[Page 30104]]
commenters believed that we should not score topped out measures
differently from other measures because commenters believed changing
the scoring could reduce quality, add complexity to the program, and
reduce incentives to participate in MIPS. Several commenters
recommended that if we do score topped out measures differently, we use
flat percentages rather than cluster-based benchmarks, with a few
commenters noting that using flat percentages could help ensure those
with high performance on a measure are not penalized as low performers
and another noting that allowing high scorers to earn maximum or near
maximum points is similar to the approach in the Shared Savings
Program. A few commenters recommended that we publish information about
topped out and potentially topped out measures prior to the performance
period to allow clinicians time to adjust their reporting strategies,
with one commenter noting that improvement may be rewarded in addition
to achievement. One commenter recommended pushing back the baseline
performance period for identifying topped out measures to the 2018 MIPS
performance period because in the transition year it is unclear how
many eligible clinicians will be reporting at different times and for
what period they will report.
As described in section II.C.6.c.(2) of this proposed rule, we are
proposing a lifecycle for topped out measures by which, after a measure
benchmark is identified as topped out in the published benchmark for 2
years, in the third consecutive year it is identified as topped out it
will be considered for removal through notice-and-comment rulemaking or
the QCDR approval process and may be removed from the benchmark list in
the fourth year, subject to the phased in approach described in section
II.C.6.c.(2) of this proposed rule.
As part of the lifecycle for topped out measures, we also propose
in this section II.C.7.a.(2)(c) of this proposed rule, a method to
phase in special scoring for topped out measure benchmarks starting
with the 2018 MIPS performance period, provided that is the second
consecutive year the measure benchmark is identified as topped out in
the benchmarks published for the performance period. This special
scoring would not apply to measures in the CMS Web Interface, as
explained later in this section. The phased-in approach described in
this section represents our first step in methodically implementing
special scoring for topped out measures.
We are not proposing to remove topped out measures for the 2018
MIPS performance period because we recognize that there are currently a
large number of topped out measures and removing them may impact the
ability of some MIPS eligible clinicians to submit 6 measures and may
impact some specialties more than others. We note, however, that as
described in section II.C.6.c.(2) of this proposed rule, we are
proposing a timeline for removing topped out measures in future years.
We believe this provides MIPS eligible clinicians the ability to
anticipate and plan for the removal of specific topped out measures,
while providing measure developers time to develop new measures.
We note that because we create a separate benchmark for each
submission mechanism available for a measure, a benchmark for one
submission mechanism for the measure may be identified as topped out
while another submission mechanism's benchmark may not be topped out.
The topped out designation and special scoring apply only to the
specific benchmark that is topped out, not necessarily every benchmark
for a measure. For example, the benchmark for the claims submission
mechanism may be topped out for a measure, but the benchmark for the
EHR submission mechanisms for that same measure may not be topped out.
In this case, the topped out scoring would only apply to measures
submitted via the claims submission mechanism, which has the topped out
benchmark. We also describe in section II.C.6.c.(2) of this proposed
rule that, similarly, only the submission mechanism that is topped out
for the measure would be removed.
We propose to cap the score of topped out measures at 6 measure
achievement points. We are proposing a 6-point cap for multiple
reasons. First, we believe applying a cap to the current method of
scoring a measure against a benchmark is a simple approach that can
easily be predicted by clinicians. Second, the cap will create
incentives for clinicians to submit other measures for which they can
improve and earn future improvement points. Third, considering our
proposed topped out measure lifecycle, we believe this cap would only
be used for a few years and the simplicity of a cap on the current
benchmarks would outweigh the cluster-based options or applying a cap
on benchmarks based on flat-percentage, which are more complicated. The
rationale for a 6-point cap is that 6 points is the median score for
any measure as it represents the start of the 6th decile for
performance and represents the spot between the bottom 5 deciles and
start of the top 5 deciles.
We believe this proposed capped scoring methodology will
incentivize MIPS eligible clinicians to begin submitting non-topped out
measures without performing below the median score. This methodology
also would not impact scoring for those MIPS eligible clinicians that
do not perform near the top of the measure and therefore have
significant room to improve on the measure. We may also consider
lowering the cap below 6 points in future years, especially if we
remove the 3-point floor for performance in future years.
We note that although we are proposing a new methodology for
assigning measure achievement points for topped out measures, we are
not changing the policy for awarding measure bonus points for topped
out measures. Topped out measures will still be eligible for measure
bonus points if they meet the required criteria. We refer readers to
sections II.C.7.a.(2)(f) and II.C.7.a.(2)(g) of this proposed rule for
more information about measure bonus points.
We request comments on our proposal to score topped out measures
differently by applying a 6-point cap, provided it is the second
consecutive year the measure is identified as topped out. Specifically,
we seek feedback on whether 6 points is the appropriate cap or whether
we should consider another value. We also seek comment on other
possible options for scoring topped out measures that would meet our
policy goals to encourage clinicians to begin to submit measures that
are not topped out while also providing stability for MIPS eligible
clinicians.
While we believe it is important to score topped out measures
differently because they could have a disproportionate impact on the
scores for certain MIPS eligible clinicians and topped out measures
provide little room for improvement for the majority of MIPS eligible
clinicians who submit them, we also recognize that numerous measure
benchmarks are currently identified as topped out and special scoring
for topped out measures could impact some specialties more than others.
Therefore, we considered ways to phase in special scoring for topped
out measures in a way that will begin to apply special scoring, but
would not overwhelm any one specialty and would also provide additional
time to evaluate the impact of topped out measures before implementing
it for all topped out measures, while also beginning to encourage
submission of measures that are not topped out.
[[Page 30105]]
We believe the best way to accomplish this is by applying special
topped out scoring to a select number of measures for the 2018
performance period and to then apply the special topped out scoring to
all topped out measures for the 2019 performance period, provided it is
the second consecutive year the measure is topped out. We believe this
approach allows us time to further evaluate the impact of topped out
measures and allows for a methodical way to phase in topped out
scoring.
We identified measures we believe should be scored with the special
topped out scoring for the 2018 performance period by using the
following set criteria, which are only intended as a way to phase in
our topped-out measure policy for selected measures and are not
intended to be criteria for use in future policies:
Measure is topped out and there is no difference in
performance between decile 3 through decile 10. We applied this
limitation because, based on historical data, there is no room for
improvement for over 80 percent of MIPS eligible clinicians that
reported on these measures.
Process measures only because we want to continue to
encourage reporting on high priority outcome measures, and the small
subset of structure measures was confined to only three specialties.
MIPS measures only (which does not include measures that
can only be reported through a QCDR) given that QCDR measures go
through a separate process for approval and because we want to
encourage use of QCDRs required by section 1848(q)(1)(E) of the Act.
Measure is topped out for all mechanisms by which the
measure can be submitted. Because we create a separate benchmark for
each submission mechanism available for a measure, a benchmark for one
submission mechanism for the measure may be identified as topped out
while another submission mechanism's benchmark may not be topped out.
For example, the benchmark for the claims submission mechanism may be
topped out for a measure, but the benchmark for the EHR submission
mechanisms for that same measure may not be topped out. We decided to
limit our criteria to only measures that were topped out for all
measures for simplicity and to avoid confusion about what scoring is
applied to a measure.
Measure is in a specialty set with at least 10 measures,
because 2 measures in the pathology specialty set, which only has 8
measures total would have been included.
Applying these criteria results in the 6 measures as listed in
Table 21.
Table 21--Topped Out Measures Proposed for Special Scoring for the 2018 MIPS Performance Period
----------------------------------------------------------------------------------------------------------------
Topped out for all
Measure name Measure ID Measure type submission Specialty set
mechanisms
----------------------------------------------------------------------------------------------------------------
Perioperative Care: Selection 21 Process............. Yes................ General Surgery,
of Prophylactic Antibiotic-- Orthopedic Surgery,
First OR Second Generation Otolaryngology,
Cephalosporin. Thoracic Surgery,
Plastic Surgery.
Melanoma: Overutilization of 224 Process............. Yes................ Dermatology.
Imaging Studies in Melanoma.
Perioperative Care: Venous 23 Process............. Yes................ General Surgery,
Thromboembolism (VTE) Orthopedic Surgery,
Prophylaxis (When Indicated Otolaryngology,
in ALL Patients). Thoracic Surgery,
Plastic Surgery.
Image Confirmation of 262 Process............. Yes................ n/a.
Successful Excision of Image--
Localized Breast Lesion.
Optimizing Patient Exposure to 359 Process............. Yes................ Diagnostic Radiology.
Ionizing Radiation:
Utilization of a Standardized
Nomenclature for Computerized
Tomography (CT) Imaging
Description.
Chronic Obstructive Pulmonary 52 Process............. Yes................ n/a.
Disease (COPD): Inhaled
Bronchodilator Therapy.
----------------------------------------------------------------------------------------------------------------
We propose to apply the special topped out scoring method that we
finalize for the 2018 performance period to only the 6 measures in
Table 21 for the 2018 performance period, provided they are again
identified as topped out in the benchmarks for the 2018 performance
period. If these measures are not identified as topped out in the
benchmarks published for the 2018 performance period, they will not be
scored differently because they would not be topped out for a second
consecutive year.
We seek comment on our proposal to apply special topped out scoring
only to the 6 measures identified in Table 21 for the 2018 performance
period.
Starting with the 2019 performance period, we propose to apply the
special topped out scoring method to all topped out measures, provided
it is the second (or more) consecutive year the measure is identified
as topped out. We seek comment on our proposal to apply special topped
out scoring to all topped out measures, provided it is the second (or
more) consecutive year the measure is identified as topped out.
We illustrate the lifecycle for scoring and removing topped out
measures based on our proposals as follows:
Year 1: Measure benchmarks are identified as topped out,
which in this example would be in the benchmarks published for the 2017
MIPS performance period.
Year 2: Measure benchmarks are identified as topped out,
which in this example would be in the benchmarks published for the 2018
MIPS performance period. Measures identified in Table 21 have special
scoring applied, provided they are identified as topped out for the
2018 MIPS performance period, meaning it is the second consecutive year
they are identified as topped out.
Year 3: Measure benchmarks are identified as topped out in
the benchmarks published for the 2019 MIPS performance period. All
measure benchmarks identified as topped out for the second (or more)
consecutive year have special scoring applied for the 2019 MIPS
performance period. In Year 3 we would also consider removal of the
select set of topped out measures identified in Table 21, through
notice and comment rulemaking, provided they are identified as topped
out during the previous two (or more) consecutive
[[Page 30106]]
years. In our example, Year 3 would be the 2019 performance period.
Year 4: Measure benchmarks are identified as topped out in
the benchmarks published for the 2020 MIPS performance period. Measure
benchmarks identified as topped out for a second (or more) consecutive
year continue to have special scoring applied. Topped out measures
finalized for removal for the 2020 MIPS performance period are no
longer available for reporting.
An example of applying the proposed scoring cap compared to scoring
applied for the 2017 MIPS performance period is provided in Table 22.
Table 22--Proposed Scoring for Topped Out Measures* Starting in the CY 2018 MIPS Performance Period Compared to the Transition Year Scoring
--------------------------------------------------------------------------------------------------------------------------------------------------------
Quality Cate-
Scoring policy Measure 1 Measure 2 Measure 3 Measure 4 Measure 5 (not Measure 6 (not gory Percent
(topped out) (topped out) (topped out) (topped out) topped out) topped out) Score *
--------------------------------------------------------------------------------------------------------------------------------------------------------
2017 MIPS performance period 10 measure 10 measure 10 measure 4 measure 10 measure 5 measure 49/60 = 81.67%.
Scoring. achievement achievement achievement achievement achievement achievement
points. points. points. points (did not points. points.
get max score).
Proposed Capped Scoring 6 measure 6 measure 6 measure 4 measure 10 measure 5 measure 37/60 = 61.67%.
applied. achievement achievement achievement achievement achievement achievement
points. points. points. points. points. points.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Notes........................ Topped out measures scored with 6-point measure achievement point cap.
Cap does not impact score if the MIPS eligible clinician's score is
below the cap.
Still possible to earn maximum
measure achievement points on the
non-topped out measures.
--------------------------------------------------------------------------------------------------------------------------------------------------------
* This example would only apply to the 6 measures identified in Table 21 for the CY 2018 MIPS Performance Period. This example also excludes bonus
points and improvement scoring proposed in section II.C.7.a.(2)(i) of this proposed rule.
Together the proposed policies for phasing in capped scoring and
removing topped out measures are intended to provide an incentive for
MIPS eligible clinicians to begin to submit measures that are not
topped out while also providing stability by allowing MIPS eligible
clinicians who have few alternative measures to continue to receive
standard scoring for most topped out measures for an additional year,
and not perform below the median score for those 6 measures that
receive special scoring. It also provides MIPS eligible clinicians the
ability to anticipate and plan for the removal of specific topped out
measures, while providing measure developers time to develop new
measures.
We propose to add a new paragraph at Sec. 414.1380(b)(1)(xiii) to
codify our proposal for the lifecycle for removing topped out measures.
We also propose to add at Sec. 414.1380(b)(1)(xiii)(A) that for
the 2018 MIPS performance period, the 6 measures identified in Table 21
will receive a maximum of 6 measure achievement points, provided that
the measure benchmarks are identified as topped out again in the
benchmarks published for the 2018 MIPS performance period. We also
propose to add at Sec. 414.1380(b)(1)(xiii)(B) that beginning with the
2019 MIPS performance period, measure benchmarks, except for measures
in the CMS Web Interface, that are identified as topped out for two 2
or more consecutive years will receive a maximum of 6 measure
achievement points in the second consecutive year it is identified as
topped out, and beyond. We specifically seek comment on whether the
proposed policy to cap the score of topped out measures beginning with
the 2019 performance period should apply to SSMs in the CAHPS for MIPS
survey measure or whether there is another alternative policy that
could be applied for the CAHPS for MIPS survey measure due to high,
unvarying performance within the SSM. We note that we would like to
encourage groups to report the CAHPS for MIPS survey as it incorporates
beneficiary feedback.
We stated in the CY 2017 Quality Payment Program final rule that we
do not believe it would be appropriate to remove topped out measures
from the CMS Web Interface for the Quality Payment Program because the
CMS Web Interface measures are used in MIPS and in APMs such as the
Shared Savings Program and because we have aligned policies, where
possible, with the Shared Savings Program, such as using the Shared
Savings Program benchmarks for the CMS Web Interface measures (81 FR
77285). In the CY 2017 Quality Payment Program final rule, we also
finalized that MIPS eligible clinicians submitting via the CMS Web
Interface must submit all measures included in the CMS Web Interface
(81 FR 77116). Thus, if a CMS Web Interface measure is topped out, the
CMS Web Interface submitter cannot select other measures. Because of
the lack of ability to select measures, we are not proposing to apply a
special scoring adjustment to topped out measures for CMS Web Interface
for the Quality Payment Program.
Additionally, because the Shared Savings Program incorporates a
methodology for measures with high performance into the benchmark, we
do not believe capping benchmarks from the CMS Web Interface for the
Quality Payment Program is appropriate. We finalized in the CY 2017
Quality Payment Program final rule at Sec. 414.1380(b)(1)(ii)(A) to
use benchmarks from the corresponding reporting year of the Shared
Savings Program. The Shared Savings Program adjusts some benchmarks to
a flat percentage when the 60th percentile is equal to or greater than
80.00 percent for individual measures (78 FR 74759 through 74763), and,
for other measures, benchmarks are set using flat percentages when the
90th percentile for a measure are equal to or greater than 95.00
percent (79 FR 67925). Thus, we are not proposing to apply the topped
out measure cap to measures in the CMS Web Interface for the Quality
Payment Program.
We seek comment on this proposal not to apply the topped out
measure cap to measures in the CMS Web Interface for the Quality
Payment Program.
(d) Case Minimum Requirements and Measure Reliability and Validity
To help ensure reliable measurement, in the CY 2017 Quality Payment
Program final rule (81 FR 77288), we finalized a 20-case minimum for
all quality measures except the all-cause hospital readmission measure.
For the all-cause hospital readmission measure, we finalized in the CY
2017 Quality Payment Program final rule a 200-case minimum and
finalized to apply the all-cause hospital readmission measure only to
groups of 16 or more clinicians that meet the 200-case minimum
requirement (81 FR 77288).
[[Page 30107]]
We are not proposing any changes to these policies.
For the 2019 MIPS payment year, we finalized in the CY 2017 Quality
Payment Program final rule that if the measure is submitted but is
unable to be scored because it does not meet the required case minimum,
does not have a benchmark, or does not meet the data completeness
requirement, the measure would receive a score of 3 points (81 FR 77288
through 77289). We identified two classes of measures for the
transition year. Class \9\ 1 measures are measures that can be scored
based on performance because they have a benchmark, meet the case
minimum requirement, and meet the data completeness standard. We
finalized that Class 1 measures would receive 3 to 10 points based on
performance compared to the benchmark (81 FR 77289). Class 2 measures
are measures that cannot be scored based on performance because they do
not have a benchmark, do not have at least 20 cases, or the submitted
measure does not meet data completeness criteria. We finalized that
Class 2 measures, which do not include measures submitted with the CMS
Web Interface or administrative claims-based measures, receive 3 points
(81 FR 77289).
---------------------------------------------------------------------------
\9\ References to ``Classes'' of measures in this section
II.C.7.a.(2)(d) are intended only to characterize the measures for
ease of discussion.
---------------------------------------------------------------------------
We propose to maintain the policy to assign 3 points for measures
that are submitted but do not meet the required case minimum or does
not have a benchmark for the 2020 MIPS payment year and amend Sec.
414.1380(b)(1)(vii) accordingly.
We also propose a change to the policy for scoring measures that do
not meet the data completeness requirement for the 2020 MIPS payment
year.
To encourage complete reporting, we are proposing that in the 2020
MIPS payment year, measures that do not meet data completeness
standards will receive 1 point instead of the 3 points that were
awarded in the 2019 MIPS payment year. We propose lowering the point
floor to 1 for measures that do not meet data completeness standards
for several reasons. First, we want to encourage complete reporting
because data completeness is needed to reliably measure quality.
Second, unlike case minimum and availability of a benchmark, data
completeness is within the direct control of the MIPS eligible
clinician. In the future, we intend that measures that do not meet the
completeness criteria will receive zero points; however, we believe
that during the second year of transitioning to MIPS, clinicians should
continue to receive at least 1 measure achievement point for any
submitted measure, even if the measure does not meet the data
completeness standards.
We are concerned, however, that data completeness may be harder to
achieve for small practices. For example, small practices tend to have
small case volume and missing one or two cases could cause the MIPS
eligible clinician to miss the data completeness standard as each case
may represent multiple percentage points for data completeness. For
example, for a small practice with only 20 cases for a measure, each
case is worth 5 percentage points, and if they miss reporting just 11
or more cases, they would fail to meet the data completeness threshold,
whereas for a practice with 200 cases, each case is worth 0.5
percentage points towards data completeness and the practice would have
to miss more than 100 cases to fail to meet the data completeness
criteria. Applying 1 point for missing data completeness based on
missing a relatively small number of cases could disadvantage these
clinicians, who may have additional burdens for reporting in MIPS,
although we also recognize that failing to report on 10 or more
patients is undesirable. In addition, we know that many small practices
may have less experience with submitting quality performance category
data and may not yet have systems in place to ensure they can meet the
data completeness criteria. Thus, we are also proposing an exception to
the proposed policy for measures submitted by small practices, as
defined in Sec. 414.1305. We propose that these clinicians would
continue to receive 3 points for measures that do not meet data
completeness.
Therefore, we propose to revise Class 2 measures to include only
measures that cannot be scored based on performance because they do not
have a benchmark or do not have at least 20 cases. We also propose to
create Class 3 measures, which are measures that do not meet the data
completeness requirement. We propose that the revised Class 2 measure
would continue to receive 3 points. The proposed Class 3 measures would
receive 1 point, except if the measure is submitted by a small practice
in which case the Class 3 measure would receive 3 points. However,
consistent with the policy finalized in the CY 2017 Quality Payment
Program final rule, these policies for Class 2 and Class 3 measures
would not apply to measures submitted with the CMS Web Interface or
administrative claims-based measures. A summary of the proposals is
provided in Table 23.
Table 23--Quality Performance Category: Scoring Measures Based on Performance
----------------------------------------------------------------------------------------------------------------
Scoring rules in 2017 Description proposed Proposed for 2018
Measure type Description in MIPS performance for 2018 MIPS MIPS performance
transition year period performance period period
----------------------------------------------------------------------------------------------------------------
Class 1.............. Measures that can be 3 to 10 points based Same as transition Same as transition
scored based on on performance year. year.
performance. compared to the 3 to 10 points based
Measures that were benchmark. on performance
submitted or compared to the
calculated that met benchmark.
the following
criteria:
(1) The measure
has a benchmark;.
(2) Has at least
20 cases; and.
(3) Meets the data
completeness
standard
(generally 50
percent.).
[[Page 30108]]
Class 2.............. Measures that cannot 3 points............. Measures that were 3 points
be scored based on * This Class 2 submitted and meet *This Class 2
performance. measure policy does data completeness, measure policy
Measures that were not apply to CMS Web but does not have would not apply to
submitted, but fail Interface measures one or both of the CMS Web Interface
to meet one of the and administrative following: measures and
Class 1 criteria. claims based (1) a benchmark...... administrative
The measure either measures. (2) at least 20 cases claims based
measures.
(1) does not have
a benchmark,.
(2) does not have
at least 20
cases, or.
(3) does not meet
data completeness
criteria..
Class 3.............. n/a.................. n/a.................. Measures that were 1 point except for
submitted, but do small practices,
not meet data which would receive
completeness 3 points.
criteria, regardless *This Class 3
of whether they have measure policy
a benchmark or meet would not apply to
the case minimum. CMS Web Interface
measures and
administrative
claims based
measures.
----------------------------------------------------------------------------------------------------------------
We propose to amend Sec. 414.1380(b)(1)(vii) to assign 3 points
for measures that do not meet the case minimum or do not have a
benchmark in the 2020 MIPS payment year, and to assign 1 point for
measures that do not meet data completeness requirements, unless the
measure is submitted by a small practice, in which case it would
receive 3 points.
We invite comment on our proposal to assign 1 point to measures
that do not meet data completeness criteria, with an exception for
measures submitted by small practices.
We are not proposing to change the methodology we use to score
measures submitted via the CMS Web Interface that do not meet the case
minimum, do not have a benchmark, or do not meet the data completeness
requirement finalized in the CY 2017 Quality Payment Program final rule
and codified at paragraph (b)(1)(viii) of Sec. 414.1380. However, we
note that as described in section II.C.7.a.(2)(h)(ii) of this proposed
rule, we are proposing to add that CMS Web Interface measures with a
benchmark that are redesignated from pay for performance to pay for
reporting by the Shared Savings Program will not be scored. We refer
readers to the discussion at 81 FR 77288 for more details on our
previously finalized policy.
We are also not proposing any changes to the policy to not include
administrative claims measures in the quality performance category
percent score if the case minimum is not met or if the measure does not
have a benchmark finalized in the CY 2017 Quality Payment Program final
rule and codified at paragraph (b)(1)(viii) of Sec. 414.1380. We refer
readers to the discussion at 81 FR 77288 for more details on that
policy.
To clarify the exclusion of measures submitted via the CMS Web
Interface and based on administrative claims from the policy changes
proposed to be codified at paragraph (b)(1)(vii) previously, we are
amending paragraph (b)(1)(vii) to make it subject to paragraph
(b)(1)(viii), which codifies the exclusion.
(e) Scoring for MIPS Eligible Clinician That Do Not Meet Quality
Performance Category Criteria
In the CY 2017 Quality Payment Program final rule, we finalized
that MIPS eligible clinicians who fail to submit a measure that is
required to satisfy the quality performance category submission
criteria would receive zero points for that measure (81 FR 77291). For
each required measure that is not submitted, a MIPS eligible clinician
would receive zero points out of 10. For example, if a MIPS eligible
clinician had 6 measures available and applicable but submitted only 4
measures, the MIPS eligible clinician would be assigned zero out of 10
measure achievement points for the 2 missing measures, which would be
calculated into their performance category percent score.
We are not proposing any changes to the policy to assign zero
points for failing to submit a measure that is required in this
proposed rule.
In the CY 2017 Quality Payment Program final rule, we also
finalized implementation of a validation process for claims and
registry submissions to validate whether MIPS eligible clinicians have
6 applicable and available measures, whether an outcome measure is
available or whether another high priority measure is available if an
outcome measure is not available (81 FR 77290 through 77291).
We are not proposing any changes to apply a process to validate
whether MIPS eligible clinicians that submit measures via claims and
registry submissions have measures available and applicable. As stated
in the CY 2017 Quality Payment Program final rule (81 FR 77290), we did
not intend to establish a validation process for QCDRs because we
expect that MIPS eligible clinicians that enroll in QCDRs will have
sufficient meaningful measures to meet the quality performance category
criteria (81 FR 77290 through 77291). We do not propose any changes to
this policy.
We also stated that if a MIPS eligible clinician did not have 6
measures relevant within their EHR to meet the full specialty set
requirements or meet the requirement to submit 6 measures, the MIPS
eligible clinician should select a different submission mechanism to
meet the quality performance category requirements and should work with
their EHR vendors to incorporate applicable measures as feasible (81 FR
77290 through 77291). Under our proposals in section II.C.6.a.(1) of
this proposed rule to allow measures to be submitted and scored via
multiple mechanisms within a performance category, we anticipate that
MIPS
[[Page 30109]]
eligible clinicians that submit fewer than 6 measures via EHR will have
sufficient additional measures available via a combination of
submission mechanisms to submit the measures required to meet the
quality performance category criteria. For example, the MIPS eligible
clinician could submit 2 measures via EHR and supplement that with 4
measures via QCDR or registry.
Therefore, given our proposal to score multiple mechanisms, if a
MIPS eligible clinician submits any quality measures via EHR or QCDR,
we would not conduct a validation process because we expect these MIPS
eligible clinicians to have sufficient measures available to meet the
quality performance category requirements.
Given our proposal in section II.C.7.a.(2)(h) of this proposed rule
to score measures submitted via multiple mechanisms, we propose to
validate the availability and applicability of measures only if a MIPS
eligible clinician submits via claims submission options only, registry
submission options only, or a combination of claims and registry
submission options. In these cases, we propose that we will apply the
validation process to determine if other measures are available and
applicable broadly across claims and registry submission options. We
will not check if there are measures available via EHR or QCDR
submission options for these reporters. We note that groups cannot
report via claims and therefore groups and virtual groups will only
have validation applied across registries. We would validate the
availability and applicability of a measure through a clinically
related measure analysis based on patient type, procedure, or clinical
action associated with the measure specifications. For us to recognize
fewer than 6 measures, an individual MIPS eligible clinician must
submit exclusively using claims or qualified registries or a
combination of the two, and a group or virtual group must submit
exclusively using qualified registries. Given our proposal in section
II.C.7.a.(2)(h) of this proposed rule to score measures submitted via
multiple mechanisms, validation will be conducted first by applying the
clinically related measure analysis for the individual measure and
then, to the extent technically feasible, validation will be applied to
check for available measures available via both claims and registries.
We recognize that in extremely rare instances there may be a MIPS
eligible clinician who may not have available and applicable quality
measures. For example, a subspecialist who focuses on a very targeted
clinical area may not have any measures available. However, in many
cases, the clinician may be part of a broader group or would have the
ability to select some of the cross-cutting measures that are
available. Given the wide array of submission options, including QCDRs
which have the flexibility to develop additional measures, we believe
this scenario should be extremely rare. If we are not able to score the
quality performance category, we may reweight their score according to
the reweighting policies described in section II.C.7.b.(3)(b) and
II.C.7.b.(3)(d) of this proposed rule. We note that we anticipate this
will be a rare circumstance given our proposals to allow measures to be
submitted and scored via multiple mechanisms within a performance
category and to allow facility-based measurement for the quality
performance category.
(f) Incentives To Report High Priority Measures
In the CY 2017 Quality Payment Program final rule, we finalized
that we would award 2 bonus points for each outcome or patient
experience measure and 1 bonus point for each additional high priority
measure that is reported in addition to the 1 high priority measure
that is already required to be reported under the quality performance
category submission criteria, provided the measure has a performance
rate greater than zero, and the measure meets the case minimum and data
completeness requirements (81 FR 77293). High priority measures were
defined as outcome, appropriate use, patient safety, efficiency,
patient experience and care coordination measures, as identified in
Tables A and E in the Appendix of the CY 2017 Quality Payment Program
final rule (81 FR 77558 and 77686). We also finalized that we will
apply measure bonus points for the CMS Web Interface for the Quality
Payment Program based on the finalized set of measures reportable
through that submission mechanism (81 FR 77293). We note that in
addition to the 14 required measures, CMS Web Interface reporters may
also report the CAHPS for MIPS survey and receive measure bonus points
for submitting that measure.
We are not proposing any changes to these policies for awarding
measure bonus points for reporting high priority measures in this
proposed rule.
In the CY 2017 Quality Payment Program final rule, we finalized a
cap on high priority measure bonus points at 10 percent of the
denominator (total possible measure achievement points the MIPS
eligible clinician could receive in the quality performance category)
of the quality performance category for the first 2 years of MIPS (81
FR 77294). Groups that submit via the CMS Web Interface for the Quality
Payment Program are also subject to the 10 percent cap on high priority
measure bonus points. We are not proposing any changes to the cap on
measure bonus points for reporting high priority measures, which is
codified at Sec. 414.1380(b)(1)(xiv)(D) \10\, in this proposed rule.
---------------------------------------------------------------------------
\10\ Redesignated from Sec. 414.1380(b)(1)(xiii)(D).
---------------------------------------------------------------------------
(g) Incentives to Use CEHRT To Support Quality Performance Category
Submissions
Section 1848(q)(5)(B)(ii) of the Act outlines specific scoring
rules to encourage the use of CEHRT under the quality performance
category. For more of the statutory background and description of the
proposed and finalized policies, we refer readers to the CY 2017
Quality Payment Program final rule (81 FR 77294 through 77299).
In the CY 2017 Quality Payment Program final rule at Sec.
414.1380(b)(1)(xiv), we codified that 1 bonus point is available for
each quality measure submitted with end-to-end electronic reporting,
under certain criteria described below (81 FR 77297). We also finalized
a policy capping the number of bonus points available for electronic
end-to-end reporting at 10 percent of the denominator of the quality
performance category percent score, for the first 2 years of the
program (81 FR 77297). For example, when the denominator is 60, the
number of measure bonus points will be capped at 6 points. We also
finalized that the CEHRT bonus would be available to all submission
mechanisms except claims submissions. Specifically, MIPS eligible
clinicians who report via qualified registries, QCDRs, EHR submission
mechanisms, or the CMS Web Interface for the Quality Payment Program,
in a manner that meets the end-to-end reporting requirements, may
receive 1 bonus point for each reported measure with a cap as described
(81 FR 77297).
We are not proposing changes to these policies related to bonus
points for using CEHRT for end-to-end reporting in this proposed rule.
However, we are seeking comment on the use of health IT in quality
measurement and how HHS can encourage the use of certified EHR
technology in quality measurement as established in the statute. What
other incentives within this category for reporting in an end-to-end
manner could be leveraged to incentivize more clinicians to report
electronically? What format should these incentives take? For
[[Page 30110]]
example, should clinicians who report all of their quality performance
category data in an end-to-end manner receive additional bonus points
than those who report only partial electronic data? Are there other
ways that HHS should incentivize providers to report electronic quality
data beyond what is currently employed? We welcome public comment on
these questions.
(h) Calculating Total Measure Achievement and Measure Bonus Points
In section II.C.7.a.(2)(i) of this proposed rule, we are proposing
a new methodology to reward improvement based on achievement, from 1
year to another, which requires modifying the calculation of the
quality performance category percent score. In this section
II.C.7.a.(2)(h) of the proposed rule, we are summarizing the policies
for calculating the total measure achievement points and total measure
bonus points, prior to scoring improvement and the final quality
performance category percent score. We note that we will refer to
policies finalized in the CY 2017 Quality Payment Program final rule
that apply to the quality performance category score, which is referred
to as the quality performance category percent score in this proposed
rule, in this section. We are also proposing some refinements to
address the ability for MIPS eligible clinicians to submit quality data
via multiple submission mechanisms.
(i) Calculating Total Measure Achievement and Measure Bonus Points for
Non-CMS Web Interface Reporters
In the CY 2017 Quality Payment Program final rule (81 FR 77300), we
finalized that if a MIPS eligible clinician elects to report more than
the minimum number of measures to meet the MIPS quality performance
category criteria, then we will only include the scores for the
measures with the highest number of assigned points, once the first
outcome measure is scored, or if an outcome measure is not available,
once another high priority measure is scored. We are not proposing any
changes to the policy to score the measures with the highest number of
assigned points in this proposed rule; however, we are proposing
refinements to account for measures being submitted across multiple
submission mechanisms.
In the CY 2017 Quality Payment Program final rule, we sought
comment on whether to score measures submitted across multiple
submission mechanisms (81 FR 77275). As described in section
II.C.6.a.(1) of this proposed rule, we are proposing that MIPS eligible
clinicians be able to submit measures within a performance category via
multiple submission mechanisms. In the CY 2017 Quality Payment Program
final rule, we also sought comment on what approach we should use to
combine the scores for quality measures from multiple submission
mechanisms into a single aggregate score for the quality performance
category (81 FR 77275). Examples of possible scoring options were a
weighted average score on quality measures submitted through two or
more different mechanisms or taking the highest scores for any
submitted measure regardless of how the measure is submitted. A few
comments received in response to the CY 2017 Quality Payment Program
final rule did not support developing different weights for different
submission methods. One commenter recommended that we take the highest
score for any submitted measure, regardless of submission mechanisms,
or alternatively, calculate independent scores that would each
contribute equally to the final score.
After consideration of the comments we received, we are proposing,
beginning with the 2018 MIPS performance period, a method to score
quality measures if a MIPS eligible clinician submits measures via more
than one of the following submission mechanisms: Claims, qualified
registry, EHR or QCDR submission options. We believe that allowing MIPS
eligible clinicians to be scored across these data submission
mechanisms in the quality performance category will provide additional
options for MIPS eligible clinicians to report the measures required to
meet the quality performance category criteria, and encourage MIPS
eligible clinicians to begin using electronic submission mechanisms,
even if they may not have 6 measures to report via a single electronic
submission mechanism alone. We note that we also continue to score the
CMS-approved survey vendor for CAHPS for MIPS submission options in
conjunction with other submission mechanisms (81 FR 77275) as noted in
Table 24.
We propose to score measures across multiple mechanisms using the
following rules:
As with the rest of MIPS, we will only score measures
within a single identifier. For example, as codified in Sec.
414.1310(e), eligible clinicians and MIPS eligible clinicians within a
group aggregate their performance data across the TIN in order for
their performance to be assessed as a group. Therefore, measures can
only be scored across multiple mechanisms if reported by the same
individual MIPS eligible clinician, group, virtual group or APM Entity,
as described in Table 24.
We do not propose to aggregate measure results across
different submitters to create a single score for an individual measure
(for example, we are not going to aggregate scores from different TINs
within a virtual group TIN to create a single virtual group score for
the measures; rather, virtual groups must perform that aggregation
across TINs prior to data submission to CMS). Virtual groups are
treated like other groups and must report all of their measures at the
virtual group level, for the measures to be scored. Data completeness
and all the other criteria will be evaluated at the virtual group
level. Then the same rules apply for selecting which measures are used
for scoring. In other words, if a virtual group representative submits
some measures via a qualified registry and other measures via EHR, but
an individual TIN within the virtual group also submits measures, we
will only use the scores from the measures that were submitted at the
virtual group level, because the TIN submission does not use the
virtual group identifier. This is consistent with our other scoring
principles, where, for virtual groups, all quality measures are scored
at the virtual group level.
Separately, as also described in Table 24, because CMS Web
Interface and facility-based measurement each have a comprehensive set
of measures that meet the proposed MIPS submission requirements, we do
not propose to combine CMS Web Interface measures or facility-based
measurement with other group submission mechanisms (other than CAHPS
for MIPS, which can be submitted in conjunction with the CMS Web
Interface). We refer readers to section II.C.7.a.(2)(h)(ii) of this
proposed rule for discussion of calculating the total measure
achievement and measure bonus points for CMS Web Interface reporters
and to section II.C.7.a.(4) of this proposed rule for a description of
our proposed policies on facility-based measurement. We list these
submission mechanisms in Table 24, to illustrate that CMS Web Interface
submissions and facility-based measurement cannot be combined with
other submission options, except that the CAHPS for MIPS survey can be
combined with CMS Web Interface, as described in section
II.C.7.a.(2)(h)(ii) of this proposed rule.
[[Page 30111]]
Table 24--Scoring Allowed Across Multiple Mechanisms by Submission
Mechanism
[Determined by MIPS identifier and submission mechanism]
------------------------------------------------------------------------
When can quality measures be
MIPS identifier and submission scored across multiple
mechanisms mechanisms?
------------------------------------------------------------------------
Individual eligible clinician reporting Can combine claims, EHR, QCDR,
via claims, EHR, QCDR, and registry and registry.
submission options.
Group reporting via EHR, QCDR, Can combine EHR, QCDR,
registry, and the CAHPS for MIPS registry, and CAHPS for MIPS
survey. survey.
Virtual group reporting via EHR, QCDR, Can combine EHR, QCDR,
registry, and the CAHPS for MIPS registry, and CAHPS for MIPS
survey. survey.
Group reporting via CMS Web Interface.. Cannot be combined with other
submission mechanisms, except
for the CAHPS for MIPS survey.
Virtual group reporting via CMS Web Cannot be combined with other
Interface. submission mechanisms, except
for the CAHPS for MIPS survey.
Individual or group reporting facility- Cannot be combined with other
based measures. submission mechanisms.
MIPS APMs reporting Web Interface or MIPS APMs are subject to
other quality measures. separate scoring standards and
cannot be combined with other
submission mechanisms.
------------------------------------------------------------------------
If a MIPS eligible clinician submits the same measure via
2 different submission mechanisms, we will score each mechanism by
which the measure is submitted for achievement and take the highest
measure achievement points of the 2 mechanisms.
Measure bonus points for high priority measures would be
added for all measures submitted via all the different submission
mechanisms available, even if more than 6 measures are submitted, but
high priority measure bonus points are only available once for each
unique measure (as noted by the measure number) that meets the criteria
for earning the bonus point. For example, if a MIPS eligible clinician
submits 8 measures--6 process and 2 outcome--and both outcome measures
meet the criteria for a high priority bonus (meeting the required data
completeness, case minimum, and has a performance rate greater than
zero), the outcome measure with the highest measure achievement points
would be scored as the required outcome measure and then the measures
with the next 5 highest measure achievement points will contribute to
the final quality score. This could include the second outcome measure
but does not have to. Even if the measure achievement points for the
second outcome measure are not part of the quality performance category
percent score, measure bonus points would still be available for
submitting a second outcome measure and meeting the requirement for the
high priority measure bonus points. The rationale for providing measure
bonus points for measures that do not contribute measure achievement
points to the quality performance category percent score is that it
would help create better benchmarks for outcome and other high priority
measures by encouraging clinicians to report them even if they may not
have high performance on the measure. We also want to encourage MIPS
eligible clinicians to submit to us all of their available MIPS data,
not only the data that they or their intermediary deem to be their best
data. We believe it will be in the best interest of all MIPS eligible
clinicians that we determine which measures will result in the
clinician receiving the highest MIPS score. If the same measure is
submitted through multiple submission mechanisms, we would apply the
bonus points only once to the measure. We propose to amend Sec.
414.1380(b)(1)(xiv) (as redesignated from Sec. 414.1380(b)(1)(xiii))
to add paragraph (b)(1)(xiv)(E) that if the same high priority measure
is submitted via two or more submission mechanisms, as determined using
the measure ID, the measure will receive high priority measure bonus
points only once for the measure. The total measure bonus points for
high-priority measures would still be capped at 10 percent of the total
possible measure achievement points.
Measure bonus points that are available for the use of
end-to-end electronic reporting would be calculated for all submitted
measures across all submission mechanisms, including measures that
cannot be reliably scored against a benchmark. If the same measure is
submitted through multiple submission mechanisms, then we would apply
the bonus points only once to the measure. For example, if the same
measure is submitted using end-to-end reporting via both a QCDR and EHR
reporting mechanism, the measure would only get a measure bonus point
one time. We propose to amend Sec. 414.1380(b)(1)(xv) (as
redesignated) to add that if the same measure is submitted via two or
more submission mechanisms, as determined using the measure ID, the
measure will receive measure bonus points only once for the measure.
The total measure bonus points for end-to-end electronic reporting
would still be capped at 10 percent of the total available measure
achievement points.
Although we provide a policy to account for scoring in those
circumstances when the same measure is submitted via multiple
mechanisms, we anticipate that this will be a rare circumstance and do
not encourage clinicians to submit the same measure via multiple
mechanisms. Table 25 illustrates how we would assign total measure
achievement points and total measure bonus points across multiple
submission mechanisms under our proposal. In this example, a MIPS
eligible clinician elects to submit quality data via 3 submission
mechanisms: 3 Measures via registry, 4 measures via claims, and 5
measures via EHR. The 3 registry measures are also submitted via claims
(as noted by the same measure letter in this example). The EHR measures
do not overlap with either the registry or claims measures. In this
example, we assign measure achievement and bonus points for each
measure. If the same measure (as determined by measure ID) is
submitted, then we use the highest achievement points for that measure.
For the bonus points, we assess which of the outcome measures meets the
outcome measure requirement and then we identify any other unique
measures that qualify for the high priority bonus. We also identify the
unique measures that qualify for end-to-end electronic reporting bonus.
[[Page 30112]]
Table 25--Example of Assigning Total Measure Achievement and Bonus Points for an Individual MIPS Eligible
Clinician That Submits Measures Across Multiple Submission Mechanisms
----------------------------------------------------------------------------------------------------------------
High priority Incentive for
Measure achievement 6 Scored measures measure bonus CEHRT measure
points points bonus points
----------------------------------------------------------------------------------------------------------------
Registry
----------------------------------------------------------------------------------------------------------------
Measure A (Outcome)............ 7.1................... 7.1 (Outcome (required outcome
measure with measure does not
highest receive bonus
achievement points).
points).
Measure B...................... 6.2 (points not
considered because it
is lower than the 8.2
points for the same
claims measure).
Measure C (high priority 5.1 (points not ................. 1
patient safety measure that considered because it
meets requirements for is lower than the 6.0
additional bonus points). points for the same
claims measure).
----------------------------------------------------------------------------------------------------------------
Claims
----------------------------------------------------------------------------------------------------------------
Measure A (Outcome)............ 4.1 (points not ................. No bonus points
considered because it because the
is lower than the 7.1 registry
points for the same submission of
measure submitted via the same measure
a registry). satisfies
requirement for
outcome measure.
Measure B...................... 8.2................... 8.2
Measure C (High priority 6.0................... 6.0.............. No bonus (Bonus
patient safety measure that applied to the
meets requirements for registry
additional bonus points). measure).
Measure D (outcome measure <50% 1.0................... 1.0.............. (no high priority
of data submitted). bonus points
because below
data
completeness).
----------------------------------------------------------------------------------------------------------------
EHR (using end-to-end) Reporting that
meets CEHRT
bonus point
criteria
----------------------------------------------------------------------------------------------------------------
Measure E...................... 5.1................... 5.1.............. ................. 1
Measure F...................... 5.0................... 5.0.............. ................. 1
Measure G...................... 4.1................... ................. ................. 1
Measure H...................... 4.2................... 4.2.............. ................. 1
Measure I (high priority 3.0................... ................. (no high priority 1
patient safety measure that is bonus points
below case minimum). because below
case minimum).
35.6.................. 1 (below 10% 5 (below 10% cap)
cap\1\).
--------------------------------------------------------
Quality Performance Category ...................... (35.6 + 1 + 5)/60 = 69.33%
Percent Score Prior to
Improvement Scoring.
----------------------------------------------------------------------------------------------------------------
\1\ In this example the cap would be 6 points, which is 10 percent of the total available measure achievement
points of 60.
We propose to amend Sec. 414.1380(b)(1)(xii) to add paragraph (A)
to state that if a MIPS eligible clinician submits measures via claims,
qualified registry, EHR, or QCDR submission options, and submits more
than the required number of measures, they are scored on the required
measures with the highest assigned measure achievement points. MIPS
eligible clinicians that report a measure via more than 1 submission
mechanism can be scored on only 1 submission mechanism, which will be
the submission mechanism with the highest measure achievement points.
Groups that submit via these submission mechanisms may also submit and
be scored on CMS-approved survey vendor for CAHPS for MIPS submission
mechanisms.
We invite comments on our proposal to calculate the total measure
achievement points by using the measures with the 6 highest measure
achievement points across multiple submission mechanisms. We invite
comments on our proposal that if the same measure is submitted via 2 or
more mechanisms, we will only take the one with the highest measure
achievement points. We invite comments on our proposal to assign high
priority measure bonus points to all measures, with performance greater
than zero, that meet case minimums, and that meet data completeness
requirements, regardless of submission mechanism and to assign measure
[[Page 30113]]
bonus points for each unique measure submitted using end-to-end
electronic reporting. We invite comments on our proposal that if the
same measure is submitted using 2 different mechanisms, the measure
will receive measure bonus points once.
We are not proposing any changes to our policy that if a MIPS
eligible clinician does not have any scored measures, then a quality
performance category percent score will not be calculated as finalized
in the CY 2017 Quality Payment Program final rule at 81 FR 77300. We
refer readers to the discussion at 81 FR 77299 through 77300 for more
details on that policy. As stated in section II.C.7.a.(2)(e) of this
proposed rule, we anticipate that it will be only in rare case that a
MIPS eligible clinician does not have any scored measures and a quality
performance category percent score cannot be calculated.
(ii) Calculating Total Measure Achievement and Measure Bonus Points for
CMS Web Interface Reporters
In the CY 2017 Quality Payment Program final rule, we finalized
that CMS Web Interface reporters are required to report 14 measures, 13
individual measures, and a 2-component measure for diabetes (81 FR
77302 through 77305). We note that for the transition year, 3 measures
did not have a benchmark in the Shared Savings Program. Therefore, for
the transition year, CMS Web Interface reporters are scored on 11 of
the total 14 required measures, provided that they report all 14
required measures.
In the CY 2017 Quality Payment Program final rule, we finalized a
global floor of 3 points for all CMS Web Interface measures submitted
in the transition year, even with measures at zero percent performance
rate, provided that these measures have met the data completeness
criteria, have a benchmark and meet the case minimum requirements (82
FR 77305). Therefore, measures with performance below the 30th
percentile will be assigned a value of 3 points during the transition
year to be consistent with the floor established for other measures and
because the Shared Savings Program does not publish benchmarks below
the 30th percentile (82 FR 77305). We stated that we will reassess
scoring for measures below the 30th percentile in future years.
We propose to continue to assign 3 points for measures with
performance below the 30th percentile, provided the measure meets data
completeness, has a benchmark, and meets the case minimum requirements
for the 2018 MIPS performance year; we make this proposal in order to
continue to align with the 3-point floor for other measures and because
the Shared Savings Program does not publish benchmarks with values
below the 30th percentile. We will reassess this policy again next year
through rulemaking.
We are not proposing any changes to our previously finalized policy
to exclude from scoring CMS Web Interface measures that are submitted
but that do not meet the case minimum requirement or that lack a
benchmark, or to our policy that measures that are not submitted and
measures submitted below the data completeness requirements will
receive a zero score (82 FR 77305). However, to further increase
alignment with the Shared Savings Program, we propose to also exclude
CMS Web Interface measures from scoring if the measure is redesignated
from pay for performance to pay for reporting for all Shared Savings
Program ACOs, although we will recognize the measure was submitted.
While the Shared Savings Program designates measures that are pay for
performance in advance of the reporting year, the Shared Savings
Program may redesignate a measure as pay for reporting under certain
circumstances (see 42 CFR 425.502(a)(5)). Therefore, we propose to
amend Sec. 414.1380(b)(1)(viii) to add that CMS Web Interface measures
that have a measure benchmark but are redesignated as pay for reporting
for all Shared Savings Program ACOs by the Shared Savings Program will
not be scored, as long as the data completeness requirement is met.
We invite comment on our proposal to not score CMS Web Interface
measures redesignated as pay for reporting by the Shared Savings
Program.
We also note that, while we did not state explicitly in the CY 2017
Quality Payment Program final rule, groups that choose to report
quality measures via the CMS Web Interface may, in addition to the 14
required measures, also submit the CAHPS for MIPS survey in the quality
performance category (81 FR 77094 through 77095; 81 FR 77292). If they
do so, they can receive bonus points for submitting this high priority
measure and will be scored on it as an additional measure. Therefore,
we propose to amend Sec. 414.1380(b)(1)(xii) to add paragraph (B) to
state that groups that submit measures via the CMS Web Interface may
also submit and be scored on CMS-approved survey vendor for CAHPS for
MIPS submission options.
In addition, groups of 16 or more eligible clinicians that meet the
case minimum for administrative claims measures will automatically be
scored on the all-cause hospital readmission measure and have that
measure score included in their quality category performance percent
score.
We are not proposing any changes to calculating the total measure
achievement points and measure bonus points for CMS Web Interface
measures in this proposed rule, although we are proposing to add
improvement to the quality performance category percent score for such
submissions (as well as other submission mechanisms) in section
II.C.7.a.(2)(j) of this proposed rule.
(i) Scoring Improvement for the MIPS Quality Performance Category
Percent Score
(i) Calculating Improvement at the Quality Performance Category Level
In the CY 2017 Quality Payment Program final rule, we noted that we
consider achievement to mean how a MIPS eligible clinician performs
relative to performance standards, and improvement to mean how a MIPS
eligible clinician performs compared to the MIPS eligible clinician's
own previous performance on measures and activities in the performance
category (81 FR 77274). We also solicited public comments in the CY
2017 Quality Payment Program proposed rule on potential ways to
incorporate improvement in the scoring methodology. In section
II.C.7.a.(1)(b)(i) of this proposed rule, we explain why we believe
that the options set forth in the CY 2017 Quality Payment Program
proposed rule, including the Hospital VBP Program, the Shared Savings
Program, and Medicare Advantage 5-star Ratings Program, were not fully
translatable to MIPS. Beginning with the 2018 MIPS performance period,
we propose here to score improvement as well as achievement in the
quality performance category level when data is sufficient. We believe
that scoring improvement at the performance category level, rather than
measuring improvement at the measure level, for the quality performance
category would allow improvement to be available to the broadest number
of MIPS eligible clinicians because we are connecting performance to
previous MIPS quality performance as a whole rather than changes in
performance for individual measures. Just as we believe it is important
for a MIPS eligible clinician to have the flexibility to choose
measures that are meaningful to their practice, we want them to be able
to adopt new measures without concern
[[Page 30114]]
about losing the ability to be measured on improvement. In addition, we
are encouraging MIPS eligible clinicians to select more outcome
measures and to move away from topped out measures. We do not want to
remove the opportunity to score improvement from those who select
different measures between performance periods for the quality
performance category; therefore, we are proposing to measure
improvement at the category level which can be calculated with
different measures.
We propose at Sec. 414.1380(b)(1)(xvi)(E) to define an improvement
percent score to mean the score that represents improvement for the
purposes of calculating the quality performance category percent score.
We also propose at Sec. 414.1380(b)(1)(xvi)(C) that an improvement
percent score would be assessed at the quality performance category
level and included in the calculation of the quality performance
category percent score. When we evaluated different improvement scoring
options, we saw two general methods for incorporating improvement. One
method measures both achievement and improvement and takes the higher
of the two scores for each measure that is compared. The Hospital VBP
Program incorporates such a methodology. The second method is to
calculate an achievement score and then add an improvement score if
improvement is measured. The Shared Savings Program utilizes a similar
methodology for measuring improvement. For the quality performance
category, we are proposing to calculate improvement at the category
level and believe adding improvement to an existing achievement percent
score would be the most straight-forward and simple way to incorporate
improvement. For the purpose of improvement scoring methodology, the
term ``quality performance category achievement percent score'' means
the total measure achievement points divided by the total possible
available measure achievement points, without consideration of bonus
points or improvement adjustments and is discussed in section
II.C.7.a.(2)(i)(iv) of this proposed rule.
Consistent with bonuses available in the quality performance
category, we propose at Sec. 414.1380(b)(1)(xvi)(B) that the
improvement percent score may not total more than 10 percentage points.
We invite public comments on these proposals.
(ii) Data Sufficiency Standard To Measure Improvement for Quality
Performance Category
Section 1848(q)(5)(D)(i) of the Act stipulates that beginning with
the second year to which the MIPS applies, if data sufficient to
measure improvement is available then we shall measure improvement for
the quality performance category. Measuring improvement requires a
direct comparison of data from one Quality Payment Program year to
another. Starting with the 2020 MIPS payment year, we propose that a
MIPS eligible clinician's data would be sufficient to score improvement
in the quality performance category if the MIPS eligible clinician had
a comparable quality performance category achievement percent score for
the MIPS performance period immediately prior to the current MIPS
performance period; we explain our proposal to identify how we will
identify ``comparable'' quality performance category achievement
percent scores below. We believe that this approach would allow
improvement to be broadly available to MIPS eligible clinicians and
encourage continued participation in the MIPS program. Moreover, this
approach would encourage MIPS eligible clinicians to focus on efforts
to improve the quality of care delivered. We note that, by measuring
improvement based only on the overall quality performance category
achievement percent score, some MIPS eligible clinicians and groups may
generate an improvement score simply by switching to measures on which
they perform more highly, rather than actually improving at the same
measures. We will monitor how frequently improvement is due to actual
improvement versus potentially perceived improvement by switching
measures and will address through future rulemaking, as needed. We also
solicit comment on whether we should require some level of year to year
consistency when scoring improvement.
We propose that ``comparability'' of quality performance category
achievement percent scores would be established by looking first at the
submitter of the data. As discussed in more detail in section
II.C.7.a.(2)(i)(i) of this proposed rule, we are comparing results at
the category, rather than the performance measure level because we
believe that the performance category score from 1 year is comparable
to the performance category score from the prior year, even if the
measures in the performance category have changed from year to year.
We propose to compare results from an identifier when we receive
submissions with that same identifier (either TIN/NPI for individual,
or TIN for group, APM entity, or virtual group identifier) for two
consecutive performance periods. However, if we do not have the same
identifier for two consecutive performance periods, we propose a
methodology to create a comparable performance category score that can
be used for improvement measurement. Just as we do not want to remove
the opportunity to earn an improvement score from those who elect new
measures between performance periods for the quality performance
category, we also do not want to restrict improvement for those MIPS
eligible clinicians who elect to participate in MIPS using a different
identifier.
There are times when submissions from a particular individual
clinician or group of clinicians use different identifiers between 2
years. For example, a group of 20 MIPS eligible clinicians could choose
to submit as a group (using their TIN identifier) for the current
performance period. If the group also submitted as a group for the
previous year's performance period, we would simply compare the group
scores associated with the previous performance period to the current
performance period (following the methodology explained in section
II.C.7.a.(2)(i)(iv) of this proposed rule). However, if the group
members had previously elected to submit to MIPS as individual
clinicians, we would not have a group score at the TIN level from the
previous performance period to which to compare the current performance
period.
In circumstances where we do not have the same identifier for two
consecutive performance periods, we propose to identify a comparable
score for individual submissions or calculate a comparable score for
group, virtual group, and APM entity submissions. For individual
submissions, if we do not have a quality performance category
achievement percent score for the same individual identifier in the
immediately prior period, then we propose to apply the hierarchy logic
that is described in section II.C.8.a.(2) of this proposed rule to
identify the quality performance category achievement score associated
with the final score that would be applied to the TIN/NPI for payment
purposes. For example, if there is no historical score for the TIN/NPI,
but there is a TIN score (because in the previous period the TIN
submitted as a group), then we would use the quality performance
category achievement
[[Page 30115]]
percent score associated with the TIN's prior performance. If the NPI
had changed TINs and there was no historical score for the same TIN/
NPI, then we would take the highest prior score associated with the
NPI.
When we do not have a comparable TIN group, virtual group, or APM
Entity score, we propose to calculate a score based on the individual
TIN/NPIs in the practice for the current performance period. For
example, in a group of 20 clinicians that previously participated in
MIPS as individuals, but now want to participate as a group, we would
not have a comparable TIN score to use for scoring improvement. We
believe however it is still important to provide to the MIPS eligible
clinicians the improvement points they have earned. Similarly, in cases
where a group of clinicians previously participated in MIPS as
individuals, but now participates as a new TIN, or a new virtual group,
or a new APM Entity submitting data in the performance period, we would
not have a comparable TIN, virtual group, or APM Entity score to use
for scoring improvement. Therefore, we propose to calculate a score by
taking the average of the individual quality performance category
achievement scores for the MIPS eligible clinicians that were in the
group for the current performance period. If we have more than one
quality performance category achievement percent score for the same
individual identifier in the immediately prior period, then we propose
to apply the hierarchy logic that is described in section II.C.8.a.(2)
of this proposed rule to identify the quality performance category
score associated with the final score that would be applied to the TIN/
NPI for payment purposes. We would exclude any TIN/NPI's that did not
have a final score because they were not eligible for MIPS. We would
include quality performance category achievement percent scores of zero
in the average.
There are instances where we would not be able to measure
improvement due to lack of sufficient data. For example, if the MIPS
eligible clinicians did not participate in MIPS in the previous
performance period because they were not eligible for MIPS, we could
not calculate improvement because we would not have a previous quality
performance category achievement percent score.
Table 26 summarizes the different cases when a group or individual
would be eligible for improvement scoring under this proposal.
Table 26--Eligibility for Improvement Scoring Examples
----------------------------------------------------------------------------------------------------------------
Prior MIPS
performance
Current MIPS period identifier Eligible for
Scenario performance (with score improvement Data comparability
period identifier greater than scoring
zero)
----------------------------------------------------------------------------------------------------------------
No change in identifier........ Individual (TIN A/ Individual (TIN A/ Yes.............. Current individual
NPI 1). NPI 1). score is compared to
individual score from
prior performance
period.
No change in identifier........ Group (TIN A).... Group (TIN A).... Yes.............. Current group score is
compared to group
score from prior
performance period.
Individual is with same group, Individual (TIN A/ Group (TIN A).... Yes.............. Current individual
but selects to submit as an NPI 1). score is compared to
individual whereas previously the group score
the group submitted as a group. associated with the
TIN/NPI from the
prior performance
period.
Individual changes practices, Individual (TIN B/ Individual (TIN A/ Yes.............. Current individual
but submitted to MIPS NPI). NPI). score is compared to
previously as an individual. the individual score
from the prior
performance period.
Individual changes practices Individual (TIN C/ Group (TIN A/ Yes.............. Current individual
and has multiple scores in NPI). NPI); Individual score is compared to
prior performance period. (TIN B/NPI). highest score from
the prior performance
period.
Group does not have a previous Group (TIN A).... Individual scores Yes.............. The current group
group score from prior (TIN A/NPI 1, score is compared to
performance period. TIN A/NPI 2, TIN the average of the
A/NPI 3, etc.). scores from the prior
performance period of
individuals who
comprise the current
group.
Virtual group does not have Virtual Group Individuals (TIN Yes.............. The current group
previous group score from (Virtual Group A/NPI 1, TIN A/ score is compared to
prior performance period. Identifier A) NPI 2, TIN B/NPI the average of the
(Assume virtual 1, TIN B/NPI 2). scores from the prior
group has 2 TINs performance period of
with 2 individuals who
clinicians.). comprise the current
group.
Individual does not have a Individual (TIN A/ Individual was No............... The individual quality
quality performance category NPI 1). not eligible for performance category
achievement score for the MIPS and did not score is missing for
prior performance period. voluntarily the prior performance
submit any period and not
quality measures eligible for
to MIPS. improvement scoring.
----------------------------------------------------------------------------------------------------------------
We propose at Sec. 414.1380(b)(1)(xvi)(A) to state that
improvement scoring is available when the data sufficiency standard is
met, which means when data are available and a MIPS eligible clinician
or group has a quality performance category achievement percent score
for the previous performance period. We also propose at Sec.
414.1380(b)(1)(xvi)(A)(1) that data must be comparable to meet the
requirement of data sufficiency,
[[Page 30116]]
which means that the quality performance category achievement percent
score is available for the current performance period and the previous
performance period and, therefore, quality performance category
achievement percent scores can be compared. We also propose at Sec.
414.1380(b)(1)(xvi)(A)(2) that quality performance category achievement
percent scores are comparable when submissions are received from the
same identifier for two consecutive performance periods. We also
propose an exception at Sec. 414.1380(b)(1)(xvi)(A)(3) that if the
identifier is not the same for 2 consecutive performance periods, then
for individual submissions, the comparable quality performance category
achievement percent score is the quality performance category
achievement percent score associated with the final score from the
prior performance period that will be used for payment. For group,
virtual group, and APM entity submissions, the comparable quality
performance category achievement percent score is the average of the
quality performance category achievement percent score associated with
the final score from the prior performance period that will be used for
payment for each of the individuals in the group. As noted above, these
proposals are designed to offer improvement scoring to all MIPS
eligible clinicians with sufficient data in the prior MIPS performance
period. We invite public comments on our proposals as they relate to
data sufficiency for improvement scoring.
We also seek comment on an alternative to this proposal: Whether we
should restrict improvement to those who submit quality performance
data using the same identifier for two consecutive MIPS performance
periods. We believe this option would be simpler to apply, communicate
and understand than our proposal is, but this alternative could have
the unintended consequence of not allowing improvement scoring for
certain MIPS eligible clinicians, groups, virtual groups and APM
entities.
(iii) Additional Requirement for Full Participation To Measure
Improvement for Quality Performance Category
To receive a quality performance category improvement percent score
greater than zero, we are also proposing that MIPS eligible clinicians
must fully participate, which we propose in Sec.
414.1380(b)(1)(xvi)(F) to mean compliance with Sec. 414.1330 and Sec.
414.1340, in the current performance year. Compliance with those
referenced regulations entails the submission of all required measures,
including meeting data completeness, for the quality performance
category for the current performance period. For example, for MIPS
eligible clinicians submitting via QCDR, full participation would
generally mean submitting 6 measures including 1 outcome measure if an
outcome measure is available or 1 high priority measure if an outcome
measure is not available, and meeting the 50 percent data completeness
criteria for each of the 6 measures.
We believe that improvement is most meaningful and valid when we
have a full set of quality measures. A comparison of data resulting
from full participation of a MIPS eligible clinician from 1 year to
another enables a more accurate assessment of improvement because the
performance being compared is based on the applicable and available
measures for the performance periods and not from changes in
participation. While we are not requiring full participation for both
performance periods, requiring full participation for the current
performance period means that any future improvement scores for a
clinician or group would be derived solely from changes in performance
and not because the clinician or group submitted more measures. We
propose at Sec. 414.1380(b)(1)(xvi)(C)(5) that the quality improvement
percent score is zero if the clinician did not fully participate in the
quality performance category for the current performance period.
Because we want to award improvement for net increases in
performance and not just improved participation in MIPS, we want to
measure improvement above a floor for the 2018 MIPS performance period,
to account for our transition year policies. We considered that MIPS
eligible clinicians who chose the ``test'' option of the ``pick your
pace'' approach for the transition year may not have submitted all the
required measures and, as a result, may have a relatively low quality
performance category achievement score for the 2017 MIPS performance
period. Due to the transition year policy to award at least 3 measure
achievement points for any submitted measure via claims, EHR, QCDR,
qualified registry, and CMS-approved survey vendor for CAHPS for MIPS,
and the 3-point floor for the all-cause readmission measure (if the
measure applies), a MIPS eligible clinician that submitted some data
via these mechanisms on the required number of measures would
automatically have a quality performance category achievement score of
at least 30 percent because they would receive at least 3 of 10
possible measure achievement points for each required measure. For
example, if a solo practitioner submitted 6 measures and received 3
points for each measure, then the solo practitioner would have 18
measure achievement points out of a possible 60 total possible measure
achievement points (3 measure achievement points x 6 measures). The
quality performance category achievement percent score is 18/60 which
equals 30 percent. For groups with 16 or more clinicians that submitted
6 measures and receive 3 measure achievement points for each submitted
measure as well as the all-cause hospital readmission measure, then the
group would have 21 measure achievement points out of 70 total possible
measure achievement points or a quality performance category
achievement percent score of 21/70 which equals 30 percent (3 measure
achievement points x 7 measures). For the CMS Web Interface submission
option, MIPS eligible clinicians that fully participate by submitting
and meeting data completeness for all measures, would also be able to
achieve a quality performance category achievement percent score of at
least 30 percent, as each scored measure would receive 3 measure
achievement points out of 10 possible measure achievement points.
Therefore, we propose at Sec. 414.1380(b)(1)(xvi)(C)(4) that if a
MIPS eligible clinician has a previous year quality performance
category score less than or equal to 30 percent, we would compare 2018
performance to an assumed 2017 quality performance category achievement
percent score of 30 percent. In effect, for the MIPS 2018 performance
period, improvement would be measured only if the clinician's 2018
quality performance category achievement percent score for the quality
performance category exceeds 30 percent. We believe this approach
appropriately recognizes the participation of MIPS eligible clinicians
who participated in the transition year and accounts for MIPS eligible
clinicians who participated minimally and may otherwise be awarded for
an increase in participation rather than an increase in achievement
performance.
We invite public comment on these proposals.
(iv) Measuring Improvement Based on Changes in Achievement
To calculate improvement with a focus on quality performance, we
are proposing to focus on improvement based on achievement performance
and would not consider measure bonus
[[Page 30117]]
points in our improvement algorithm. Bonus points may be awarded for
reasons not directly related to performance such as the use of end-to-
end electronic reporting. We believe that improvement points should be
awarded based on improvement related to achievement. Accordingly, we
are proposing to use an individual MIPS eligible clinician's or group's
total measure achievement points from the prior MIPS performance period
without the bonus points the individual MIPS eligible clinician or
group may have received, to calculate improvement. Therefore, to
measure improvement at the quality performance category level, we will
use the quality performance category achievement percent score
excluding measure bonus points (and any improvement score) for the
applicable years. We propose at Sec. 414.1380(b)(1)(xvi)(D) to call
this score, which is based on achievement only, the ``quality
performance category achievement percent score'' which is calculated
using the following formula:
Quality performance category achievement percent score = total measure
achievement points/total available measure achievement points.
Table 27 illustrates how the quality performance category
achievement percent score is calculated. For simplicity, we assume the
MIPS eligible clinician received 6 measure achievement points for each
of the submitted 6 required measures in the current performance period,
which equals 36 total measure achievement points. This is compared to
the previous performance period when the MIPS eligible clinician
received only 5 measure achievement points per measure, for 30 total
measure achievement points. The quality performance category
achievement percent score is represented in line 2. For improvement,
performance in the current 2018 MIPS performance period (60 percent) is
compared to the performance category achievement percent score in the
2017 MIPS performance period (50 percent).
Table 27--Comparison of Quality Performance Category Achievement Percent
Scores
------------------------------------------------------------------------
Current MIPS Previous MIPS
performance period performance period
------------------------------------------------------------------------
(1) Total Measure 6 measure 5 measure
Achievement Points. achievement points achievement points
x 6 measures = 36 x 6 measures = 30
total measure total measure
achievement points. achievement points.
(2) Quality Performance 36/60 = 60 percent.. 30/60 = 50 percent.
Category Achievement
Percent Score (measure
achievement points/60 for
this example).
------------------------------------------------------------------------
The current MIPS performance period quality performance category
achievement percent score is compared to the previous performance
period quality performance category achievement percent score. If the
current score is higher, the MIPS eligible clinician may qualify for an
improvement percent score to be added into the quality performance
category percent score for the current performance year.
We propose to amend the regulatory text at Sec.
414.1380(b)(1)(xvi) to state that improvement scoring is available to
MIPS eligible clinicians and groups that demonstrate improvement in
performance in the current MIPS performance period compared to the
performance in the previous MIPS performance period, based on
achievement. Bonus points or improvement percent score adjustments made
to the category score in the prior or current performance period are
not taken into account when determining whether an improvement has
occurred or the size of any improvement percent score.
We invite public comment on our proposal to award improvement based
on changes in the quality performance category achievement percent
score.
(v) Improvement Scoring Methodology for the Quality Performance
Category
We believe the improvement scoring methodology that we are
proposing for the quality performance category recognizes the rate of
increase in quality performance category scores of MIPS eligible
clinicians from one performance period to another performance period so
that a higher rate of improvement results in a higher improvement
percent score. We believe this is particularly true for those
clinicians with lower performance who will be incentivized to begin
improving with the opportunity to increase their improvement
significantly and achieve a higher improvement percent score.
We propose to award an ``improvement percent score'' based on the
following formula:
Improvement percent score = (increase in quality performance category
achievement percent score from prior performance period to current
performance period/prior year quality performance category achievement
percent score) * 10 percent.
Using the example from Table 27, the quality performance category
achievement percent score for the current performance period is 60
percent, and the previous performance period achievement percent score
is 50 percent. The increase in achievement is 10 percentage points (60
percent--50 percent). Therefore, the improvement percent score is 10
percent (increase in achievement)/50 percent (previous performance
period achievement percent score) * 10 percent = 2 percentage points.
Another way to explain the logic is a 20 percent rate of improvement
for achievement (for example increasing the achievement percent score
10 percentage points which is 20 percent higher than the original 50
percent achievement percent score) is worth a 2 percentage point
increase to the quality performance category achievement percent score.
We believe that this improvement scoring methodology provides an
easily explained and applied approach that is consistent for all MIPS
eligible clinicians. Additionally, it provides additional incentives
for MIPS eligible clinicians who are lower performers to improve
performance. We believe that providing larger incentives for MIPS
eligible clinicians with lower quality performance category scores to
improve will not only increase the quality performance category scores
but also will have the greatest impact on improving quality for
beneficiaries.
We also propose that the improvement percent score cannot be
negative (that is, lower than zero percentage points). The improvement
percent score would be zero for those who do not have sufficient data
or who are not eligible under our proposal for improvement points. For
example, as noted in section II.C.7.a.(2)(i)(ii) of this proposed rule,
a MIPS eligible clinician would not be eligible for improvement if the
clinician was not eligible for MIPS
[[Page 30118]]
in the prior performance period and did not have a quality performance
category achievement percent score. We are also proposing to cap the
size of the improvement award at 10 percentage points, which we believe
appropriately rewards improvement and does not outweigh percentage
points available through achievement. In effect, 10 percentage points
under our proposed formula would represent 100 percent improvement--or
doubling of achievement measure points--over the immediately preceding
period. For the reasons stated, we anticipate that this amount will
encourage participation by individual MIPS eligible clinicians and
groups and will provide an appropriate recognition and award for the
largest increases in performance improvement.
Table 28 illustrates examples of the proposed improvement percent
scoring methodology, which is based on rate of increase in quality
performance category achievement percent scores.
Table 28--Improvement Scoring Examples Based on Rate of Increase in Quality Performance Category Achievement
Percent Scores
----------------------------------------------------------------------------------------------------------------
Year 1 quality Year 2 quality
performance performance
category category Increase in Rate of Improvement
achievement achievement achievement improvement percent score
percent score percent score
----------------------------------------------------------------------------------------------------------------
Individual Eligible 5% (Will 50 20% Because the 20%/30%= 0.67.. 0.67*10% = 6.7%
Clinician #1 (Pick your substitute 30% year 1 score No cap needed.
Pace Test Option). which is the is below 30%,
lowest score a we measure
clinician can improvement
achieve with above 30%.
complete
reporting in
year 1.).
Individual Eligible 60%............ 66 6%............. 6%/60%= 0.10... 0.10*10% = 1.0%
Clinician #2. No cap needed.
Individual Eligible 90%............ 93 3%............. 3%/90%= 0.033.. 0.033*10% =
Clinician #3. 0.3% No cap
needed.
Individual Eligible 30%............ 70 40%............ 40%/30%=1.33... 1.33*10%=13.3%
Clinician #4. Apply cap at
10%.
----------------------------------------------------------------------------------------------------------------
We also considered an alternative to measuring the rate of
improvement. The alternative would use band levels to determine the
improvement points for MIPS eligible clinicians who qualify for
improvement points. Under the band level methodology, a MIPS eligible
clinician's improvement points would be determined by an improvement in
the quality performance category achievement percent score from 1 year
to the next year to determine improvement in the same manner as set
forth in the rate of improvement methodology. However, for the band
level methodology, an improvement percent score would then be assigned
by taking into account a portion (50, 75 or 100 percent) of the
improvement in achievement, based on the clinician's performance
category achievement percent score for the prior year. Bands would be
set for category achievement percent scores, with increases from lower
category achievement scores earning a larger portion (percentage) of
the improvement points. Under this alternative, simple improvement
percentage points for improvement are awarded to MIPS eligible
clinicians whose category scores improved across years according to the
band level, up to a maximum of 10 percent of the total score.
In Table 29, we illustrate the band levels we considered as part of
this alternative proposal. The chart depicts the band level and the
improvement points allotted for the increases in improvement scores
that fall within the transition year score range.
Table 29--Band Level and Improvement Points Allotted for Determining
Improvement Percent Scores
------------------------------------------------------------------------
% Credit for each percent
Transition year score range increase in achievement
------------------------------------------------------------------------
1-50................................... 100% of increase in
achievement.
51-75.................................. 75% of increase in achievement.
75-100................................. 50% of increase in achievement.
------------------------------------------------------------------------
Table 30 illustrates examples of the improvement scoring
methodology based on band levels. Generally, this methodology would
generate a higher improvement percent score for clinicians; however, we
believe the policy we proposed would provide a score that better
represents true improvement at the performance category level, rather
than comparing simple increases in performance category scores.
[[Page 30119]]
Table 30--Examples of Improvement Scoring Methodology Based on Band Levels
----------------------------------------------------------------------------------------------------------------
Year 1 quality Year 2 quality
performance performance Band for Improvement
category category Increase in improvement percent score
achievement achievement achievement adjustment (after applying
percent score percent score the cap)
----------------------------------------------------------------------------------------------------------------
Individual Eligible Clinician 5% (Will 50% 20% Because the 100% 20%*100%= 20%
#1 (Pick your Pace Test substitute 30% year 1 score which is
Option). which is the is below 30%, capped at 10%.
lowest score a we measure
clinician can improvement
achieve with above 30%.
complete
reporting in
year 1.)
Individual Eligible Clinician 60%............ 66% 6%............. 75% 6%*75%= 4.5% No
#2. cap needed
Individual Eligible Clinician 90%............ 93% 3%............. 50% 3%*50%= 1.5% No
#3. cap needed
----------------------------------------------------------------------------------------------------------------
In addition, we considered another alternative that would adopt the
improvement scoring methodology of the Shared Savings Program\11\ for
CMS Web Interface submissions in the quality performance category, but
decided to not adopt this approach. Under the Shared Savings Program
approach, eligible clinicians and groups that submit through the CMS
Web Interface would have been required to submit on the same set of
quality measures, and we would have awarded improvement for all
eligible clinicians or groups who submitted complete data in the prior
year. As Shared Savings Program and Next Generation ACOs report using
the CMS Web Interface, using the same improvement score approach would
align MIPS with these other programs. We believed it could be
beneficial to align improvement between the programs because it would
align incentives for those who participate in the Shared Savings
Program or ACOs. The Shared Savings Program approach would test each
measure for statistically significant improvement or statistically
significant decline. We would sum the number of measures with a
statistically significant improvement and subtract the number of
measures with a statistically significant decline to determine the Net
Improvement. We would next divide the Net Improvement in each domain by
the number of eligible measures in the domain to calculate the
Improvement Score. We would cap the number of possible improvement
percentage points at 10.
---------------------------------------------------------------------------
\11\ For additional information on the Shared Savings Program's
scoring methodology, we refer readers to the Quality Measurement
Methodology and Resources, September 2016, Version 1 and the
Medicare Shared Savings Program Quality Measure Benchmarks for the
2016 and 2017 Reporting Years (available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/MSSP-QM-Benchmarks-2016.pdf.)
---------------------------------------------------------------------------
We considered the Shared Savings Program methodology because it
would promote alignment with ACOs. We ultimately decided not to adopt
this scoring methodology because we believe having a single performance
category level approach for all quality performance category scores
encourages a uniformity in our approach to improvement scoring and
simplifies the scoring rules for MIPS eligible clinicians. It also
allows us greater flexibility to compare performance scores across the
diverse submission mechanisms, which makes improvement scoring more
broadly available to eligible clinicians and groups that elect
different ways of participating in MIPS.
We propose to add regulatory text at Sec.
414.1380(b)(1)(xvi)(C)(3) to state that an improvement percent score
cannot be negative (that is, lower than zero percentage points). We
also propose to add regulatory text at Sec. 414.1380(b)(1)(xvi)(C)(1)
to state that improvement scoring is awarded based on the rate of
increase in the quality performance category achievement percent score
of individual MIPS eligible clinicians or groups from the current MIPS
performance period compared to the score in the year immediately prior
to the current MIPS performance period. We also propose to add
regulatory text at Sec. 414.1380(b)(1)(xvi)(C)(2) to state that an
improvement percent score is calculated by dividing the increase in the
quality performance category achievement percent score of an individual
MIPS eligible clinician or group, which is calculated by comparing the
quality performance category achievement percent score the current MIPS
performance period to the quality performance category achievement
percent score from the MIPS performance period in the year immediately
prior to the current MIPS performance period, by the prior year quality
performance category achievement percent score, and multiplying by 10
percent.
We invite public comments on our proposal to calculate improvement
scoring using a methodology that awards improvement points based on the
rate of improvement and, alternatively, on rewarding improvement at the
band level or using the Shared Saving Program approach for CMS Web
Interface submissions.
(j) Calculating the Quality Performance Category Percent Score
Including Improvement
In the CY 2017 Quality Payment Program final rule, we finalized at
Sec. 414.1380(b)(1)(xv) that the quality performance category score is
the sum of all points assigned for the measures required for the
quality performance category criteria plus bonus points, divided by the
sum of total possible points (81 FR 77300). Using the terminology
proposed in section II.C.7.a.(2) of this proposed rule, this formula
can be represented as:
Quality performance category percent score = (total measure achievement
points + measure bonus points)/total available measure achievement
points.
We propose to incorporate the improvement percent score, which is
proposed in section II.C.7.a.(2)(i)(i) of this proposed rule, into the
quality performance category percent score. We propose to amend Sec.
414.1380(b)(1)(xv) (redesignated as Sec. 414.1380(b)(1)(xvii)) to add
the improvement percent score (as calculated pursuant to proposed
paragraph (b)(1)(xvi)(A) through (F)) to the quality performance score.
We also propose to amend Sec. 414.1380(b)(1)(xv) (redesignated as
Sec. 414.1380(b)(1)(xvii)) to amend the text that states the quality
performance category percent score cannot exceed the total possible
points for the quality performance category to clarify that the total
possible points for
[[Page 30120]]
the quality performance category cannot exceed 100 percentage points.
Thus, the calculation for the proposed quality performance category
percent score including improvement, can be summarized in the following
formula:
Quality performance category percent score = ([total measure
achievement points + measure bonus points]/total available measure
achievement points) + improvement percent score, not to exceed 100
percent.
This same formula and logic will be applied for both CMS Web
Interface and Non-CMS Web Interface reporters.
Table 31 illustrates an example of calculating the quality
performance category percent score including improvement for a non-CMS
Web Interface reporter. In this example, an individual MIPS eligible
clinician received measure achievement points for their 6 required
measures, and received 6 measure bonus points. Because this is an
individual clinician and the administrative claims based measure is not
applicable, the total available measure achievement points for this
clinician is 60. The improvement percent score would be calculated
based on the proposal in section II.C.7.a.(2)(i) of this proposed rule;
Table 31 does not illustrate the underlying calculations for the
improvement percent score. To calculate the quality performance
category percent score, the total measures achievement points would be
summed with the total measure bonus points and then divided by the
total available measure achievement points. The improvement percent
score would be added to that calculation. The resulting quality
performance category percent score cannot exceed 100 percentage points.
Table 31--Example of Scoring the Quality Performance Category Percent Score Including Improvement
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total
Total measure available Improvement
achievement Total measure measure Calculation prior to percent score Quality performance
points bonus points achievement improvement (%) category percent score
points
--------------------------------------------------------------------------------------------------------------------------------------------------------
Individual Eligible Clinician... 35.6 6 60 (35.6 + 6)/60 = 69.33%.... 1.9 69.33% + 1.9% = 71.23%
Individual Eligible Clinician 35.6 6 60 (35.6 + 6)/60 = 69.33%.... 0 69.33% + 0% = 69.33%
(did not submit in Year 1).
Individual Eligible Clinician 50 6 60 (50 + 6)/60 = 93.33%...... 10 93.33% + 10% = 103.33%,
(with maximum improvement). which is capped at 100%
--------------------------------------------------------------------------------------------------------------------------------------------------------
We note that the quality performance category percent score is then
multiplied by the performance category weight for calculating the final
score.
We invite public comment on this overall methodology and formula
for calculating the quality performance category percent score.
(3) Scoring the Cost Performance Category
We score the cost performance category using a methodology that is
generally consistent with the methodology used for the quality
performance category. In the CY 2017 Quality Payment Program final rule
(81 FR 77309), we codified at Sec. 414.1380(b)(2) that a MIPS eligible
clinician receives 1 to 10 achievement points for each cost measure
attributed to the MIPS eligible clinician based on the MIPS eligible
clinician's performance compared to the measure benchmark. We establish
a single benchmark for each cost measure and base those benchmarks on
the performance period (81 FR 77309). Because we base the benchmarks on
the performance period, we will not be able to publish the actual
numerical benchmarks in advance of the performance period (81 FR
77309). We develop a benchmark for a cost measure only if at least 20
groups (for those MIPS eligible clinicians participating in MIPS as a
group practice) or TIN/NPI combinations (for those MIPS eligible
clinicians participating in MIPS as an individual) can be attributed
the case minimum for the measure (81 FR 77309). If a benchmark is not
developed, the cost measure is not scored or included in the
performance category (81 FR 77309). For each set of benchmarks, we
calculate the decile breaks based on cost measure performance during
the performance period and assign 1 to 10 achievement points for each
measure based on which benchmark decile range the MIPS eligible
clinician's performance on the measure is between (81 FR 77309 through
77310). We also codified at Sec. 414.1380(b)(2)(iii) that a MIPS
eligible clinician's cost performance category score is the equally-
weighted average of all scored cost measures (81 FR 77311).
In the CY 2017 Quality Payment Program final rule (81 FR 77311), we
adopted a final policy to not calculate a cost performance category
score if a MIPS eligible clinician or group is not attributed any cost
measures because the MIPS eligible clinician or group has not met the
case minimum requirements for any of the cost measures or a benchmark
has not been created for any of the cost measures that would otherwise
be attributed to the clinician or group. We inadvertently failed to
include this policy in the regulation text and are proposing to codify
it under Sec. 414.1380(b)(2)(v).
For more of the statutory background and descriptions of our
current policies for the cost performance category, we refer readers to
the CY 2017 Quality Payment Program final rule (81 FR 77308 through
77311).
In section II.C.7.a.(3)(a) of this proposed rule, we propose to add
improvement scoring to the cost performance category scoring
methodology starting with the 2020 MIPS payment year. We do not propose
any changes to the methodology for scoring achievement in the cost
performance category for the 2020 MIPS payment year other than the
method used for facility-based measurement described in II.C.7.a.(4) of
this proposed rule. We are proposing a change in terminology to refer
to the ``cost performance category percent score in order to be
consistent with the terminology used in the quality performance
category. In section II.C.7.a.(2) of this proposed rule, we propose to
calculate a ``quality performance category percent score'' which is
reflective of performance in the quality performance category based on
dividing the sum of total measure achievement points and bonus points
by the total available measure achievement points. We propose to revise
Sec. 414.1380(b)(2)(iii) to provide that a
[[Page 30121]]
MIPS eligible clinician's cost performance category percent score is
the sum of the following, not to exceed 100 percent: The total number
of achievement points earned by the MIPS eligible clinician divided by
the total number of available achievement points (which can be
expressed as a percentage); and the cost improvement score. This
terminology change to refer to the score as a percentage is consistent
with the change in section II.C.7.a.(2) for the quality performance
category. We discuss our proposals for improvement scoring in the cost
performance category in section II.C.7.b.3.(a) of this proposed rule.
(a) Measuring Improvement
(i) Calculating Improvement at the Cost Measure Level
In section II.C.7.a.(1)(b) of this proposed rule, we propose to
make available to MIPS eligible clinicians and groups a method of
measuring improvement in the quality and cost performance categories.
In section II.C.7.a.(2)(i) of this proposed rule, for the quality
performance category, we propose to assess improvement on the basis of
the score at the performance category level. For the cost performance
category, similar to the quality performance category, we propose at
Sec. 414.1380(b)(2)(iv) that improvement scoring is available to MIPS
eligible clinicians and groups that demonstrate improvement in
performance in the current MIPS performance period compared to their
performance in the immediately preceding MIPS performance period (for
example, demonstrating improvement in the 2018 MIPS performance period
over the 2017 MIPS performance period).
In section II.C.7.a.(2)(i) of this proposed rule, we note the
various challenges associated with attempting to measure improvement in
the quality performance category at the measure level, given the many
opportunities available to clinicians to select which measures to
report. The cost performance category is not subject to this same issue
of measure selection. Cost measures are calculated based on Medicare
administrative claims data maintained by CMS, without any additional
data input from or reporting by clinicians, and MIPS eligible
clinicians are not given the opportunity to select which cost measures
apply to them. We believe that there are advantages to measuring cost
improvement at the measure level. Principally, MIPS eligible clinicians
could see their performance on each cost measure and better understand
how practice improvement changes can drive changes for each specific
cost measure. Additionally, as discussed in section II.C.7.a.(1)(b)(i)
of this proposed rule, other Medicare value-based purchasing programs
generally assess performance improvement at the measure level.
Therefore, we propose at section Sec. 414.1380(b)(2)(iv)(A) to measure
cost improvement at the measure level for the cost performance
category.
As described in section II.C.7.a.(1)(b)(ii) of this proposed rule,
we believe that we would have data sufficient to measure improvement
when we can measure performance in the current performance period
compared to the prior performance period. Due to the differences in our
proposals for measuring improvement for the quality and cost
performance categories, such as measuring improvement at the measure
level versus the performance category level, we are proposing a
different data sufficiency standard for the cost performance category
than for the quality performance category, which is proposed in section
II.C.7.a.(2)(i)(ii) of this proposed rule. First, for data sufficient
to measure improvement to be available for the cost performance
category, the same cost measure(s) would need to be specified for the
cost performance category for 2 consecutive performance periods. For
the 2020 MIPS payment year, only 2 cost measures, the MSPB measure and
the total per capita cost measure, would be eligible for improvement
scoring. For a measure to be scored in either performance period, a
MIPS eligible clinician would need to have a sufficient number of
attributed cases to meet or exceed the case minimum for the measure.
In addition, a clinician would have to report for MIPS using the
same identifier (TIN/NPI combination for individuals, TIN for groups,
or virtual group identifiers for virtual groups) and be scored on the
same measure(s) for 2 consecutive performance periods. We wish to
encourage action on the part of clinicians in reviewing and
understanding their contribution to patient costs. For example, a
clinician who is shown to have lower performance on the MSPB measure
could focus on the efficient use of post-acute care and be able to see
that improvement reflected in the cost improvement score in future
years. This review could highlight opportunities for better stewardship
of healthcare costs such as better recognition of unnecessary costs
related to common ordering practices. For these reasons, we believe
that improvement should be evaluated only when there is a consistent
identifier.
Therefore, for the cost performance category, we are proposing at
Sec. 414.1380(b)(2)(iv)(B) that we would calculate a cost improvement
score only when data sufficient to measure improvement is available. We
are proposing that sufficient data would be available when a MIPS
eligible clinician participates in MIPS using the same identifier in 2
consecutive performance periods and is scored on the same cost
measure(s) for 2 consecutive performance periods (for example, in the
2017 MIPS performance period and the 2018 MIPS performance period). If
the cost improvement score cannot be calculated because sufficient data
is not available, we are proposing to assign a cost improvement score
of zero percentage points. While the total available cost improvement
score would be limited at first because only 2 cost measures would be
included in both the first and second performance periods of the
program (total per capita cost and MSPB), more opportunities for
improvement scoring would be available in the future as additional cost
measures, including episode-based measures, are added in future
rulemaking. MIPS eligible clinicians would be able to review their
performance feedback and make improvements compared to the score in
their previous feedback.
We invite public comments on these proposals.
(ii) Improvement Scoring Methodology
In section II.C.7.a.(1)(b)(i) of this proposed rule, we discuss a
number of different programs and how they measure improvement at the
category or measure level as part of their scoring systems. For
example, the Hospital Value-Based Purchasing (VBP) Program awards
either measure improvement or measure achievement, but not both. In the
proposed method for the quality performance category, we compare the
overall rate of achievement on all the underlying measures in the
quality performance category and measure a rate of overall improvement
to calculate an improvement percent score. We then add the improvement
percent score after taking into account measure achievement points and
measure bonus points as described in proposed Sec.
414.1380(b)(1)(xvii). In reviewing the methodologies that are specified
in section II.C.7.a.(1)(b)(i) of this proposed rule that include
consideration of improvement at the measure level, we noted that the
methodology used in the Shared Savings Program would best reward
achievement and improvement
[[Page 30122]]
for the cost performance category because this program includes
measures for clinicians, the methodology is straightforward, and it
only recognizes significant improvement. We propose to quantify
improvement in the cost performance category by comparing the number of
cost measures with significant improvement in performance and the
number of cost measures with significant declines in performance. We
propose at Sec. 414.1380(b)(2)(iv)(C) to determine the cost
improvement score by subtracting the number of cost measures with
significant declines from the number of cost measures with significant
improvement, and then dividing the result by the number of cost
measures for which the MIPS eligible clinician or group was scored in
both performance periods, and then multiplying the result by the
maximum cost improvement score. For the 2020 MIPS payment year,
improvement scoring would be possible for the total per capita cost
measure and the MSPB measure as those 2 measures would be available for
2 consecutive performance periods under our proposals in section
II.C.6.d.(3)(a). As in our proposed quality improvement methodology, we
propose at Sec. 414.1380(b)(2)(iv)(D) that the cost improvement score
could not be lower than zero, and therefore, could only be positive.
We propose to determine whether there was a significant improvement
or decline in performance between the 2 performance periods by applying
a common standard statistical test, a t-test, as is used in the Shared
Savings Program (79 FR 67930 through 67931). The t-test's statistical
significance and the t-test's effect size are the 2 primary outputs of
the t-test. Statistical significance indicates whether the difference
between sample averages is likely to represent an actual difference
between populations and the effect size indicates whether that
difference is large enough to be practically meaningful. Statistical
significance testing in this case assesses how unlikely it is that
differences as large as those observed would be due to chance when the
performance is actually the same. The test recognizes and appropriately
adjusts measures at both high and low levels of performance for
statistically significant levels of change. However, as an alternative,
we welcome public comments on whether we should consider instead
adopting an improvement scoring methodology that measures improvement
in the cost performance category the same way we propose to do in the
quality performance category; that is, using the rate of improvement
and without requiring statistical significance. We refer readers to
section II.C.7.a.(2)(i) of this proposed rule for our proposal related
to measuring improvement in the quality performance category.
Section 1848(q)(5)(D)(ii) of the Act specifies that the Secretary
may assign a higher scoring weight under subparagraph (F) with respect
to the achievement of a MIPS eligible clinician than with respect to
any improvement of such clinician with respect to a measure, activity,
or category described in paragraph (2). We believe that there are many
opportunities for clinicians to actively work on improving their
performance on cost measures, through more active care management or
reductions in certain services. However, we recognize that most
clinicians are still learning about their opportunities in cost
measurement. We aim to continue to educate clinicians about
opportunities in cost measurement and continue to develop opportunities
for robust feedback and measures that better recognize the role of
clinicians. Since MIPS is still in its beginning years and we
understand that clinicians are working hard to understand how we
measure costs for purposes of the cost performance category, as well as
how we score their performance in all other aspects of the program, we
believe improvement scoring in the cost performance category should be
limited to avoid creating additional confusion. Based on these
considerations, we propose in section II.C.6.d.(2) of this proposed
rule to weight the cost performance category at zero percent for the
2020 MIPS payment year/2018 MIPS performance period. With the entire
cost performance category proposed to be weighted at zero percent, we
believe that the focus of clinicians should be on achievement as
opposed to improvement, and therefore we propose at Sec.
414.1380(b)(2)(iv)(E) that although improvement would be measured
according to the method described above, the maximum cost improvement
score for the 2020 MIPS payment year would be zero percentage points.
Section 1848(q)(5)(D)(ii) of the Act provides discretion for the
Secretary to assign a higher scoring weight under subparagraph (F),
which refers to section 1848(q)(5)(F) of the Act, with respect to
achievement than with respect to improvement. Section 1848(q)(5)(F) of
the Act provides if there are not sufficient measures and activities
applicable and available to each type of MIPS eligible clinician, the
Secretary shall assign different scoring weights (including a weight of
zero) for measures, activities, and/or performance categories. When
read together, we interpret sections 1848(q)(5)(D)(ii) and
1848(q)(5)(F) of the Act to provide discretion to the Secretary to
assign a scoring weight of zero for improvement on the measures
specified for the cost performance category. Under the improvement
scoring methodology we have proposed, we believe a maximum cost
improvement score of zero would be effectively the same as a scoring
weight of zero. As a result of our proposal, the cost improvement score
would not contribute to the cost performance category percent score
calculated for the 2020 MIPS payment year. In other words, we would
calculate a cost improvement score, but the cost improvement score
would not contribute any points to the cost performance category
percent score for the 2020 MIPS payment year.
In section II.C.6.d.(2) of this proposed rule, we consider an
alternative to make no changes to the previously finalized weight of 10
percent for the cost performance category for the 2020 MIPS payment
year. If we finalize this alternative, we believe that improvement
should be given weight towards the cost performance category percent
score, but it should still be limited. Therefore, we propose that if we
maintain a weight of 10 percent for the cost performance category for
the 2020 MIPS payment year, the maximum cost improvement score
available in the cost performance category would be 1 percentage point
out of 100 percentage points available for the cost performance
category percent score. If a clinician were measured on only one
measure consistently from one performance period to the next and met
the requirements for improvement, the clinician would receive one
improvement percentage point in the cost performance category percent
score. If a clinician were measured on 2 measures consistently,
improved significantly on one, and did not show significant improvement
on the other (as measured by the t-test method described above), the
clinician would receive 0.5 improvement percentage points.
We invite comments on these proposals as well as alternative ways
to measure changes in statistical significance for the cost measure.
(b) Calculating the Cost Performance Category Percent Score With
Achievement and Improvement
In section II.C.7.a.(1)(b) of this proposed rule, we evaluated
different improvement scoring options used in other CMS programs. In
those programs, we saw 2 general methods for
[[Page 30123]]
incorporating improvement. One method measures both achievement and
improvement and takes the higher of the 2 scores for each measure that
is compared. The Hospital VBP Program incorporates such a methodology.
The second method is to calculate an achievement score and then add an
improvement score if improvement is measured. The Shared Savings
Program utilizes a similar methodology for measuring improvement. For
the cost performance category, we are proposing to evaluate improvement
at the measure level, unlike the quality performance category where we
are proposing to evaluate improvement at the performance category
level. For both the quality performance category and the cost
performance category, we are proposing to add improvement to an
existing category percent score. We believe this is the most straight-
forward and simple way to incorporate improvement. It is also
consistent with other Medicare programs that reward improvement.
As noted in section II.7.b.(3) of this proposed rule, we have
proposed a change in terminology to express the cost performance
category percent score as a percentage. We propose to revise Sec.
414.1380(b)(2)(iii) to provide that a MIPS eligible clinician's cost
performance category percent score is the sum of the following, not to
exceed 100 percent: The total number of achievement points earned by
the MIPS eligible clinician divided by the total number of available
achievement points (which can be expressed as a percentage); and the
cost improvement score. With these two proposed changes, the formula
would be (Cost Achievement Points/Available Cost Achievement Points) +
(Cost Improvement Score) = (Cost Performance Category Percent Score).
We invite public comments on these proposals.
In Table 32, we provide an example of cost performance category
percent scores along with the determination of improvement or decline.
For illustrative purposes, we are using the alternative proposal of a
maximum cost improvement score of 1. This example is for group
reporting where the group is measured on both the total per capita cost
measure and the MSPB measure for 2 consecutive performance periods.
Table 32--Example of Assessing Achievement and Improvement in the Cost Performance Category
----------------------------------------------------------------------------------------------------------------
Significant Significant
Measure Total possible improvement decline from
Measure achievement measure from prior prior
points earned achievement performance performance
by the group points period period
----------------------------------------------------------------------------------------------------------------
Total per Capita Cost Measure................... 8.2 10 Yes No
MSPB Measure.................................... 6.4 10 No No
----------------------------------------------------------------------------------------------------------------
In this example, there are 20 total possible measure achievement
points and 14.6 measure achievement points earned by the group, and the
group improved on one measure but not the other, with both measures
being scored in each performance period. The cost improvement score
would be determined as follows: ((1 measure with significant
improvement-zero measures with significant decline)/2 measures) * 1
percentage point = 0.5 percentage points. Under the proposed revised
formula, the cost performance category percent score would be (14.6/20)
+ 0.5% = 73.5%.
As discussed in section II.C.7.b.(2) of this proposed rule, in
determining the MIPS final score, the cost performance category percent
score is multiplied by the cost performance category weight. For the
2020 MIPS payment year, if we finalize the cost performance category
weight of zero percent, then the cost performance category percent
score will not contribute to the final score.
(4) Facility-Based Measures Scoring Option for the 2020 MIPS Payment
Year for the Quality and Cost Performance Categories
(a) Background
Section 1848(q)(2)(C)(ii) of the Act provides that the Secretary
may use measures used for payment systems other than for physicians,
such as measures for inpatient hospitals, for purposes of the quality
and cost performance categories. However, the Secretary may not use
measures for hospital outpatient departments, except in the case of
items and services furnished by emergency physicians, radiologists, and
anesthesiologists. In the MIPS and APMs RFI (80 FR 59108), we sought
comment on how we could best use this authority. We refer readers to
the CY 2017 Quality Payment Program final rule (81 FR 77127) for a
summary of these comments.
As noted in the CY 2017 Quality Payment Program proposed rule (81
FR 28192), we considered an option for facility-based MIPS eligible
clinicians to elect to use their institution's performance rates as a
proxy for the MIPS eligible clinician's quality score. However, we did
not propose an option for the transition year of MIPS because there
were several operational considerations that we believed needed to be
addressed before this option could be implemented. We requested
comments on the following issues: (1) Whether we should attribute a
facility's performance to a MIPS eligible clinician for purposes of the
quality and cost performance categories and under what conditions such
attribution would be appropriate and representative of the MIPS
eligible clinician's performance; (2) possible criteria for attributing
a facility's performance to a MIPS eligible clinician for purposes of
the quality and cost performance categories; (3) the specific measures
and settings for which we can use the facility's quality and cost data
as a proxy for the MIPS eligible clinician's quality and cost
performance categories; and (4) if attribution should be automatic or
if an individual MIPS eligible clinician or group should elect for it
to be done and choose the facilities through a registration process.
As noted in the CY 2017 Quality Payment Program final rule (81 FR
77127 through 77130), the majority of the comments we received
supported attributing a facility's performance to a MIPS eligible
clinician for purposes of the quality and cost performance categories.
Some commenters opposed using a facility's quality and cost performance
as a proxy for MIPS eligible clinicians. Many of these commenters
expressed the view that facility scores do not represent the individual
MIPS eligible clinician's performance. In addition, we received
suggestions on how we should attribute a facility's performance to a
MIPS eligible clinician, as well as comments suggesting that
attribution should be voluntary and that the facility's measures should
be relevant to the MIPS eligible clinician. A full discussion of the
comments we received
[[Page 30124]]
and our responses can be found in the CY 2017 Quality Payment Program
final rule (81 FR 77127 through 77130).
In addition, we have received ongoing feedback from various
stakeholder associations and individuals regarding facility-based
measurement for MIPS eligible clinicians, which included: Support for
MIPS eligible clinicians being able to choose to be assessed in this
manner; several groups' preference that value-based purchasing and
quality reporting program measure data be used for facility-based
scoring; support for a ``hybrid'' approach where MIPS eligible
clinicians could select both clinician-based measures and facility-
based measures for purposes of MIPS scoring; and a suggested 2-year
pilot program before expanding facility-based scoring more broadly with
an emphasis on no negative impact on those who are measured in this
fashion. We took this feedback, as well as the comments discussed in
the CY 2017 Quality Payment Program final rule, into consideration when
developing proposals for the application of facility-based measures.
(b) Facility-Based Measurement
We believe that facility-based measurement is intended to reduce
reporting burden on facility-based MIPS eligible clinicians by
leveraging existing quality data sources and value-based purchasing
experiences and aligning incentives between facilities and the MIPS
eligible clinicians who provide services there. In addition, we believe
that facility-based MIPS eligible clinicians contribute substantively
to their respective facilities' performance on facility-based measures
of quality and cost, and that their performance may be better reflected
by their facilities' performance on such measures.
Medicare operates both pay-for-reporting programs and pay-for-
performance programs. Pay-for-reporting programs incentivize the act of
reporting data on quality and/or other measures and activities,
typically by applying a downward payment adjustment to facilities or
clinicians, as applicable, that fail to submit data as required by the
Secretary. This type of program does not adjust payments based on
performance. In contrast, pay-for-performance programs, such as VBP
programs, score facilities or clinicians, as applicable, on their
performance on specified quality and/or other measures and activities
and adjust payments based on that performance. Pay-for-performance
programs, such as VBP programs, are more analogous to MIPS given its
focus on performance and not just reporting. For this reason, we
believe that facility-based measurement under MIPS should be based on
pay-for-performance programs rather than pay-for-reporting programs.
Many Medicare payment systems include a pay-for-performance
program, such as the Hospital VBP Program, the Skilled Nursing Facility
VBP Program (SNF VBP), the End Stage Renal Disease Quality Incentive
Program (ESRD QIP), and the Home Health Value-Based Purchasing Program
(HHVBP). We believe that clinicians play a role in contributing to
quality performance in all of these programs. However, we believe that
a larger and more diverse group of clinicians contributes to quality in
the inpatient hospital setting than in other settings in which we might
begin to implement this measurement option. In addition, the inpatient
hospital setting has a mature value-based purchasing program, first
established to adjust payment for hospitals in FY 2013 (76 FR 26489).
Therefore, we believe it is appropriate to implement this scoring
option in a limited fashion in the first year of incorporating
additional facility-based measures under MIPS by focusing on inpatient
hospital measures that are used for certain pay-for-performance
programs as facility-based measures.
The inpatient hospital setting includes three distinct pay-for-
performance programs: The Hospital VBP Program, the Hospital
Readmissions Reduction Program (HRRP), and the Hospital-Acquired
Condition Reduction Program (HACRP). We believe that the Hospital VBP
Program is most analogous to the MIPS program at this time because the
Hospital VBP Program compares facilities on a series of different
measures that intend to capture the breadth of care provided in a
facility. In contrast, the HACRP and HRRP each focus on a single type
of outcome for patients treated in a hospital (safety and readmissions,
respectively), though we note that these outcomes are critically
important to health care improvement. The payment adjustments
associated with those 2 programs are intended to provide negative
adjustments for poor performance but do not similarly reward high
performance. In contrast, the Hospital VBP Program compares performance
among hospitals and rewards high performers and provides negative
adjustments to poor performers.
We also considered program timing when determining what Hospital
VBP Program year to use for facility-based measurement for the 2020
MIPS payment year. Quality measurement for the FY 2019 Hospital VBP
Program's performance period will be concluded by December 31, 2017 (we
refer readers to the finalized FY 2019 performance periods in the FY
2017 Inpatient Prospective Payment System/Long-Term Care Hospital
Prospective Payment System Final Rule, 81 FR 57002), and the Hospital
VBP Program scoring reports (referred to as the Percentage Payment
Summary Reports) will be provided to participating hospitals not later
than 60 days prior to the beginning of FY 2019, pursuant to the
Hospital VBP Program's statutory requirement at section 1886(o)(8) of
the Act. We further note that hospitals must meet case and measure
minimums during the performance period to receive a Total Performance
Score under that Program. We discuss eligibility for facility-based
measurement in section II.C.7.b.(4)(c) of this proposed rule, and we
note that the determination of the applicable hospital will be made on
the basis of a period that overlaps with the applicable Hospital VBP
Program performance period. Although Hospital VBP Program measures have
different measurement periods, the FY 2019 measures all overlap from
January to June in 2017, which also overlaps with our first 12-month
period to determine MIPS eligibility.
We believe that MIPS eligible clinicians electing the facility-
based measurement option under MIPS should be able to consider as much
information as possible when making that decision, including how their
attributed hospital performed in the Hospital VBP Program because an
individual clinician is a part of the clinical team in the hospital,
rather than the sole clinician responsible for care as tracked by
quality measures. Therefore, we concluded that we should be as
transparent as possible with MIPS eligible clinicians about their
potential facility-based scores before they begin data submission for
the MIPS performance period since this policy option is intended to
minimize reporting burdens on clinicians that are already participating
in quality improvement efforts through other CMS programs. We expect
that MIPS eligible clinicians that would consider facility-based
scoring would generally be aware of their hospital's performance on its
quality measures, but believe that providing this information directly
to clinicians ensures that such clinicians are fully aware of the
implications of their scoring elections under MIPS. However, we note
that this policy could conceivably place non-facility-based MIPS
eligible clinicians at a competitive
[[Page 30125]]
disadvantage since they would not have any means by which to ascertain
their MIPS measure scores in advance. We view that compromise as a
necessity to maximize transparency, and we request comment on whether
this notification in advance of the conclusion of the MIPS performance
period is appropriate, or if we should consider notifying facility-
based clinicians later in the MIPS performance period or even after its
conclusion. Notification after the MIPS performance period would
prevent facility-based clinicians from being able to compare their
expected MIPS performance category scores under the facility-based
measurement option with their expected scores under the options
available to all MIPS eligible clinicians and pick the higher of the
two. Since higher performance category scores may result in a higher
final score and a higher MIPS payment adjustment, there is a
substantial incentive for a clinician to undertake this comparison, a
comparison unavailable to non-facility-based peers.
The performance periods proposed in section II.C.5. of this
proposed rule for the 2020 MIPS payment year occur in 2018, with data
submission for most mechanisms starting in January 2019. To provide
potential facility-based scores to clinicians by the time the data
submission period for the 2018 MIPS performance period begins assuming
that timeframe is operationally feasible), we believe that the FY 2019
program year of the Hospital VBP Program, as well as the corresponding
performance periods, is the most appropriate program year to use for
purposes of facility-based measurement under the quality and cost
performance categories for the 2020 MIPS payment year. However, we note
also that Hospital VBP performance periods can run for periods as long
as 36 months, and for some FY 2019 Hospital VBP Program measures, the
performance period begins in 2014. We request comment on whether this
lengthy performance period duration should override our desire to
include all Hospital VBP Program measures as discussed further below.
We propose at Sec. 414.1380(e)(6)(iii) that the performance period for
facility-based measurement is the performance period for the measures
for the measures adopted under the value-based purchasing program of
the facility of the year specified.
We considered whether we should include the entire set of Hospital
VBP Program measures for purposes of facility-based measurement under
MIPS or attempt to differentiate those which may be more influenced by
clinicians' contribution to quality performance than others. However,
we believe that clinicians have a broad and important role as part of
the healthcare team at a hospital and that attempting to differentiate
certain measures undermines the team-based approach of facility-based
measurement. We propose at Sec. 414.1380(e)(6)(i) that the quality and
cost measures are those adopted under the value-based purchasing
program of the facility program for the year specified.
Therefore, we propose for the 2020 MIPS payment year to include all
the measures adopted for the FY 2019 Hospital VBP Program on the MIPS
list of quality measures and cost measures. Under this proposal, we
consider the FY 2019 Hospital VBP Program measures to meet the
definition of additional system-based measures provided in section
1848(q)(2)(C)(ii) of the Act, and we propose at Sec. 414.1380(e)(1)(i)
that facility-based measures available for the 2018 MIPS performance
period are the measures adopted for the FY 2019 Hospital VBP Program
year authorized by section 1886(o) of the Act and codified in our
regulations at Sec. Sec. 412.160 through 412.167. Measures in the FY
2019 Hospital VBP Program have different performance periods as noted
in Table 33.
We request comments on these proposals. We also request comments on
what other programs, if any, we should consider including for purposes
of facility-based measurement under MIPS in future program years.
(c) Facility-Based Measurement Applicability
(i) General
The percentage of professional time a clinician spends working in a
hospital varies considerably. Some clinicians may provide services in
the hospital regularly, but also treat patients extensively in an
outpatient office or another environment. Other clinicians may practice
exclusively within a hospital. Recognizing the various levels of
presence of different clinicians within a hospital environment, we seek
to limit the potential applicability of facility-based measurement to
those MIPS eligible clinicians with a significant presence in the
hospital.
In the CY 2017 Quality Payment Program final rule (81 FR 77238
through 77240), we adopted a definition of ``hospital-based MIPS
eligible clinician'' under Sec. 414.1305 for purposes of the advancing
care information performance category. Section 414.1305 defines a
hospital-based MIPS eligible clinician as a MIPS eligible clinician who
furnishes 75 percent or more of his or her covered professional
services in sites of service identified by the POS codes used in the
HIPAA standard transaction as an inpatient hospital, on-campus
outpatient hospital, or emergency room setting, based on claims for a
period prior to the performance period as specified by CMS. We
considered whether we should simply use this definition to determine
eligibility for facility-based measurement under MIPS. However, we are
concerned that this definition could include many clinicians that have
limited or no presence in the inpatient hospital setting. We have noted
that hospital-based clinicians may not have control over important
aspects of the certified EHR technology that is available in the
hospital setting (81 FR 77238). In that regard, there is little
difference between outpatient and inpatient hospital settings. But we
are proposing to determine a MIPS eligible clinician's quality
performance category score and cost performance category score based on
a hospital's Hospital VBP performance, which is based on inpatient
services. Section 1848(q)(2)(C)(ii) of the Act limits our ability to
incorporate measures used for hospital outpatient departments. Our
proposal at section II.C.6.f.(7)(a)(i) of this proposed rule to expand
the definition of a hospital-based MIPS eligible clinician for the
advancing care information performance category to include clinicians
who practice primarily in off-campus outpatient hospitals could include
clinicians that practice many miles away from the hospital in practices
which are owned by the hospital, but do not substantially contribute to
the hospital's Hospital VBP Program performance. As we discuss further
in this section, the measures used in the Hospital VBP Program are
focused on care provided in the inpatient setting. We do not believe it
is appropriate for a MIPS eligible clinician to use a hospital's
Hospital VBP Program performance for MIPS scoring if they did not
provide services in that setting.
Therefore, we believe establishing a different definition for
purposes of facility-based measurement is necessary to implement this
option. We also note that, since we are seeking comments above on other
programs to consider including for purposes of facility-based
measurement in future years, we believe establishing a separate
definition that could be expanded as needed for this purpose is
appropriate. We propose at Sec. 414.1380(e)(2) that a MIPS eligible
clinician is eligible for facility-based
[[Page 30126]]
measurement under MIPS if they are determined facility-based as an
individual. We propose at Sec. 414.1380(e)(2)(i) that a MIPS eligible
clinician is considered facility-based as an individual if the MIPS
eligible clinician furnishes 75 percent or more of their covered
professional services (as defined in section 1848(k)(3)(A) of the Act)
in sites of service identified by the POS codes used in the HIPAA
standard transaction as an inpatient hospital, as identified by POS
code 21, or an emergency room, as identified by POS code 23, based on
claims for a period prior to the performance period as specified by
CMS. We understand that the services of some clinicians who practice
solely in the hospital are billed using place of service codes such as
code 22, reflecting an on-campus outpatient hospital for patients who
are in observation status. Because there are limits on the length of
time a Medicare patient may be seen under observation status, we
believe that these clinicians would still furnish 75 percent or more of
their covered professional services using POS code 21, but seek comment
on whether a lower or higher threshold of inpatient services would be
appropriate. We do not propose to include POS code 22 in determining
whether a clinician is facility-based because many clinicians who bill
for services using this POS code may work on a hospital campus but in a
capacity that has little to do with the inpatient care in the hospital.
In contrast, we believe those who provide services in the emergency
room or the inpatient hospital clearly contribute to patient care that
is captured as part of the Hospital VBP Program because many patients
who are admitted are admitted through the emergency room. We seek
comments on whether POS 22 should be included in determining if a
clinician is facility-based and how we might distinguish those
clinicians who contribute to inpatient care from those who do not. We
note that the inclusion of any POS code in our definition is pending
technical feasibility to link a clinician to a facility under the
method described in section II.C.7.b.(4)(d) of this proposed rule.
We note that this more limited definition would mean that a
clinician who is determined to be facility-based likely would also be
determined to be hospital-based for purposes of the advancing care
information performance category, because this proposed definition of
facility-based is narrower than the hospital-based definition
established for that purpose. Clinicians would be determined to be
facility-based through an evaluation of covered professional services
between September 1 of the calendar year 2 years preceding the
performance period through August 31 of the calendar year preceding the
performance period with a 30-day claims run out. For example, for the
2020 MIPS payment year, where we have adopted a performance period of
CY 2018 for the quality and cost performance categories, we would use
the data available at the end of October 2017 to determine whether a
MIPS eligible clinician is considered facility-based by our definition.
At that time, those data would include Medicare claims with dates of
service between September 1, 2016 and August 31, 2017. In the event
that it is not operationally feasible to use claims from this exact
time period, we would use a 12-month period as close as practicable to
September 1 of the calendar year 2 years preceding the performance
period and August 31 of the calendar year preceding the performance
period. This determination would allow clinicians to be made aware of
their eligibility for facility-based measurement near the beginning of
the MIPS performance period. We believe that this definition allows us
to identify MIPS eligible clinicians who are significant contributors
to facilities' care for Medicare beneficiaries and other patients for
purposes of facility-based measurement.
We also recognize that in addition to the variation in the
percentage of time a clinician is present in the hospital, there is
also great variability in the types of services that clinicians
perform. Some may be responsible for overall management of patients
throughout their stay, others may perform a procedure, and others may
serve a role in supporting diagnostics. We considered whether certain
clinicians should be identified as eligible for this facility-based
measurement option based on characteristics in addition to their
percentage of covered professional services furnished in the inpatient
hospital or emergency room setting, such as by requiring a certain
specialty such as hospital medicine or by limiting eligibility to those
who served in patient-facing roles. However, we believe that all MIPS
eligible clinicians with a significant presence in the facility play a
role in the overall performance of a facility, and therefore, are not
proposing at this time to further limit this option based on
characteristics other than the percentage of covered professional
services furnished in an inpatient hospital or emergency room setting.
Additionally, we believe that allowing facility-based MIPS eligible
clinicians the most flexibility possible, while still being able to
accurately measure the value of care those clinicians provide, as we
continue implementation of the Quality Payment Program is paramount in
ensuring that clinicians understand the program and its effects on the
care they provide.
We request comments on this proposal.
(ii) Facility-Based Measurement Group Participation
We are also proposing at Sec. 414.1380(e)(2) that a MIPS eligible
clinician is eligible for facility-based measurement under MIPS if they
are determined facility-based as part of a group. We are proposing at
Sec. 414.1380(e)(2)(ii) that a facility-based group is a group in
which 75 percent or more of the MIPS eligible clinician NPIs billing
under the group's TIN are eligible for facility-based measurement as
individuals as defined in Sec. 414.1380(e)(2)(i). We also considered
an alternative proposal in which a facility-based group would be a
group where the TIN overall furnishes 75 percent or more of its covered
professional services (as defined in section 1848(k)(3)(A) of the Act)
in sites of service identified by the POS codes used in the HIPAA
standard transaction as an inpatient hospital, as identified by POS
code 21, or the emergency room, as identified by POS code 23, based on
claims for a period prior to the performance period as specified by
CMS. Groups would be determined to be facility-based through an
evaluation of covered professional services between September 1 of the
calendar year 2 years preceding the performance period through August
31 of the calendar year preceding the performance period with a 30 day
claims run out period (or if not operationally feasible to use claims
from this exact time period, a 12-month period as close as practicable
to September 1 of the calendar year 2 years preceding the performance
period and August 31 of the calendar year preceding the performance
period).
We request comments on our proposal and alternative proposal.
(d) Facility Attribution for Facility-Based Measurement
Many MIPS eligible clinicians provide services at more than one
hospital, so we must develop a method to identify which hospital's
scores should be associated with that MIPS eligible clinician under
this facility-based measurement option. We considered
[[Page 30127]]
whether a clinician should be required to identify for us the hospital
with which they were affiliated, but felt that such a requirement would
add unnecessary administrative burden in a process that we believe was
intended to reduce burden. We also considered whether we could combine
scores from multiple hospitals, but believe that such a combination
would reduce the alignment between a single hospital and a clinician or
group and could be confusing for participants. We believe we must
establish a reasonable threshold for a MIPS eligible clinician's
participation in clinical care at a given facility to allow that MIPS
eligible clinician to be scored using that facility's measures. We do
not believe it to be appropriate to allow MIPS eligible clinicians to
claim credit for facilities' measures if the MIPS eligible clinician
does not participate meaningfully in the care provided at a given
facility.
Therefore, we propose at Sec. 414.1380(e)(5) that MIPS eligible
clinicians who elect facility-based measurement would receive scores
derived from the value-based purchasing score (using the methodology
described in section II.B.7.b.4 of this proposed rule) for the facility
at which they provided services for the most Medicare beneficiaries
during the period of September 1 of the calendar year 2 years preceding
the performance period through August 31 of the calendar year preceding
the performance period with a 30 day claims run out. This mirrors our
period of determining if a clinician is eligible for facility-based
measurement and also overlaps with parts of the performance period for
the applicable Hospital VBP program measures. For the first year, the
value-based purchasing score for the facility is the FY 2019 Hospital
VBP Program's Total Performance Score. In cases in which there was an
equal number of Medicare beneficiaries treated at more than one
facility, we propose to use the value-based purchasing score from the
facility with the highest score.
(e) Election of Facility-Based Measurement
Stakeholders have expressed a strong preference that facility-based
measurement be a voluntary process, and we agree with this preference
considering our general goal in making MIPS as flexible as possible.
Therefore, we propose at Sec. 414.1380(e)(3) that individual MIPS
eligible clinicians or groups who wish to have their quality and cost
performance category scores determined based on a facility's
performance must elect to do so. We propose that those clinicians or
groups who are eligible for and wish to elect facility-based
measurement would be required to submit their election during the data
submission period as determined at Sec. 414.1325(f) through the
attestation submission mechanism established for the improvement
activities and advancing care information performance categories. If
technically feasible, we would let the MIPS eligible clinician know
that they were eligible for facility-based measurement prior to the
submission period, so that MIPS eligible clinicians would be informed
if this option is available to them.
We also considered an alternative approach of not requiring an
election process but instead automatically applying facility-based
measurement to MIPS eligible clinicians and groups who are eligible for
facility-based measurement, if technically feasible. Under this
approach, we would calculate a MIPS eligible clinician's facility-based
measurement score based on the hospital's (as identified using the
process described in section II.C.6.b. of this proposed rule)
performance using the methodology described in section II.C.7.a.2.b. of
this proposed rule, and automatically use that facility-based
measurement score for the quality and cost performance category scores
if the facility-based measurement score is higher than the quality and
cost performance category scores as determined based on data submitted
by the MIPS eligible clinician through any available reporting
mechanism. This facility-based measurement score would be calculated
even if an individual MIPS eligible clinician or group did not submit
any data for the quality performance category. This option would reduce
burden for MIPS eligible clinicians by not requiring them to elect
facility-based measurement, but is contrary to stakeholders' request
for a voluntary policy. Additionally, under this option, our
considerations about Hospital VBP Program timing would be less
applicable. That is, we explained our rationale for specifying the FY
2019 Hospital VBP Program above, in part to ensure that MIPS eligible
clinicians are informed about their potential facility-based scores
prior to the conclusion of the MIPS performance period. However, under
an automatic process, we could consider automatically using other
Hospital VBP Program years' scores. For example, we could apply FY 2020
Hospital VBP Program scores instead of FY 2019. We intend in general to
align Hospital VBP and MIPS performance periods when feasible, and the
timing considerations we described above led us to conclude that FY
2019 was the most appropriate Hospital VBP Program year for the first
year of the facility-based measurement option under MIPS, and selecting
other years would result in further divergence between the MIPS
performance period and the Hospital VBP Program's performance periods.
We are also concerned that a method that does not require active
selection may result in MIPS eligible clinicians being scored on
measures at a facility and being unaware that such scoring is taking
place. We are also concerned that such a method could provide an
advantage to those facility-based clinicians who do not submit quality
measures in comparison to those who work in other environments. We also
note that this option may not be technically feasible for us to
implement for the 2018 MIPS performance period.
We invite comments on this proposal and alternate proposal.
(e) Facility-Based Measures
For the FY 2019 program year, the Hospital VBP Program has adopted
13 quality and efficiency measures. The Hospital VBP Program currently
includes 4 domains: Person and community engagement, clinical care,
safety, and efficiency and cost reduction. These domains align with
many MIPS high priority measures (outcome, appropriate use, patient
safety, efficiency, patient experience, and care coordination measures)
in the quality performance category and the efficiency and cost
reduction domain closely aligns with our cost performance category. We
believe this set of measures covering 4 domains and composed primarily
of measures that would be considered high priority under the MIPS
quality performance category capture a broad picture of hospital-based
care. For example, the HCAHPS survey under the Hospital VBP Program is
a patient experience measure, which would make it a high-priority
measure under MIPS. Additionally, the Hospital VBP Program has adopted
several measures of clinical outcomes in the form of 30-day mortality
measures, and clinical outcomes are a high-priority topic for MIPS. The
Hospital VBP Program includes several measures in a Safety domain,
which meets our definition of patient safety measures as high-priority.
Therefore, we propose that facility-based individual MIPS eligible
clinicians or groups that are attributed to a hospital would be scored
on all the measures on which the hospital is scored for the Hospital
VBP Program via the Hospital VBP Program's Total
[[Page 30128]]
Performance Score (TPS) scoring methodology.
The Hospital VBP Program's FY 2019 measures, and their associated
performance periods, have been reproduced in Table 33 (see 81 FR 56985
and 57002).
Table 33--FY 2019 Hospital VBP Program Measures
----------------------------------------------------------------------------------------------------------------
Short name Domain/measure name NQF No. Performance period
----------------------------------------------------------------------------------------------------------------
Person and Community Engagement Domain
----------------------------------------------------------------------------------------------------------------
HCAHPS.............................. Hospital Consumer Assessment 0166 (0228) CY 2017
of Healthcare Providers and
Systems (HCAHPS) (including
Care Transition Measure).
----------------------------------------------------------------------------------------------------------------
Clinical Care Domain
----------------------------------------------------------------------------------------------------------------
MORT-30-AMI......................... Hospital 30-Day, All-Cause, 0230 July 1, 2014--June 30,
Risk-Standardized Mortality 2017
Rate (RSMR) Following Acute
Myocardial Infarction (AMI)
Hospitalization.
MORT-30-HF.......................... Hospital 30-Day, All-Cause, 0229 July 1, 2014--June 30,
Risk-Standardized Mortality 2017
Rate (RSMR) Following Heart
Failure (HF) Hospitalization.
MORT-30-PN.......................... Hospital 30-Day, All-Cause, 0468 July 1, 2014--June 30,
Risk-Standardized Mortality 2017
Rate (RSMR) Following
Pneumonia Hospitalization.
THA/TKA............................. Hospital-Level Risk- 1550 January 1, 2015--June
Standardized Complication 30, 2017
Rate (RSCR) Following
Elective Primary Total Hip
Arthroplasty (THA) and/or
Total Knee Arthroplasty
(TKA).
----------------------------------------------------------------------------------------------------------------
Safety Domain
----------------------------------------------------------------------------------------------------------------
CAUTI............................... National Healthcare Safety 0138 CY 2017
Network (NHSN) Catheter-
Associated Urinary Tract
Infection (CAUTI) Outcome
Measure.
CLABSI.............................. National Healthcare Safety 0139 CY 2017
Network (NHSN) Central Line-
Associated Bloodstream
Infection (CLABSI) Outcome
Measure.
Colon and Abdominal Hysterectomy SSI American College of Surgeons-- 0753 CY 2017
Centers for Disease Control
and Prevention (ACS-CDC)
Harmonized Procedure
Specific Surgical Site
Infection (SSI) Outcome
Measure.
MRSA Bacteremia..................... National Healthcare Safety 1716 CY 2017
Network (NHSN) Facility-wide
Inpatient Hospital-onset
Methicillin-resistant
Staphylococcus aureus (MRSA)
Bacteremia Outcome Measure.
CDI................................. National Healthcare Safety 1717 CY 2017
Network (NHSN) Facility-wide
Inpatient Hospital-onset
Clostridium difficile
Infection (CDI) Outcome
Measure.
PSI-90*............................. Patient Safety for Selected 0531 July 1, 2015--June 30
Indicators (Composite 2017
Measure).
PC-01............................... Elective Delivery............ 0469 CY 2017
----------------------------------------------------------------------------------------------------------------
Efficiency and Cost Reduction Domain
----------------------------------------------------------------------------------------------------------------
MSPB................................ Payment-Standardized Medicare 2158 CY 2017
Spending Per Beneficiary
(MSPB).
----------------------------------------------------------------------------------------------------------------
* PSI-90 has been proposed in the FY 2018 IPPS/LTCH PPS proposed rule for removal beginning with the FY 2019
program year.
We note that the Patient Safety Composite Measure (PSI-90) was
proposed for removal beginning with the FY 2019 measure set in the FY
2018 IPPS/LTCH proposed rule (82 FR 19970) due to issues with
calculating the measure score. If the proposal to remove that measure
from the hospital measure set is finalized, we would remove the measure
from the list of those adopted for facility-based measurement in the
MIPS program.
We propose at Sec. 414.1380(e)(4) that there are no data
submission requirements for the facility-based measures used to assess
performance in the quality and cost performance categories, other than
electing the option through attestation as proposed in section
II.C.7.a.(4)(e). We also refer readers to section II.C.7. of this
proposed rule for further details on how we will incorporate scoring
for facility-based measurements into MIPS.
(f) Scoring Facility-Based Measurement
(i) Hospital VBP Program Scoring
As we discuss above in subsection (b), we believe that the Hospital
VBP Program represents the most appropriate value-based purchasing
program with which to begin implementation of the facility-based
measurement option under MIPS.
Section 1886(o) of the Act, as added by section 3001(a)(1) of the
Affordable Care Act, requires the Secretary to establish a hospital
value-based purchasing program (the Hospital VBP Program) under which
value-based incentive payments are made in a fiscal year to hospitals
that meet performance standards established for a performance period
for such fiscal year. These value-based incentive payments are funded
through a reduction to participating hospitals' base-operating DRG
payment amounts, with the amount of the reduction specified by statute.
For the FY 2019 program year, that reduction will be equal to 2
percent. Participating hospitals then receive value-based incentive
payments depending on their performance on measures adopted
[[Page 30129]]
under the Program. For more detail on the statutory background and
history of the Hospital VBP Program's implementation, we refer readers
to 81 FR 56979.
As noted previously, the FY 2019 Hospital VBP Program will score
participating hospitals on 13 measures covering 4 domains of care,
although as discussed in the FY 2018 IPPS/LTCH proposed rule (82 FR
19970), we have proposed to remove the PSI 90 Patient Safety Composite
measure from the FY 2019 measure set. For each of the measures,
performance standards are established for the applicable fiscal year
that include levels of achievement and improvement. For the FY 2019
program year, the achievement threshold and benchmark are calculated
using baseline period data with respect to that fiscal year, with the
achievement threshold for each of these measures being the median of
hospital performance on the measure during the baseline period and the
benchmark for each of these measures being the arithmetic mean of the
top decile of hospital performance during the baseline period. The
achievement threshold and benchmark for the MSPB measure are calculated
using the same methodology, except that we use performance period data
instead of baseline period data in our calculations. We then calculate
hospital performance on each measure during the performance period for
which they have sufficient data and calculate a measure score based on
that performance as compared with the performance standards that apply
to the measure. For achievement scoring, those hospitals that perform
below (or above in the case of measures for which a lower rate is
better) the level of the achievement threshold are not awarded any
achievement points. Those that perform between the level of the
achievement threshold and the benchmark are awarded points based on the
relative performance of the hospital, according to formulas specified
by the Hospital VBP Program (see the Hospital Inpatient VBP Program
final rule, 76 FR 26518 through 26519). Those hospitals whose
performance meets or exceeds the benchmark are awarded 10 achievement
points for the measure. Hospitals are also provided the opportunity to
receive improvement points based on their improvement between the
baseline period for the measure and the performance period. A hospital
is awarded between 0 and 10 points for achievement and 0 and 9 points
for improvement, and is awarded the higher of the 2 scores for each
individual measure. There are no floors established for scoring and no
bonus points are available in this scoring system.
Points awarded for measures within each domain are summed to reach
the unweighted domain score. We note for the person and community
engagement domain only, the domain score consists of a base score and a
consistency score. The base score is based on the greater of
improvement or achievement points for each of the 8 HCAHPS survey
dimensions. Consistency points are awarded based on a hospital's lowest
HCAHPS dimension score during the performance period relative to
national hospital scores on that dimension during the baseline period.
The domain scores are then weighted according to domain weights
specified each Program year, then summed to reach the Total Performance
Score, which is converted to a value-based incentive payment percentage
that is used to adjust payments to each hospital for inpatient services
furnished during the applicable program year. For the FY 2019 program
year, all 4 domains will be weighted equally. We refer readers to 81 FR
57005 and 81 FR 79857 through 79858 for additional information on the
Hospital VBP Program's performance standards, as well as the QualityNet
Web site for certain technical updates to the performance standards.
(ii) Applying Hospital VBP Program Scoring to the MIPS Quality and Cost
Performance Categories
We considered several methods to incorporate facility-based
measures into scoring for the 2020 MIPS payment year, including
selecting hospitals' measure scores, domain scores, and the Hospital
VBP Program Total Performance Scores to form the basis for the cost and
quality performance category scores for individual MIPS eligible
clinicians and groups that are eligible to participate in facility-
based measurement. Although each of these approaches may have merit, we
have proposed the option that we believe provides the fairest
comparison between performance in the 2 programs and will best allow us
to expand the opportunity to other programs in the future.
Unlike MIPS, the Hospital VBP Program does not have performance
categories. There are instead four domains of measures. We considered
whether we should try to identify certain domains or measures that were
more closely aligned with those identified in the quality performance
category or the cost performance category. We also considered whether
we should limit the application of facility-based measurement to the
quality performance category and calculate the cost performance
category score as we do for other clinicians. However, we believe that
value-based purchasing programs are generally constructed to assess an
overall picture of the care provided by the facility, taking into
account both the costs and the quality of care provided. Given our
focus on alignment between quality and cost, we also do not believe it
is appropriate to measure quality on one unit (a hospital) and cost on
another (such as an individual clinician or TIN). Therefore, we propose
at Sec. 414.1380(e) that facility-based scoring is available for the
quality and cost performance categories and that the facility-based
measurement scoring standard is the MIPS scoring methodology applicable
for those who meet facility-based eligibility requirements and who
elect facility-based measurement.
(iii) Benchmarking Facility-Based Measures
Measures in the MIPS quality performance category are benchmarked
to historical performance on the basis of performance during the 12-
month calendar year that is 2 years prior to the performance period for
the MIPS payment year. If a historical benchmark cannot be established,
a benchmark is calculated during the performance period. In the cost
performance category, benchmarks are established during the performance
period because changes in payment policies year to year can make it
challenging to compare performance on cost measure year to year.
Although we propose a different performance period for MIPS eligible
clinicians in facility-based measurement, the baseline period used for
creating MIPS benchmarks is generally consistent with this approach. We
note that the Hospital VBP Program uses measures for the same fiscal
year even if those measures do not have the same performance period
length, but the baseline period closes well before the performance
period. The MSPB is benchmarked in a manner that is similar to measures
in the MIPS cost performance category. The MSPB only uses a historical
baseline period for improvement scoring and bases its achievement
threshold and benchmark solely on the performance period (81 FR 57002).
We propose at Sec. 414.1380(e)(6)(ii) that the benchmarks for
facility-based measurement are those that are adopted under the value-
based purchasing program of the facility for the year specified.
[[Page 30130]]
(iv) Assigning MIPS Performance Category Scores Based on Hospital VBP
Performance
Performance measurement in the Hospital VBP Program and MIPS is
quite different in part due to the design and the maturity of the
programs. As noted above, the Hospital VBP Program only assigns
achievement points to a hospital for its performance on a measure if
the hospital's performance during the performance period meets or
exceeds the median of hospital performance on that measure during the
applicable baseline period, whereas MIPS assigns achievement points to
all measures that meet the required data completeness and case
minimums. In addition, the Hospital VBP Program has removed many
process measures and topped out measures since its first program year
(FY 2013), while both process and topped out measures are available in
MIPS. With respect to the FY 2017 program year, for example, the median
Total Performance Score for a hospital in Hospital VBP was 33.88 out of
100 possible points. If we were to simply assign the Hospital VBP Total
Performance Score for a hospital to a clinician, the performance of
those MIPS eligible clinicians electing facility-based measurement
would likely be lower than most who participated in the MIPS program,
particularly in the quality performance category.
We believe that we should recognize relative performance in the
facility programs that reflects their different designs. Therefore, we
propose at Sec. 414.1380(e)(6)(iv) that the quality performance
category score for facility-based measurement is reached by determining
the percentile performance of the facility determined in the value-
based purchasing program for the specified year as described under
Sec. 414.1380(e)(5) and awarding a score associated with that same
percentile performance in the MIPS quality performance category score
for those clinicians who are not scored using facility-based
measurement. We also propose at Sec. 414.1380(e)(6)(v) that the cost
performance category score for facility-based measurement is
established by determining the percentile performance of the facility
determined in the value-based purchasing program for the specified year
as described in Sec. 414.1380(e)(5) and awarding the number of points
associated with that same percentile performance in the MIPS cost
performance category score for those clinicians who are not scored
using facility-based measurement. For example, if the median Hospital
VBP Program Total Performance Score was 35 out of 100 possible points
and the median quality performance category percent score in MIPS was
75 percent and the median cost performance category score was 50
percent, then a clinician or group that is evaluated based on a
hospital that received an Hospital VBP Program Total Performance Score
of 35 points would receive a score of 75 percent for the quality
performance category and 50 percent for the cost performance category.
The percentile distribution for both the Hospital VBP Program and MIPS
would be based on the distribution during the applicable performance
periods for each of the programs and not on a previous benchmark year.
We believe this proposal offers a fairer comparison of the
performance among participants in MIPS and the Hospital VBP Program
compared to other options we considered and provides an objective means
to normalize differences in measured performance between the programs.
In addition, we believe this method will make it simpler to apply the
concept of facility-based measurement to additional programs in the
future.
We welcome public comments on this proposal.
(v) Scoring Improvement for Facility-Based Measurement
The Hospital VBP Program includes a methodology for recognizing
improvement on individual measures which is then incorporated into the
total performance score for each participating hospital. A hospital's
performance on a measure is compared to a national benchmark as well as
its own performance from a corresponding baseline period.
In this proposed rule, we have proposed to consider improvement in
the quality and cost performance categories. In section II.C.7.a.(2)(i)
of this proposed rule, we propose to measure improvement in the quality
performance category based on improved achievement for the performance
category percent score and award improvement even if, under certain
circumstances, a clinician moves from one identifier to another from 1
year to the next. For those who may be measured under facility-based
measurement, improvement is already captured in the scoring method used
by the Hospital VBP Program, so we do not believe it is appropriate to
separately measure improvement using the proposed MIPS methodology.
Although the improvement methodology is not identical, a hospital that
demonstrated improvement in the individual measures would in turn
receive a higher score through the Hospital VBP Program methodology, so
that improvement is reflected in the underlying Hospital VBP Program
measurement. In addition, improvement is already captured in the
distribution of MIPS performance scores that is used to translate
Hospital VBP Total Performance Score into a MIPS quality performance
category score. Therefore, we are not proposing any additional
improvement scoring for facility-based measurement for either the
quality or cost performance category.
Because we intend to allow clinicians the flexibility to elect
facility-based measurement on an annual basis, some clinicians may be
measured through facility-based measurement in 1 year and through
another MIPS method in the next. Because the first MIPS performance
period in which a clinician could switch from facility-based
measurement to another MIPS method would be in 2019, we seek comment on
how to assess improvement for those that switch from facility-based
scoring to another MIPS method. We request comment on whether it is
appropriate to include measurement of improvement in the MIPS quality
performance category for facility-based measured clinicians and groups
given that the Hospital VBP Program already takes improvement into
account in its scoring methodology.
In section II.C.7.a.(3)(a) of this proposed rule, we discuss our
proposal to measure improvement in the cost performance category at the
measure level. We propose that clinicians under facility-based
measurement would not be eligible for a cost improvement score in the
cost performance category. As in the quality performance category, we
believe that a clinician participating in facility-based measurement in
subsequent years would already have improvement recognized as part of
the Hospital VBP Program methodology and should therefore not be given
additional credit. In addition, because we propose to limit measurement
of improvement to those MIPS eligible clinicians that participate in
MIPS using the same identifier and are scored on the same cost
measure(s) in 2 consecutive performance periods, those MIPS eligible
clinicians who elect facility-based measurement would not be eligible
for a cost improvement score in the cost performance category under our
proposed methodology because they would not be scored on the same cost
measure(s) for 2 consecutive performance periods.
[[Page 30131]]
We invite comments on these proposals.
(vi) Bonus Points for Facility-Based Measurement
MIPS eligible clinicians that report on quality measures are
eligible for bonus points for the reporting of additional outcome and
high priority measures beyond the one that is required. 2 bonus points
are awarded for each additional outcome or patient experience measure,
and one bonus point is awarded for each additional other high priority
measure. These bonus points are intended to encourage the use of
measures that are more impactful on patients and better reflect the
overall goals of the MIPS program. Many of the measures in the Hospital
VBP Program meet the criteria that we have adopted for high-priority
measures. We support measurement that takes clinicians' focus away from
clinical process measures; however, our proposed scoring method
described above is based on a percentile distribution of scores within
the quality and cost performance categories that already accounts for
bonus points. For this reason, we are not proposing to calculate
additional high priority bonus points for facility-based measurement.
We note that clinicians have an additional opportunity to receive
bonus points in the quality performance category score for using end-
to-end electronic submission of quality measures. The Hospital VBP
Program does not capture whether or not measures are reported using
end-to-end electronic reporting. In addition, our proposed facility-
based scoring method described above is based on a percentile
distribution of scores within the quality and cost performance
categories that already accounts for bonus points. For this reason, we
are not proposing to calculate additional end-to-end electronic
reporting bonus points for facility-based measurement.
We welcome public comments on our approach.
(vii) Special Rules for Facility-Based Measurement
Some hospitals do not receive a Total Performance Score in a given
year in the Hospital VBP Program, whether due to insufficient quality
measure data, failure to meet requirements under the Hospital Inpatient
Quality Reporting Program, or other reasons. In these cases, we would
be unable to calculate a facility-based score based on the hospital's
performance, and facility-based clinicians would be required to
participate in MIPS via another method. Most hospitals which do not
receive a Total Performance Score in the Hospital VBP Program are
routinely excluded, such as hospitals in Maryland. In such cases,
facility-based clinicians would know well in advance that the hospital
would not receive a Total Performance Score, and that they would need
to participate in MIPS through another method. However, we are
concerned that some facility-based clinicians may provide services in
hospitals which they expect will receive a Total Performance Score but
do not due to various rare circumstances such as natural disasters. In
section II.C.7.b.(3)(c) of this proposed rule, we propose a process for
requesting a reweighting assessment for the quality, cost and
improvement activities performance categories due to extreme and
uncontrollable circumstances, such as natural disasters. We propose
that MIPS eligible clinicians who are facility-based and affected by
extreme and uncontrollable circumstances, such as natural disasters,
may apply for reweighting.
In addition, we note that hospitals may submit correction requests
to their Total Performance Scores calculated under the Hospital VBP
Program, and may also appeal the calculations of their Total
Performance Scores, subject to Hospital VBP Program requirements
established in prior rulemaking. We intend to use the final Hospital
VBP Total Performance Score for the facility-based measurement option
under MIPS. In the event that a hospital obtains a successful
correction or appeal of its Total Performance Score, we would update
MIPS eligible clinicians' quality and cost performance category scores
accordingly, as long as the update could be made prior to the
application of the MIPS payment adjustment for the relevant MIPS
payment year. We welcome public comments on whether a different
deadline should be considered.
Additionally, although we wish to tie the hospital and clinician
performance as closely together as possible for purposes of the
facility-based scoring policy, we do not wish to disadvantage those
clinicians and groups that select this measurement method. In section
II.C.7.a.(2) of this proposed rule, we propose to retain a policy
equivalent to the 3-point floor for all measures with complete data in
the quality performance category scored against a benchmark in the 2020
MIPS payment year. However, the Hospital VBP Program does not have a
corresponding scoring floor. Therefore, we propose to adopt a floor on
the Hospital VBP Program Total Performance Score for purposes of
facility-based measurement under MIPS so that any score in the quality
performance category, once translated into the percentile distribution
described above, that would result in a score of below 30 percent would
be reset to a score of 30 percent in the quality performance category.
We believe that this adjustment is important to maintain consistency
with our other policies. There is no similar floor established for
measures in the cost performance category under MIPS, so we do not
propose any floor for the cost performance category for facility-based
measurement.
Some MIPS eligible clinicians who select facility-based measurement
could have sufficient numbers of attributed patients to meet the case
minimums for the cost measures established under MIPS. Although there
is no additional data reporting for cost measures, we believe that, to
facilitate the relationship between cost and quality measures, they
should be evaluated covering the same population as opposed to
comparing a hospital population and a population attributed to an
individual clinician or group. In addition, we believe that including
additional cost measures in the cost performance category score for
MIPS eligible clinicians who elect facility-based measurement would
reduce the alignment of incentives between the hospital and the
clinician. Thus, we are proposing at Sec. 414.1380(e)(6)(v)(A) that
MIPS eligible clinicians who elect facility-based measurement would not
be scored on other cost measures specified for the cost performance
category, even if they meet the case minimum for a cost measure.
If a clinician or a group elects facility-based measurement but
also submits quality data through another MIPS mechanism, we propose to
use the higher of the two scores for the quality performance category
and base the score of the cost performance category on the same method
(that is, if the facility-based quality performance category score is
higher, facility-based measurement is used for quality and cost). Since
this policy may result in a higher final score, it may provide
facility-based clinicians with a substantial incentive to elect
facility-based measurement, whether or not the clinician believes such
measures are the most accurate or useful measures of that clinician's
performance. Therefore, this policy may create an unfair advantage for
facility-based clinicians over non-facility-based clinicians, since
non-facility-based clinicians would not have the opportunity to use the
higher of two scores. Therefore, we seek comment on whether this
proposal to use the higher score is the best approach to score the
performance of facility-based clinicians
[[Page 30132]]
in comparison to their non-facility-based peers.
(5) Scoring the Improvement Activities Performance Category
Section 1848(q)(5)(C) of the Act specifies scoring rules for the
improvement activities performance category. For more of the statutory
background and description of the proposed and finalized policies, we
refer readers to the CY 2017 Quality Payment Program final rule (81 FR
77311 through 77319). We have also codified certain requirements for
the improvement activities performance category at Sec.
414.1380(b)(3). Based on these criteria, we finalized at Sec.
414.1380(b)(3) in the CY 2017 Quality Payment Program final rule the
scoring methodology for this category, which assigns points based on
certified patient-centered medical home participation or comparable
specialty practice participation, APM participation, and the
improvement activities reported by the MIPS eligible clinician (81 FR
77312). A MIPS eligible clinician's performance will be evaluated by
comparing the reported improvement activities to the highest possible
score (40 points). We are not proposing any changes to the scoring of
the improvement activities performance category in this proposed rule.
(a) Assigning Points to Reported Improvement Activities
We will assign points for each reported improvement activity within
2 categories: Medium-weighted and high-weighted activities. Each
medium-weighted activity is worth 10 points toward the total category
score of 40 points, and each high-weighted activity is worth 20 points
toward the total category score of 40 points. These points are doubled
for small practices, practices in rural areas, or practices located in
geographic HPSAs, and non-patient facing MIPS eligible clinicians. We
refer readers to Sec. 414.1380(b)(3) and the CY 2017 Quality Payment
Program final rule (81 FR 78312) for further detail on improvement
activities scoring.
Activities will be weighted as high based on the extent to which
they align with activities that support the certified patient-centered
medical home, since that is consistent with the standard under section
1848(q)(5)(C)(i) of the Act for achieving the highest potential score
for the improvement activities performance category, as well as with
our priorities for transforming clinical practice (81 FR 77311).
Additionally, activities that require performance of multiple actions,
such as participation in the Transforming Clinical Practice Initiative
(TCPI), participation in a MIPS eligible clinician's state Medicaid
program, or an activity identified as a public health priority (such as
emphasis on anticoagulation management or utilization of prescription
drug monitoring programs) are justifiably weighted as high (81 FR 77311
through 77312).
We refer readers to Table 26 of the CY 2017 Quality Payment Program
final rule for a summary of the previously finalized improvement
activities that are weighted as high (81 FR 77312 through 77313), and
we refer readers to Table H of the same final rule, for a list of all
the previously finalized improvement activities, both medium- and high-
weighted (81 FR 77817 through 77831). Please refer to Table F and Table
G in the appendices of this proposed rule for proposed additions and
changes to the Improvement Activities Inventory for the 2020 MIPS
payment year and future years. Activities included in these proposed
tables would apply for the 2020 MIPS payment year and future years
unless further modified via notice and comment rulemaking. Consistent
with our unified scoring system principles, we finalized in the CY 2017
Quality Payment Program final rule that MIPS eligible clinicians will
know in advance how many potential points they could receive for each
improvement activity (81 FR 77311 through 77319).
(b) Improvement Activities Performance Category Highest Potential Score
At Sec. 414.1380(b)(3), we finalized that we will require a total
of 40 points to receive the highest score for the improvement
activities performance category (81 FR 77315). For more of the
statutory background and description of the proposed and finalized
policies, we refer readers to the CY 2017 Quality Payment Program final
rule (81 FR 77314 through 77315).
For small practices, practices in rural areas and geographic HPSA
practices and non-patient facing MIPS eligible clinicians, the weight
for any activity selected is doubled so that these practices and
eligible clinicians only need to select one high- or two medium-
weighted activities to achieve the highest score of 40 points (81 FR
77312).
In accordance with section 1848(q)(5)(C)(ii) of the Act, we
codified at Sec. 414.1380(b)(3)(ix) that individual MIPS eligible
clinicians or groups who are participating in an APM (as defined in
section 1833(z)(3)(C) of the Act) for a performance period will
automatically earn at least one half of the highest potential score for
the improvement activities performance category for the performance
period. In addition, MIPS eligible clinicians that are participating in
MIPS APMs will be assigned an improvement activity score, which may be
higher than one half of the highest potential score. This assignment is
based on the extent to which the requirements of the specific model
meet the list of activities in the Improvement Activities Inventory.
For a further description of improvement activities and the APM scoring
standard for MIPS, we refer readers to the CY 2017 Quality Payment
Program final rule (81 FR 77246). For all other individual MIPS
eligible clinicians or groups, we refer readers to the scoring
requirements for individual MIPS eligible clinicians and groups in the
CY 2017 Quality Payment Program final rule (81 FR 77270). An individual
MIPS eligible clinician or group is not required to perform activities
in each improvement activities subcategory or participate in an APM to
achieve the highest potential score in accordance with section
1848(q)(5)(C)(iii) of the Act (81 FR 77178).
In the CY 2017 Quality Payment Program final rule, we also
finalized that individual MIPS eligible clinicians and groups that
successfully participate and submit data to fulfill the requirements
for the CMS Study on Improvement Activities and Measurement will
receive the highest score for the improvement activities performance
category (81 FR 77315). We refer readers to section II.C.6.e.(7) of
this proposed rule for further detail on this study.
(c) Points for Certified Patient-Centered Medical Home or Comparable
Specialty Practice
Section 1848(q)(5)(C)(i) of the Act specifies that a MIPS eligible
clinician who is in a practice that is certified as a patient-centered
medical home or comparable specialty practice for a performance period,
as determined by the Secretary, must be given the highest potential
score for the improvement activities performance category for the
performance period. Accordingly, at Sec. 414.1380(b)(3)(iv), we
specify that a MIPS eligible clinician who is in a practice that is
certified as a patient-centered medical home, including a Medicaid
Medical Home, Medical Home Model, or comparable specialty practice,
will receive the highest potential score for the improvement activities
performance category (81 FR 77196 through 77180).
We are not proposing any changes to the scoring of the patient-
centered medical home or comparable specialty
[[Page 30133]]
practice; although we are proposing a change to how groups qualify for
this activity. We refer readers to section II.C.6.e. of this proposed
rule for a discussion of the requirements for certified patient-
centered medical home practices or comparable specialty practices.
(d) Calculating the Improvement Activities Performance Category Score
In the CY 2017 Quality Payment Program final rule (81 FR 77318), we
finalized that individual MIPS eligible clinicians and groups must earn
a total of 40 points to receive the highest score for the improvement
activities performance category. To determine the improvement
activities performance category score, we sum the points for all of a
MIPS eligible clinician's reported activities and divide by the
improvement activities performance category highest potential score of
40. A perfect score will be 40 points divided by 40 possible points,
which equals 100 percent. If MIPS eligible clinicians have more than 40
improvement activities points we will cap the resulting improvement
activities performance category score at 100 percent.
Section 1848(q)(2)(B)(iii) of the Act requires the Secretary to
give consideration to the circumstances of small practices and
practices located in rural areas and in geographic HPSAs (as designated
under section 332(a)(1)(A) of the PHS Act) in defining activities.
Section 1848(q)(2)(C)(iv) of the Act also requires the Secretary to
give consideration to non-patient facing MIPS eligible clinicians.
Further, section 1848(q)(5)(F) of the Act allows the Secretary to
assign different scoring weights for measures, activities, and
performance categories, if there are not sufficient measures and
activities applicable and available to each type of eligible clinician.
Accordingly, we finalized that the following scoring applies to
MIPS eligible clinicians who are a non-patient facing MIPS eligible
clinician, a small practice (consisting of 15 or fewer professionals),
a practice located in a rural area, or practice in a geographic HPSA or
any combination thereof:
Reporting of one medium-weighted activity will result in
20 points or one-half of the highest score.
Reporting of two medium-weighted activities will result in
40 points or the highest score.
Reporting of one high-weighted activity will result in 40
points or the highest score.
The following scoring applies to MIPS eligible clinicians who are
not a non-patient facing clinician, a small practice, a practice
located in a rural area, or a practice in a geographic HPSA:
Reporting of one medium-weighted activity will result in
10 points which is one-fourth of the highest score.
Reporting of two medium-weighted activities will result in
20 points which is one-half of the highest score.
Reporting of three medium-weighted activities will result
in 30 points which is three-fourths of the highest score.
Reporting of four medium-weighted activities will result
in 40 points which is the highest score.
Reporting of one high-weighted activity will result in 20
points which is one-half of the highest score.
Reporting of two high-weighted activities will result in
40 points which is the highest score.
Reporting of a combination of medium-weighted and high-
weighted activities where the total number of points achieved are
calculated based on the number of activities selected and the weighting
assigned to that activity (number of medium-weighted activities
selected x 10 points + number of high-weighted activities selected x 20
points) (81 FR 78318).
We also finalized in the CY 2017 Quality Payment Program final rule
that certain activities in the improvement activities performance
category will also qualify for a bonus under the advancing care
information performance category (81 FR 78318). This bonus will be
calculated under the advancing care information performance category
and not under the improvement activities performance category. We refer
readers to section II.C.6.f.5.(d) of this proposed rule for further
details. For more information about our finalized improvement
activities scoring policies and for several sample scoring charts, we
refer readers to the CY 2017 Quality Payment Program final rule (81 FR
78319). Finally, in that same final rule, we codified at Sec.
414.1380(b)(3)(ix) that MIPS eligible clinicians participating in APMs
that are not certified patient-centered medical homes will
automatically earn a minimum score of one-half of the highest potential
score for the performance category, as required by section
1848(q)(5)(C)(ii) of the Act. For any other MIPS eligible clinician who
does not report at least one activity, including a MIPS eligible
clinician who does not identify to us that they are participating in a
certified patient-centered medical home or comparable specialty
practice, we will calculate a score of zero points (81 FR 77319).
(e) Self-Identification Policy for MIPS Eligible Clinicians
We also noted in the CY 2017 Quality Payment Program final rule (81
FR 77319), that individual MIPS eligible clinicians or groups
participating in APMs would not be required to self-identify as
participating in an APM, but that all MIPS eligible clinicians would be
required to self-identify if they were part of a certified patient-
centered medical home or comparable specialty practice, a non-patient
facing MIPS eligible clinician, a small practice, a practice located in
a rural area, or a practice in a geographic HPSA or any combination
thereof, and that we would validate these self-identifications as
appropriate. However, beginning with the 2018 MIPS performance period,
we are proposing to no longer require these self-identifications for a
non-patient facing MIPS eligible clinician, a small practice, a
practice located in a rural area, or a practice in a geographic HPSA or
any combination thereof because it is technically feasible for us to
identify these MIPS eligible clinicians during attestation to the
performance of improvement activities following the performance period.
We define these MIPS eligible clinicians in the CY 2017 Quality Payment
Program final rule (81 FR 77540), and they are discussed in this
proposed rule in section II.C.1. of this proposed rule. However, MIPS
eligible clinicians that are part of a certified patient-centered
medical home or comparable specialty practice are still required to
self-identify for the 2018 MIPS performance period, and we will
validate these self-identifications as appropriate. We refer readers to
section II.C.6.e.3.(c) of this proposed rule for the criteria for
recognition as a certified patient-centered medical home or comparable
specialty practice.
(6) Scoring the Advancing Care Information Performance Category
We refer readers to section II.C.6.f. of this proposed rule with
comment period, where we discuss scoring the advancing care information
performance category.
b. Calculating the Final Score
For a description of the statutory basis and our policies for
calculating the final score for MIPS eligible clinicians, we refer
readers to the discussion in the CY 2017 Quality Payment Program final
rule (81 FR 77319 through 77329) and Sec. 414.1380. In this proposed
rule, we propose to add a complex patient scoring bonus and add a small
practice bonus to the final score. In addition, we review the final
score calculation for the
[[Page 30134]]
2020 MIPS payment year and propose refinements to the reweighting
policies.
(1) Accounting for Risk Factors
Section 1848(q)(1)(G) of the Act requires us to consider risk
factors in our scoring methodology. Specifically, that section provides
that the Secretary, on an ongoing basis, shall, as the Secretary
determines appropriate and based on individuals' health status and
other risk factors, assess appropriate adjustments to quality measures,
cost measures, and other measures used under MIPS and assess and
implement appropriate adjustments to payment adjustments, final scores,
scores for performance categories, or scores for measures or activities
under the MIPS. In doing this, the Secretary is required to take into
account the relevant studies conducted under section 2(d) of the
Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014
and, as appropriate, other information, including information collected
before completion of such studies and recommendations. We refer readers
to our discussion of risk factors for the transition year of MIPS (81
FR 77320 through 77321).
In this section, we summarize our efforts related to social risk
and the relevant studies conducted under section 2(d) of the IMPACT Act
of 2014. We also propose some short-term adjustments to address patient
complexity.
(a) Considerations for Social Risk
We understand that social risk factors such as income, education,
race and ethnicity, employment, disability, community resources, and
social support (certain factors of which are also sometimes referred to
as socioeconomic status (SES) factors or socio-demographic status (SDS)
factors) play a major role in health. One of our core objectives is to
improve beneficiary outcomes, including reducing health disparities,
and we want to ensure that all beneficiaries, including those with
social risk factors, receive high quality care. In addition, we seek to
ensure that the quality of care furnished by providers and suppliers is
assessed as fairly as possible under our programs while ensuring that
beneficiaries have adequate access to excellent care.
We have been reviewing reports prepared by the Office of the
Assistant Secretary for Planning and Evaluation (ASPE) and the National
Academies of Sciences, Engineering, and Medicine on the issue of
accounting for social risk factors in CMS' value-based purchasing and
quality reporting programs, and considering options on how to address
the issue in these programs. On December 21, 2016, ASPE submitted the
first of several Reports to Congress on a study it was required to
conduct under section 2(d) of the IMPACT Act of 2014. The first study
analyzed the effects of certain social risk factors in Medicare
beneficiaries on quality measures and measures of resource use used in
one or more of nine Medicare value-based purchasing programs.\12\ The
report also included considerations for strategies to account for
social risk factors in these programs. A second report due October 2019
will expand on these initial analyses, supplemented with non-Medicare
datasets to measure social risk factors. In a January 10, 2017 report
released by the National Academies of Sciences, Engineering, and
Medicine, that body provided various potential methods for accounting
for social risk factors, including stratified public reporting.\13\
---------------------------------------------------------------------------
\12\ Office of the Assistant Secretary for Planning and
Evaluation. 2016. Report to Congress: Social Risk Factors and
Performance Under Medicare's Value-Based Purchasing Programs.
Available at https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-under-medicares-value-based-purchasing-programs.
\13\ National Academies of Sciences, Engineering, and Medicine.
2017. Accounting for social risk factors in Medicare payment.
Washington, DC: The National Academies Press.
---------------------------------------------------------------------------
As noted in the FY 2017 IPPS/LTCH PPS final rule (81 FR 56974), the
NQF has undertaken a 2-year trial period in which certain new measures
and measures undergoing maintenance, and measures endorsed with the
condition that they enter the trial period can be assessed to determine
whether risk adjustment for selected social risk factors is appropriate
for these measures. This trial entails temporarily allowing inclusion
of social risk factors in the risk-adjustment approach for these
measures. At the conclusion of the trial, NQF will issue
recommendations on the future inclusion of social risk factors in risk
adjustment for these quality measures, and we will closely review its
findings.
As we continue to consider the analyses and recommendations from
these and any future reports, and await the results of the NQF trial on
risk adjustment for quality measures, we are continuing in this
proposed rule to work with stakeholders in this process. As we have
previously communicated, we are concerned about holding providers to
different standards for the outcomes of their patients with social risk
factors because we do not want to mask potential disparities or
minimize incentives to improve the outcomes for disadvantaged
populations. Keeping this concern in mind, while we sought input on
this topic previously, we continue to seek public comment on whether we
should account for social risk factors in the MIPS, and if so, what
method or combination of methods would be most appropriate for
accounting for social risk factors in the MIPS. Examples of methods
include: Adjustment of MIPS eligible clinician scores (for example,
stratifying the scores of MIPS eligible clinicians based on the
proportion of their patients who are dual eligible); confidential
reporting of stratified measure rates to MIPS eligible clinicians;
public reporting of stratified measure results; risk adjustment of a
particular measure as appropriate based on data and evidence; and
redesigning payment incentives (for instance, rewarding improvement for
clinicians caring for patients with social risk factors or
incentivizing clinicians to achieve health equity). We are seeking
comments on whether any of these methods should be considered, and if
so, which of these methods or combination of methods would best account
for social risk factors in MIPS, if any.
In addition, we are seeking public comment on which social risk
factors might be most appropriate for stratifying measure scores and/or
potential risk adjustment of a particular measure. Examples of social
risk factors include, but are not limited to the following: Dual
eligibility/low-income subsidy; race and ethnicity; and geographic area
of residence. We are seeking comment on which of these factors,
including current data sources where this information would be
available, could be used alone or in combination, and whether other
data should be collected to better capture the effects of social risk.
We will take commenters' input into consideration as we continue to
assess the appropriateness and feasibility of accounting for social
risk factors in MIPS. We note that any such changes would be proposed
through future notice and comment rulemaking.
We look forward to working with stakeholders as we consider the
issue of accounting for social risk factors and reducing health
disparities in CMS programs. Of note, implementing any of the above
methods would be taken into consideration in the context of how this
and other CMS programs operate (for example, data submission methods,
availability of data, statistical considerations relating to
reliability of data calculations, among others), we also welcome
comment on operational considerations. CMS is committed to ensuring
that its beneficiaries have access to and receive excellent care, and
that the quality of care furnished by
[[Page 30135]]
providers and suppliers is assessed fairly in CMS programs.
(b) Complex Patient Bonus
While we work with stakeholders on these issues as we have
described, we are proposing, under the authority within section
1848(q)(1)(G) of the Act, which allows us to assess and implement
appropriate adjustments to payment adjustments, MIPS final scores,
scores for performance categories, or scores for measures or activities
under MIPS, to implement a short-term strategy for the Quality Payment
Program to address the impact patient complexity may have on final
scores. The overall goal when considering a bonus for complex patients
is two-fold: (1) To protect access to care for complex patients and
provide them with excellent care; and (2) to avoid placing MIPS
eligible clinicians who care for complex patients at a potential
disadvantage while we review the completed studies and research to
address the underlying issues. We used the term ``patient complexity''
to take into account a multitude of factors that describe and have an
impact on patient health outcomes; such factors include the health
status and medical conditions of patients, as well as social risk
factors. We believe that as the number and intensity of these factors
increase for a single patient, the patient may require more services,
more clinician focus, and more resources in order to achieve health
outcomes that are similar to those who have fewer factors. In
developing the policy for the complex patient bonus, we assessed
whether there was a MIPS performance discrepancy by patient complexity
using two well-established indicators in the Medicare program. Our
proposal is intended to address any discrepancy, without masking
performance. Because this bonus is intended to be a short-term
strategy, we are proposing the bonus only for the 2018 MIPS performance
period (2020 MIPS payment year) and will assess on an annual basis
whether to continue the bonus and how the bonus should be structured.
When considering approaches for a complex patient bonus, we
reviewed evidence to identify how indicators of patient complexity have
an impact on performance under MIPS as well as availability of data to
implement the bonus. Specifically, we identified two potential
indicators for complexity: Medical complexity as measured through
Hierarchical Condition Category (HCC) risk scores, and social risk as
measured through the proportion of patients with dual eligible status.
We identified these indicators because they are common indicators of
patient complexity in the Medicare program and the data is readily
available. As discussed below, both of these indicators have been used
in Medicare programs to account for risk and both data elements are
already publicly available for individual NPIs in the Medicare
Physician and Other Supplier Public Use File (referred to as the
Physician and Other Supplier PUF) (https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicare-provider-charge-data/physician-and-other-supplier.html). While we
recognize that these indicators are interrelated (as dual eligible
status is one of the factors included in calculation of HCC risk
scores), we intend for the sake of simplicity to implement one of these
indicators for the 2020 MIPS payment year.
We believe that average HCC risk scores are a valid proxy for
medical complexity that have been used by other CMS programs. The HCC
model was developed by CMS as a risk-adjustment model that uses
hierarchical condition categories to assign risk scores to Medicare
beneficiaries. Those scores estimate how Medicare beneficiaries' FFS
spending will compare to the overall average for the entire Medicare
population. According to the Physician and Other Supplier PUF
methodological overview, published in January of 2017,\14\ the average
risk score is set at 1.08; beneficiaries with scores greater than that
are expected to have above-average spending, and vice versa. Risk
scores are based on a beneficiary's age and sex; whether the
beneficiary is eligible for Medicaid, first qualified for Medicare on
the basis of disability, or lives in an institution (usually a nursing
home); and the beneficiary's diagnoses from the previous year. The HCC
model was designed for risk adjustment on larger populations, such as
the enrollees in an MA plan, and generates more accurate results when
used to compare groups of beneficiaries rather than individuals. For
more information on the HCC risk score, see: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html.
---------------------------------------------------------------------------
\14\ https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Medicare-Physician-and-Other-Supplier-PUF-Methodology.pdf.
---------------------------------------------------------------------------
HCC risk scores have been used in the VM to apply an additional
upward payment adjustment of +1.0x for clinicians whose attributed
patient population has an average risk score that is in the top 25
percent of all beneficiary risk scores (77 FR 69325 through 69326). CMS
proposes and announces changes to the HCC risk adjustment model as part
of the announcement of payment policies for Medicare Advantage plans
under section 1853 of the Act; the proposals and announcements are
posted at https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents.html.
A mean HCC risk score for a MIPS eligible clinician can be
calculated by averaging the HCC risk scores for the beneficiaries cared
for by the clinician. In considering options for a complex patient
bonus, we explored the use of average HCC risk scores while recognizing
that ``complexity'' is one of several drivers of that metric. We
believe that using the HCC risk score as a proxy for patient complexity
is a helpful starting point, and will explore methods for further
distinguishing complexity from other reasons a clinician could receive
a high average HCC risk score.
In addition to medical complexity, patient complexity includes
social risk factors, and we considered identifying patients dually
eligible for Medicare and Medicaid, which we believe is a proxy for
social risk factors. A ratio of beneficiaries seen by a MIPS eligible
clinician who are dual eligible can be calculated using claims data
based on the proportion of unique patients who are dually eligible for
Medicare and full- and partial-benefit Medicaid (referred to herein as
``dual eligible status'') seen by the MIPS eligible clinician during
the performance year among all unique Medicare beneficiaries seen
during the performance year. Dual eligible Medicare beneficiaries are
qualified to receive Medicare and Medicaid benefits. In the Physician
and Other Supplier PUF, beneficiaries are classified as Medicare and
Medicaid entitlement if in any month in the given calendar year they
were receiving full or partial Medicaid benefits.\15\ Dual eligibility
has been used in the Medicare Advantage 5-star methodology \16\ and
stratification by proportion of dual eligibility status is proposed for
the Hospital Readmissions Reduction Program (82 FR 19959 through
19961).
---------------------------------------------------------------------------
\15\ https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Medicare-Physician-and-Other-Supplier-PUF-Methodology.pdf.
\16\ Centers for Medicare & Medicaid Services. Medicare 2017
Part C & D Star Rating Technical Notes. Available at https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2017-Part-C-and-D-Medicare-Star-Ratings-Data-v04-04-2017-.zip.
---------------------------------------------------------------------------
[[Page 30136]]
We evaluated both indicators (average HCC risk score and proportion
dual eligible status) using the 2015 Physician and Other Supplier PUF.
We incorporated these factors into our scoring model that uses
historical PQRS data to simulate scores for MIPS eligible clinicians
including estimates for the quality, advancing care information, and
improvement activities performance categories, and the small practice
bonus that is proposed in section II.C.7.b.(1)(c) of this proposed
rule. The scoring model is described in more detail in the regulatory
impact analysis in section V.C. of this proposed rule. For HCC, we
merged the average HCC risk score by NPI with each TIN/NPI in our
population. We calculated a dual eligible ratio by taking a proportion
of dual eligible beneficiaries and divided by total beneficiaries for
each NPI. We created group level scores by taking an average of NPI
scores weighted by the number of beneficiaries. We divided clinicians
and groups into quartiles based on average HCC risk score and percent
of duals. To assess whether there was a difference in MIPS simulated
scores by these two variables, we analyzed the effect of average HCC
risk score and dual eligible ratio separately for groups and
individuals. When looking at individuals, we focused on individuals
that reported 6 or more measures (removing individuals who reported no
measures or who reported less than 6 measures). We restricted our
analysis to individuals who reported 6 or more measures because we
wanted to look at differences in performance for those who reported the
required 6 measures, rather than differences in scores due to
incomplete reporting.
We observed modest correlation between these two indicators. Using
the Physician and Other Supplier PUF (after restricting to those
clinicians that we estimate to be MIPS eligible in our scoring model
described in section V.C of this proposed rule), the correlation
coefficient for these two factors is 0.487 (some correlation is
expected due to the inclusion of dual eligible status in the HCC risk
model). The correlation between average HCC risk scores and proportion
of patients with dual eligible status indicates that while there is
overlap between these two indicators, they cannot be used
interchangeably.
We also assessed the correlation of these indicators with MIPS
final scores based on performance and the small practice bonus for MIPS
eligible clinicians, as well as variations by practice size, submission
mechanism, and specialty. Average MIPS simulated scores (prior to any
complex patient bonus) varied from 82.73 (fourth HCC quartile, highest
risk) to 87.14 (first HCC quartile, lowest risk) for group reporters,
and from 82.36 (fourth HCC quartile, highest risk) to 86.39 (first HCC
quartile, lowest risk) for individual reporters who reported 6 or more
measures (see Table 34). When reviewing average HCC risk scores by
practice size, we found that MIPS eligible clinicians in larger
practices had slightly higher risk scores than those in small practices
(average HCC risk score of 1.82 for practices with 100 or more
clinicians, compared with 1.61 for practices with 1-15 clinicians) (see
Table 35) and that the average HCC risk score varied by specialty, with
nephrology having the highest average HCC risk score (3.05) and
dermatology having the lowest (1.24). The average HCC risk score for
family medicine was 1.58 (see Table 36).
We also ranked MIPS eligible clinicians by proportion of patients
with dual eligibility (see Table 34). Performance for MIPS eligible
clinicians ranged from 82.35 in the fourth dual quartile (highest
proportion dual eligible patients) to 89.49 in the second dual quartile
(second lowest proportion dual eligible patients) for group reporters.
Performance for MIPS eligible clinicians reporting individually who
reported 6 or more measures ranged from 83.08 in the fourth dual
quartile (highest proportion dual eligible patients) to 86.80 in the
first dual quartile (lowest proportion dual eligible patients).
Table 34--MIPS Simulated Score * by HCC Risk Quartile and Dual Eligible
Ratio Quartile
------------------------------------------------------------------------
Individuals
with 6+ Group
measures **
------------------------------------------------------------------------
HCC Quartile
Quartile 1--Lowest Average HCC Risk 86.39 87.14
Score..............................
Quartile 2.......................... 84.89 88.41
Quartile 3.......................... 83.31 86.76
Quartile 4--Highest Average HCC Risk 82.36 82.73
Score..............................
Dual Eligible Ratio
Quartile 1--Lowest Proportion of 86.80 88.03
Dual Status........................
Quartile 2.......................... 83.76 89.49
Quartile 3.......................... 82.63 85.39
Quartile 4--Highest Proportion of 83.08 82.35
Dual Status........................
------------------------------------------------------------------------
* The simulated score includes estimated quality, advancing care
information, and improvement activities performance categories without
complex patient bonus. Simulated score does include small practice
bonus proposed in II.C.7.b.(1)(c) of this proposed rule.
** We restricted this column to individuals who reported 6 or more
measures to assess differences in performance for those who reported
the required 6 measures and to not consider changes due to incomplete
reporting.
Table 35--Average HCC Risk Score and Dual Eligible Ratio by Practice
Size
------------------------------------------------------------------------
Average HCC Dual eligible
Practice size risk score ratio (%)
------------------------------------------------------------------------
1-15 clinicians......................... 1.61 24.90
16-24 clinicians........................ 1.70 26.20
25-99 clinicians........................ 1.72 27.50
100 or more clinicians.................. 1.82 26.90
Total............................... 1.75 26.60
------------------------------------------------------------------------
[[Page 30137]]
Table 36--Average HCC Risk Score and Dual Eligible Ratio by Specialty
------------------------------------------------------------------------
Average HCC Dual eligible
Specialty * risk score ratio (%)
------------------------------------------------------------------------
Total................................... 1.75 26.60
Addiction Medicine...................... 1.77 37.00
Allergy/Immunology...................... 1.38 19.70
Anesthesiology.......................... 1.78 26.00
Anesthesiology Assistant................ 1.94 26.50
Cardiac Electrophysiology............... 1.85 23.20
Cardiac Surgery......................... 1.93 25.10
Cardiovascular Disease (Cardiology)..... 1.85 25.30
Certified Clinical Nurse Specialist..... 1.78 31.20
Certified Registered Nurse Anesthetist 1.77 25.50
(CRNA).................................
Chiropractic............................ 1.27 19.10
Clinic or Group Practice................ 1.57 30.60
Colorectal Surgery (Proctology)......... 1.70 22.10
Critical Care (Intensivists)............ 2.06 28.50
Dermatology............................. 1.24 11.90
Diagnostic Radiology.................... 1.78 26.50
Emergency Medicine...................... 1.94 34.10
Endocrinology........................... 1.78 24.70
Family Medicine *....................... 1.58 25.80
Gastroenterology........................ 1.70 24.20
General Practice........................ 1.60 35.80
General Surgery......................... 1.83 27.10
Geriatric Medicine...................... 1.93 29.60
Geriatric Psychiatry.................... 1.92 39.30
Gynecological Oncology.................. 1.76 24.20
Hand Surgery............................ 1.39 17.80
Hematology.............................. 1.95 25.80
Hematology-Oncology..................... 1.92 24.90
Hospice and Palliative Care............. 1.93 26.90
Infectious Disease...................... 2.35 31.60
Internal Medicine....................... 1.84 28.10
Interventional Cardiology............... 1.79 22.90
Interventional Pain Management.......... 1.50 26.90
Interventional Radiology................ 2.18 28.80
Maxillofacial Surgery................... 1.90 30.20
Medical Oncology........................ 1.94 23.50
Nephrology.............................. 3.05 33.00
Neurology............................... 1.79 27.40
Neuropsychiatry......................... 1.76 30.30
Neurosurgery............................ 1.68 24.70
Nuclear Medicine........................ 1.91 26.10
Nurse Practitioner...................... 1.78 28.60
Obstetrics & Gynecology................. 1.63 26.20
Ophthalmology........................... 1.37 18.70
Optometry............................... 1.33 24.80
Oral Surgery (Dentist only)............. 1.82 29.20
Orthopedic Surgery...................... 1.44 20.50
Osteopathic Manipulative Medicine....... 1.62 29.70
Otolaryngology.......................... 1.50 21.10
Pain Management......................... 1.57 29.50
Pathology............................... 1.71 23.70
Pediatric Medicine...................... 1.95 31.10
Peripheral Vascular Disease............. 1.83 23.10
Physical Medicine and Rehabilitation.... 1.76 27.00
Physician Assistant..................... 1.69 26.40
Physician, Sleep Medicine............... 1.70 23.20
Plastic and Reconstructive Surgery...... 1.74 23.60
Podiatry................................ 1.72 27.70
Preventive Medicine..................... 1.80 27.60
Psychiatry.............................. 1.80 39.50
Pulmonary Disease....................... 2.00 27.20
Radiation Oncology...................... 1.79 22.20
Rheumatology............................ 1.65 23.40
Sports Medicine......................... 1.54 22.70
Surgical Oncology....................... 1.92 25.10
Thoracic Surgery........................ 1.94 26.30
Urology................................. 1.56 20.30
Vascular Surgery........................ 2.22 26.80
------------------------------------------------------------------------
* Specialty descriptions as self-reported on Part B claims. Note that
all categories are mutually exclusive, including General Practice and
Family Practice. `Family Medicine' is used here for physicians listed
as `Family Practice' in Part B claims.
[[Page 30138]]
Based on our assessment of these two indicators, we generally see
high average simulated scores \17\ that are above 80 points for each
quartile based on average HCC risk score or proportion of dual status
patients (see Table 34). As discussed in II.C.8.d. of this proposed
rule, 70 points is the proposed additional performance threshold at
which MIPS eligible clinicians can receive the additional adjustment
factor for exceptional performance. However, even though the simulated
scores are high, we also generally see a very modest decrease in
simulated scores of 4.0 points (for individuals who report 6 or more
measures) and 4.4 points (for groups) from the top quartile to the
bottom quartile for the average patient HCC risk score and from 3.7
(for individuals who report 6 or more measures) and 5.7 points (for
groups) from the top quartile to the bottom quartile for dual eligible
ratio. While we are transitioning into MIPS and evolving our scoring
policies, we want to ensure safeguards and access for these vulnerable
patients; therefore, we are proposing to apply a small complex patient
bonus to final scores used for the 2020 MIPS payment year. As we stated
earlier, we intend to start with one dimension of patient complexity
for simplicity. For the 2020 MIPS payment year, we are proposing a
complex patient bonus based on the average HCC risk score because this
is the indicator that clinicians are familiar with from the VM.
---------------------------------------------------------------------------
\17\ Scores are simulated prior to any complex patient bonus.
---------------------------------------------------------------------------
We propose at Sec. 414.1380(c)(3) to add a complex patient bonus
to the final score for the 2020 MIPS payment year for MIPS eligible
clinicians that submit data (as explained below) for at least one
performance category. We propose at Sec. 414.1380(c)(3)(i) to
calculate an average HCC risk score, using the model adopted under
section 1853 of the Act for Medicare Advantage risk adjustment
purposes, for each MIPS eligible clinician or group, and to use that
average HCC risk score as the complex patient bonus. We would calculate
the average HCC risk score for a MIPS eligible clinician or group by
averaging HCC risk scores for beneficiaries cared for by the MIPS
eligible clinician or clinicians in the group during the second 12-
month segment of the eligibility period, which spans from the last 4
months of a calendar year 1 year prior to the performance period
followed by the first 8 months of the performance period in the next
calendar year (September 1, 2017 to August 31, 2018 for the 2018 MIPS
performance period) as described in section II.C.3.c. of this proposed
rule. We propose the second 12-month segment of the eligibility period
to align with other MIPS policies and to ensure we have sufficient time
to determine the necessary calculations. The second period 12-month
segment overlaps 8-months with the MIPS performance period which means
that many of the patients in our complex patient bonus would have been
cared for by the clinician, group, virtual group or APM Entity during
the MIPS performance period.
HCC risk scores for beneficiaries would be calculated based on the
calendar year immediately prior to the performance period. For the 2018
MIPS performance period, the HCC risk scores would be calculated based
on beneficiary services from the 2017 calendar year. We chose this
approach because CMS uses prior year diagnoses to set Medicare
Advantage rates prospectively every year and has employed this approach
in the VM (77 FR 69317-8). Additionally, this approach mitigates the
risk of ``upcoding'' to get higher expected costs, which could happen
if concurrent risk adjustments were incorporated. We realize using the
2017 calendar year to assess beneficiary HCC risk scores overlaps by 4-
months with the 12-month data period to identify beneficiaries (which
is September 1, 2017 to August 31, 2018 for the 2018 MIPS performance
period); however, we annually calculate the beneficiary HCC risk score
and use it for multiple purposes (like the Physician and Other Supplier
PUF).
For MIPS APMs and virtual groups, we propose at Sec.
414.1380(c)(3)(ii) to use the beneficiary weighted average HCC risk
score for all MIPS eligible clinicians, and if technically feasible,
TINs for models and virtual groups which rely on complete TIN
participation, within the APM Entity or virtual group, respectively, as
the complex patient bonus. We would calculate the weighted average by
taking the sum of the individual clinician's (or TIN's as appropriate)
average HCC risk score multiplied by the number of unique beneficiaries
cared for by the clinician and then divide by the sum of the
beneficiaries cared for by each individual clinician (or TIN as
appropriate) in the APM Entity or virtual group.
We propose at Sec. 414.1380(c)(3)(iii) that the complex patient
bonus cannot exceed 3 points. This value was selected because the
differences in performance we observed between simulated scores between
the first and fourth quartiles of average HCC risk scores was
approximately 4 points for individuals and approximately 5 points for
groups. We considered whether we should apply a set number of points to
those in a specific quartile (for example, for the highest risk
quartile only), but did not want to restrict the bonus to only certain
MIPS eligible clinicians. Rather than assign points based on quartile,
we believed that adding the average HCC risk score directly to the
final score would achieve our goal of accounting for patient complexity
without masking low performance and does provide a modest effect on the
final score. The 95th percentile of HCC values for individual
clinicians was 2.91 which we rounded to 3 for simplicity. We believe
applying this bonus to the final score is appropriate because caring
for complex and vulnerable patients can affect all aspects of a
practice and not just specific performance categories. It may also
create a small incentive to provide access to complex patients.
Finally, we propose that the MIPS eligible clinician, group,
virtual group or APM Entity must submit data on at least one measure or
activity in a performance category during the performance period to
receive the complex patient bonus. Under this proposal, MIPS eligible
clinicians would not need to meet submissions requirements for the
quality performance category in order to receive the bonus (they could
instead submit improvement activities or advancing care information
measures only or submit fewer than the required number of measures for
the quality performance category).
Based on our data analysis, we estimate that this bonus on average
would range from 1.16 points in the first quartile based on HCC risk
scores to 2.49 points in the fourth quartile for individual reporters
submitting 6 or more measures, and 1.26 points in the first quartile to
2.23 points in the fourth quartile for group reporters. For example, a
MIPS eligible clinician with a final score of 55.11 with an average HCC
risk score of 2.01 would receive a final score of 57.12. We propose in
section II.C.7.b.(2) of this proposed rule that if the result of the
calculation is greater than 100 points, then the final score would be
capped at 100 points.
We also seek comment on an alternative complex patient bonus
methodology, similarly for the 2020 MIPS payment year only. Under the
alternative, we would apply a complex patient bonus based on a ratio of
patients who are dual eligible, because we believe that dual eligible
status is a common indicator of social risk for
[[Page 30139]]
which we currently have data available. We believe the advantage of
this option is its relative simplicity and that it creates a direct
incentive to care for dual eligible patients, who are often medically
complex and have concurrent social risk factors. In addition, whereas
the HCC risk scores rely on the diagnoses a beneficiary receives which
could be impacted by variations in coding practices among clinicians,
the dual eligibility ratio is not impacted by variations in coding
practices. For this alternative option, we would calculate a dual
eligible ratio (including both full and partial Medicaid beneficiaries)
for each MIPS eligible clinician based on the proportion of unique
patients who have dual eligible status seen by the MIPS eligible
clinician among all unique patients seen during the second 12-month
segment of the eligibility period, which spans from the last 4 months
of a calendar year 1 year prior to the performance period followed by
the first 8 months of the performance period.
For MIPS APMs and virtual groups, we would use the average dual
eligible patient ratio for all MIPS eligible clinicians, and if
technically feasible, TINs for models and virtual groups which rely on
complete TIN participation, within the APM entity or virtual group,
respectively.
Under this alternative option, we would identify dual eligible
status (numerator of the ratio) using data on dual-eligibility status
sourced from the state Medicare Modernization Act (MMA) files, which
are files each state submits to CMS with monthly Medicaid eligibility
information. We would use dual-eligibility status data from the state
MMA files because it is the best available data for identifying dual
eligible beneficiaries. Under this alternative option, an individual
would be counted as a full-benefit or partial-benefit dual patient if
the beneficiary was identified as a full-benefit or partial-benefit
dual in the state MMA files at the conclusion of the second 12-month
segment of the eligibility determination period.
We would define the proportion of full benefit or partial dual
eligible beneficiaries as the proportion of dual eligible patients
among all unique Medicare patients seen by the MIPS eligible clinician
or group during the second 12-month segment of the eligibility period
which spans from the last 4 months of a calendar year prior to the
performance period followed by the first 8 months of the performance
period in the next calendar year (September 1, 2017 to August 31, 2018
for the 2018 MIPS performance period) as described in section II.C.3.c.
of this proposed rule, to identify MIPS eligible clinicians for
calculation of the complex patient bonus. This date range aligns with
the second low-volume threshold determination and also represents care
provided during the performance period.
We would propose to multiply the dual eligible ratio by 5 points to
calculate a complex patient bonus for each MIPS eligible clinician. For
example, a MIPS eligible clinician who sees 400 patients with dual
eligible status out of 1000 total Medicare patients seen during the
second 12-month segment of the eligibility period would have a complex
patient ratio of 0.4, which would be multiplied by 5 points for a
complex patient bonus of 2 points toward the final score. We believe
this approach is simple to explain and would be available to all
clinicians who care for dual eligible beneficiaries. We also believe a
complex patient bonus ranging from 1 to 5 points (with most MIPS
eligible clinicians receiving a bonus between 1 and 3 points) is
appropriate because, in our analysis, we estimated differences in
performance between the 1st and 4th quartiles of dual eligible ratios
to be approximately 3 points for individuals and approximately 6 points
for groups. A bonus of less than 5 points would help to mitigate the
impact of caring for patients with social risk factors while not
masking poor performance. Using this approach, we estimate that the
bonus would range from 0.45 (first dual quartile) to 2.42 (fourth dual
quartile) for individual reporters, and from 0.63 (first dual quartile)
to 2.19 (fourth dual quartile) for group reporters. Under this
alternative option, we would also include the complex patient bonus in
the calculation of the final score. Again, we propose in section
II.C.7.b.(2) of this proposed rule that if the result of the
calculation is greater than 100 points, then the final score would be
capped at 100 points. We seek comments on our proposed bonus for
complex patients based on average HCC risk scores, and our alternative
option using a ratio of dual eligible patients in lieu of average HCC
risk scores. We reiterate that the complex patient bonus is intended to
be a short-term solution, which we plan to revisit on an annual basis,
to incentivize clinicians to care for patients with medical complexity.
We may consider alternate adjustments in future years after methods
that more fully account for patient complexity in MIPS have been
developed. We also seek comments on alternative methods to construct a
complex patient bonus.
(c) Small Practice Bonus for the 2020 MIPS Payment Year
Eligible clinicians and groups who work in small practices are a
crucial part of the health care system. The Quality Payment Program
provides options designed to make it easier for these MIPS eligible
clinicians and groups to report on performance and quality and
participate in advanced alternative payment models for incentives. We
have heard directly from clinicians in small practices that they face
unique challenges related to financial and other resources,
environmental factors, and access to health information technology. We
heard from many commenters that the Quality Payment Program advantages
large organizations because such organizations have more resources
invested in the infrastructure required to track and report measures to
MIPS. Based on our scoring model, which is described in the regulatory
impact analysis in section V.C. of this proposed rule, practices with
more than 100 clinicians may perform better in the Quality Payment
Program, on average compared to smaller practices. We believe this
trend is due primarily to two factors: Participation rates and
submission mechanism. Based on the most recent PQRS data available,
practices with 100 or more MIPS eligible clinicians have participated
in the PQRS at a higher rate than small practices (99.4 percent
compared to 69.7 percent, respectively). As we indicate in our
regulatory impact analysis in section V.C. of this proposed rule, we
believe participation rates based only on historic 2015 quality data
submitted under PQRS significantly underestimate the expected
participation in MIPS particularly for small practices. Therefore, we
have modeled the regulatory impact analysis using minimum participation
assumptions of 80 percent and 90 percent participation for each
practice size category (1-15 clinicians, 16-24 clinicians, 25-99
clinicians, and 100 or more clinicians). However, even with these
enhanced participation assumptions, MIPS eligible clinicians in small
practices would have lower participation than MIPS eligible clinicians
in larger practices as 80 or 90 percent participation is still much
lower than the 99.4 percent participation for MIPS eligible clinicians
in practices with 100 or more clinicians.
In addition, practices with 100 or more MIPS eligible clinicians
are more likely to report as a group, rather than individually, which
reduces burden to individuals within those practices due
[[Page 30140]]
to the unified nature of group reporting. Specifically, 63.1 percent of
practices with 100 or more MIPS eligible clinicians are reporting via
CMS Web Interface (either through the Shared Savings Program or as a
group practice) compared to 20.5 percent of small practices (the CMS
Web Interface reporting mechanism is only available to small practices
participating in the Shared Saving Program or Next Generation ACO
Model.) \18\
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\18\ Groups must have at least 25 clinicians to participate in
Web Interface.
---------------------------------------------------------------------------
These two factors have financial implications based on the MIPS
scoring model described in section V.C. of this proposed rule. Looking
at the combined impact performance, we see consistent trends for small
practices in various scenarios. A combined impact of performance
measurement looks at the aggregate net percent change (the combined
impact of MIPS negative and positive adjustments in the final score).
In analyzing the combined impact performance, we see MIPS eligible
clinicians in small practices consistently have a lower combined impact
performance than larger practices based on actual historical data and
after we apply the 80 and 90 percent participation assumptions.
Due to these challenges, we believe an adjustment to the final
score for MIPS eligible clinicians in small practices (referred to
herein as the ``small practice bonus'') is appropriate to recognize
these barriers and to incentivize MIPS eligible clinicians in small
practices to participate in the Quality Payment Program and to overcome
any performance discrepancy due to practice size. To receive the small
practice bonus, we propose that the MIPS eligible clinician must
participate in the program by submitting data on at least one
performance category in the 2018 MIPS performance period. Therefore,
MIPS eligible clinicians would not need to meet submission requirements
for the quality performance category in order to receive the bonus
(they could instead submit improvement activities or advancing care
information measures only or submit fewer than the required number of
measures for the quality performance category). Additionally, we
propose that group practices, virtual groups, or APM Entities that
consist of a total of 15 or fewer clinicians may receive the small
practice bonus.
We propose at Sec. 414.1380(c)(4) to add a small practice bonus of
five points to the final score for MIPS eligible clinicians who
participate in MIPS for the 2018 MIPS performance period and are in
small practices or virtual groups or APM entities with 15 or fewer
clinicians (the entire virtual group or APM entity combined must
include 15 or fewer clinicians to qualify for the bonus). We believe a
bonus of 5 points is appropriate to acknowledge the challenges small
practices face in participating in MIPS, and to help them achieve the
performance threshold proposed at section II.C.8.c. of this proposed
rule at 15 points for the 2020 MIPS payment year, as this bonus
represents one-third of the total points needed to meet or exceed the
performance threshold and receive a neutral to positive payment
adjustment. With a small practice bonus of 5 points, small practices
could achieve this performance threshold by reporting 2 quality
measures or 1 quality measure and 1 improvement activity.\19\ We
believe that a higher bonus (for example, a bonus that would meet or
exceed the performance threshold) is not ideal because it might
discourage small practices from actively participating in MIPS or could
mask poor performance. We propose in section II.C.7.b.(2) of this
proposed rule that if the result of the calculation is greater than 100
points, then the final score would be capped at 100 points.
---------------------------------------------------------------------------
\19\ Assuming the small practice did not submit advancing care
information and applied for the hardship exception and had the
advancing care information performance category weight redistributed
to quality, the small practice would have a final score with 85
percent weight from the quality performance category score and 15
percent from improvement activities. With the proposed scoring for
small practices, submitting one measure one time would provide at
least 3 measure achievement points out of 60 total available measure
points. With 85 percent quality performance category weight, each
quality measure would be worth at least 4.25 point towards the final
score. ((3/60) x 85% x 100= 4.25 points). For improvement
activities, each medium weighted activity is worth 20 out of 40
possible points which translates to 7.5 points to the file score.
(20/40) x 15% x 100 = 7.5 points).
---------------------------------------------------------------------------
This bonus is intended to be a short-term strategy to help small
practices transition to MIPS, therefore, we are proposing the bonus
only for the 2018 MIPS performance period (2020 MIPS payment year) and
will assess on an annual basis whether to continue the bonus and how
the bonus should be structured.
We are inviting public comment on our proposal to apply a small
practice bonus for the 2020 MIPS payment year.
We also considered applying a bonus for MIPS eligible clinicians
that practice in either a small practice or a rural area. However, on
average, we saw less than a one point difference between scores for
MIPS eligible clinicians who practice in rural areas and those who do
not. Therefore, we are not proposing to extend the final score bonus to
those who practice in a rural area, but plan to continue to monitor the
Quality Payment Program's impacts on the performance of those who
practice in rural areas. We also seek comment on the application of a
rural bonus in the future, including available evidence demonstrating
differences in clinician performance based on rural status. If we
implement a bonus for practices located in rural areas, we would use
the definition for rural specified in section II.C.1. of this proposed
rule for individuals and groups (including virtual groups).
(2) Final Score Calculation
With the proposed addition of the complex patient and small
practice bonuses, we propose to use the formula at Sec. 414.1380(c) to
calculate the final score for all MIPS eligible clinicians, groups,
virtual groups, and MIPS APMs starting with the 2020 MIPS payment year.
We propose to revise the final score calculation at Sec.
414.1380(c) to reflect this updated formula. We also propose to revise
the policy finalized in the CY 2017 Quality Payment Program final rule
to assign MIPS eligible clinicians with only 1 scored performance
category a final score that is equal to the performance threshold (81
FR 77326 through 77328) (we note that we inadvertently failed to codify
this policy in Sec. 414.1380(c)). We are proposing this revision to
the policy to account for our proposal in section II.C.7.b.(3)(c) of
this proposed rule for extreme and uncontrollable circumstances which,
if finalized, could result in a scenario where a MIPS eligible
clinician is not scored on any performance categories. To reflect this
proposal, we propose to add to Sec. 414.1380(c) that a MIPS eligible
clinician with fewer than 2 performance category scores would receive a
final score equal to the performance threshold.
With the proposed addition of the complex patient and small
practice bonuses, we also propose to strike the following phrase from
the final score definition at Sec. 414.1305: ``The final score is the
sum of each of the products of each performance category score and each
performance category's assigned weight, multiplied by 100.'' We believe
this portion of the definition would be incorrect and redundant of the
proposed revised regulation at Sec. 414.1380(c).
We invite public comment on the proposed final score methodology
and associated revisions to regulation text.
[[Page 30141]]
(3) Final Score Performance Category Weights
(a) General Weights
Section 1848(q)(5)(E)(i) of the Act specifies weights for the
performance categories included in the MIPS final score: In general, 30
percent for the quality performance category, 30 percent for the cost
performance category, 25 percent for the advancing care information
performance category, and 15 percent for the improvement activities
performance category. However, that section also specifies different
weightings for the quality and cost performance categories for the
first and second years for which the MIPS applies to payments. Section
1848(q)(5)(E)(i)(II)(bb) of the Act specifies that for the transition
year, not more than 10 percent of the final score will be based on the
cost performance category, and for the 2020 MIPS payment year, not more
than 15 percent will be based on the cost performance category. Under
section 1848(q)(5)(E)(i)(I)(bb) of the Act, the weight of the quality
performance category for each of the first 2 years will increase by the
difference of 30 percent minus the weight specified for the cost
performance category for the year.
In the CY 2017 Quality Payment Program final rule, we established
the weights of the cost performance category as 10 percent of the final
score (81 FR 77166) and the quality performance category as 50 percent
of the final score (81 FR 77100) for the 2020 MIPS payment year.
However, we are proposing in section II.C.6.d. of this proposed rule to
change the weight of the cost performance category to zero percent and
in section II.C.6.b. of this proposed rule to change the weight of the
quality performance category to 60 percent for the 2020 MIPS payment
year. We refer readers to sections II.C.6.b. and II.C.6.d. of this
proposed rule for further information on the policies related to the
weight of the quality and cost performance categories, including our
rationale for our proposed weighting for each category.
As specified in section 1848(q)(5)(E)(i) of the Act, the weights
for the other performance categories are 25 percent for the advancing
care information performance category and 15 percent for the
improvement activities performance category. Section 1848(q)(5)(E)(ii)
of the Act provides that in any year in which the Secretary estimates
that the proportion of eligible professionals (as defined in section
1848(o)(5) of the Act) who are meaningful EHR users (as determined in
section 1848(o)(2) of the Act) is 75 percent or greater, the Secretary
may reduce the applicable percentage weight of the advancing care
information performance category in the final score, but not below 15
percent. For more on our policies concerning section 1848(q)(5)(E)(ii)
of the Act and a review of our proposal for reweighting the advancing
care information performance category in the event that the proportion
of MIPS eligible clinicians who are meaningful EHR users is 75 percent
or greater starting with the 2019 MIPS performance period, we refer
readers to section II.C.6.f.(5) of this proposed rule.
Table 37 summarizes the weights specified for each performance
category under section 1848(q)(5)(E)(i) of the Act and in accordance
with our policies in the CY 2017 Quality Payment Program final rule as
codified at Sec. Sec. 414.1380(c)(1), 414.1330(b), 414.1350(b),
414.1355(b), and 414.1375(a), and with our proposals in section II.C.6.
of this proposed rule.
Table 37--Finalized and Proposed Weights by MIPS Performance Category *
----------------------------------------------------------------------------------------------------------------
2020 MIPS payment 2021 MIPS payment
Performance category Transition year year (proposed) year and beyond
(final) (%) (%) (final) (%)
----------------------------------------------------------------------------------------------------------------
Quality............................................. 60 60 30
Cost................................................ 0 0 30
Improvement Activities.............................. 15 15 15
Advancing Care Information**........................ 25 25 25
----------------------------------------------------------------------------------------------------------------
* In sections II.C.6.b. and II.C.6.c., we propose to maintain the same weights from the transition year for the
2020 MIPS payment year for quality and cost (60 percent and zero percent, respectively).
**[hairsp]As described in section II.C.6.f. of this proposed rule, the weight for advancing care information
could decrease (not below 15 percent) starting with the 2021 MIPS payment year if the Secretary estimates that
the proportion of physicians who are meaningful EHR users is 75 percent or greater.
(b) Flexibility for Weighting Performance Categories
Under section 1848(q)(5)(F) of the Act, if there are not sufficient
measures and activities applicable and available to each type of MIPS
eligible clinician involved, the Secretary shall assign different
scoring weights (including a weight of zero) for each performance
category based on the extent to which the category is applicable and
for each measure and activity based on the extent to which the measure
or activity is applicable and available to the type of MIPS eligible
clinician involved. For the 2020 MIPS payment year, we propose to
assign a scoring weight of zero percent to a performance category and
redistribute its weight to the other performance categories in the
following scenarios.
For the quality performance category, we propose that having
sufficient measures applicable and available means that we can
calculate a quality performance category percent score for the MIPS
eligible clinician because at least one quality measure is applicable
and available to the MIPS eligible clinician. Based on the volume of
measures available to MIPS eligible clinicians via the multiple
submission mechanisms, we generally believe there will be at least one
quality measure applicable and available to every MIPS eligible
clinician. Given that we generally believe there will be at least one
quality measure applicable and available to every MIPS eligible
clinician, if we receive no quality performance category submission
from a MIPS eligible clinician, the MIPS eligible clinician generally
will receive a performance category score of zero (or slightly above
zero if the all-cause hospital readmission measure applies because the
clinician submits data for a performance category other than the
quality performance category).\20\
[[Page 30142]]
However, as described in section II.C.7.a.(2)(e) of this proposed rule,
there may be rare instances that we believe could affect only a very
limited subset of MIPS eligible clinicians (as well as groups and
virtual groups) that may have no quality measures available and
applicable and for whom we receive no quality performance category
submission (and for whom the all-cause hospital readmission measure
does not apply). In those instances, we would not be able to calculate
a quality performance category percent score.
---------------------------------------------------------------------------
\20\ As discussed in the CY 2017 Quality Payment Program final
rule (81 FR 77300), groups of 16 or more eligible clinicians that
meet the applicable case minimum requirement are automatically
scored on the all-cause readmission measure, even if they do not
submit any other data under the quality performance category,
provided that they submit data under one of the other performance
categories. If such groups do not submit data under any performance
category, the readmission measure is not scored.
---------------------------------------------------------------------------
The proposed quality performance category scoring policies for the
2020 MIPS payment year continue many of the special scoring policies
from the transition year which would enable us to determine a quality
performance category percent score whenever a MIPS eligible clinician
has submitted at least 1 quality measure. In addition, MIPS eligible
clinicians that do not submit quality measures when they have them
available and applicable would receive a quality performance category
percent score of zero percent. It is only in the rare scenarios when we
determine that a MIPS eligible clinician does not have any relevant
quality measures available to report or the MIPS eligible clinician is
approved for reweighting the quality performance category based on
extreme and uncontrollable circumstances as proposed in section
II.C.7.b.(3)(c) of this proposed rule, that we would reweight the
quality performance category. Therefore, we continue to believe that we
will not be able to calculate a score for the quality performance
category only in the rare scenarios when a MIPS eligible clinician does
not have any relevant quality measures available to report.
For the cost performance category, we continue to believe that
having sufficient measures applicable and available means that we can
reliably calculate a score for the cost measures that adequately
captures and reflects the performance of a MIPS eligible clinician, and
that MIPS eligible clinicians who are not attributed enough cases to be
reliably measured should not be scored for the cost performance
category (81 FR 77322 through 77323). We established a policy that if a
MIPS eligible clinician is not attributed a sufficient number of cases
for a measure (in other words, has not met the required case minimum
for the measure), or if a measure does not have a benchmark, then the
measure will not be scored for that clinician (81 FR 77323). If we do
not score any cost measures for a MIPS eligible clinician in accordance
with this policy, then the clinician would not receive a cost
performance category percent score. Because we have proposed in section
II.C.6.d. of this proposed rule to set the weight of the cost
performance category to zero percent of the final score for the 2020
MIPS payment year, we are not proposing to redistribute the weight of
the cost performance category to any other performance categories for
the 2020 MIPS payment year. In the event we do not finalize this
proposal, we are proposing to redistribute the weight of the cost
performance category as described in section II.C.7.b.(3)(d) of this
proposed rule.
For the improvement activities performance category, we believe
that all MIPS eligible clinicians will have sufficient activities
applicable and available; however, as discussed in section
II.C.7.b.(3)(c) of this proposed rule, we believe there are limited
extreme and uncontrollable circumstances, such as natural disasters,
where a clinician is unable to report improvement activities. Barring
these circumstances, we are not proposing any changes that would affect
our ability to calculate an improvement activities performance category
score.
We refer readers to section II.C.6.f. of this proposed rule for a
detailed discussion of our proposals and policies under which we would
not score the advancing care information performance category and would
assign a weight of zero percent to that category for a MIPS eligible
clinician.
We invite public comment on our interpretation of sufficient
measures available and applicable in the performance categories.
(c) Extreme and Uncontrollable Circumstances
In the CY 2017 Quality Payment Program final rule (81 FR 77241
through 77243), we discussed our belief that extreme and uncontrollable
circumstances, such as a natural disaster in which an EHR or practice
location is destroyed, can happen at any time and are outside a MIPS
eligible clinician's control. We stated that if a MIPS eligible
clinician's CEHRT is unavailable as a result of such circumstances,
then the measures specified for the advancing care information
performance category may not be available for the MIPS eligible
clinician to report. We established a policy allowing a MIPS eligible
clinician affected by extreme and uncontrollable circumstances to
submit an application to us to be considered for reweighting of the
advancing care information performance category under section
1848(q)(5)(F) of the Act. Although we are proposing in section
II.C.6.f. of this proposed rule to use the authority in the last
sentence of section 1848(o)(2)(D) of the Act, as amended by section
4002(b)(1)(B) of the 21st Century Cures Act, as the authority for this
policy, rather than section 1848(q)(5)(F) of the Act, we continue to
believe that extreme and uncontrollable circumstances could affect the
availability of a MIPS eligible clinician's CEHRT and the measures
specified for the advancing care information performance category.
While we did not propose or finalize a similar reweighting policy
for other performance categories in the transition year, we believe a
similar reweighting policy may be appropriate for the quality, cost,
and improvement activities performance categories beginning with the
2020 MIPS payment year. For these performance categories, we propose to
define ``extreme and uncontrollable circumstances'' as rare (that is,
highly unlikely to occur in a given year) events entirely outside the
control of the clinician and of the facility in which the clinician
practices that cause the MIPS eligible clinician to not be able to
collect information that the clinician would submit for a performance
category or to submit information that would be used to score a
performance category for an extended period of time (for example, 3
months could be considered an extended period of time with regard to
information a clinician would collect for the quality performance
category). For example, a tornado or fire destroying the only facility
in which a clinician practices likely would be considered an ``extreme
and uncontrollable circumstance;'' however, neither the inability to
renew a lease--even a long or extended lease--nor a facility being
found not compliant with federal, state, or local building codes or
other requirements would be considered ``extreme and uncontrollable
circumstances.'' We propose that we would review both the circumstances
and the timing independently to assess the availability and
applicability of measures and activities independently for each
performance category. For example, in 2018 the performance period for
improvement activities is only 90 days, whereas it is 12 months for the
quality performance category, so an issue lasting 3 months may have
more impact on the availability of measures for the quality performance
category than for the improvement activities performance category,
because
[[Page 30143]]
the MIPS eligible clinician, conceivably, could participate in
improvement activities for a different 90-day period.
We believe that extreme and uncontrollable circumstances, such as
natural disasters, may affect a clinician's ability to access or submit
quality measures via all submission mechanisms (effectively rendering
the measures unavailable to the clinician) as well as the availability
of numerous improvement activities. In addition, damage to a facility
where care is provided due to a natural disaster, such as a hurricane,
could result in practice management and clinical systems that are used
for the collection or submission of data to be down, thus impacting a
clinician's ability to submit necessary information via Qualified
Registry, QCDR, CMS Web Interface, or claims. This policy would not
include issues that third party intermediaries, such as EHRs, Qualified
Registries, or QCDRs, might have submitting information to MIPS on
behalf of a MIPS eligible clinician. Instead, this policy is geared
towards events, such as natural disasters, that affect the MIPS
eligible clinician's ability to submit data to the third party
intermediary, which in turn, could affect the ability of the clinician
(or the third party intermediary acting on their behalf) to
successfully submit measures and activities to MIPS.
We also propose to use this policy for measures which we derive
from claims data, such as the all-cause hospital readmission measure
and the cost measures. Other programs, such as the Hospital VBP
Program, allow hospitals to submit exception applications when ``a
hospital is able to continue to report data on measures . . . but can
demonstrate that its Hospital VBP Program measure rates are negatively
impacted as a result of a natural disaster or other extraordinary
circumstance and, as a result, the hospital receives a lower value-
based incentive payment'' (78 FR 50705). For the Hospital VBP Program,
we ``interpret[ed] the minimum numbers of cases and measures
requirement in the Act to enable us to not score . . . all applicable
quality measure data from a performance period and, thus, exclude the
hospital from the Hospital VBP Program for a fiscal year during which
the hospital has experienced a disaster or other extraordinary
circumstance'' (78 FR 50705). Hospitals that request and are granted an
exception are exempted from the Program entirely for the applicable
year.
For the 2020 MIPS payment year, we would score quality measures and
assign points even for those clinicians who do not meet the case
minimums for the quality measures they submit. However, we established
a policy not to score a cost measure unless a MIPS eligible clinician
has met the required case minimum for the measure (81 FR 77323), and
not to score administrative claims measures, such as the all-cause
hospital readmission measure, if they cannot be reliably scored against
a benchmark (81 FR 77288 through 77289). Even if the required case
minimums have been met and we are able to reliably calculate scores for
the measures that are derived from claims, we believe a MIPS eligible
clinician's performance on those measures could be adversely impacted
by a natural disaster or other extraordinary circumstance, similar to
the issues we identified for the Hospital VBP Program. For example, the
claims data used to calculate the cost measures or the all-cause
hospital readmission measure could be significantly affected if a
natural disaster caused wide-spread injury or health problems for the
community, which could not have been prevented by high-value
healthcare. In such cases, we believe that the measures are available
to the clinician, but are likely not applicable, because the extreme
and uncontrollable circumstance has disrupted practice and measurement
processes. Therefore, we believe an approach similar to Hospital VBP
Program is warranted under MIPS, and we are proposing that we would
exempt a MIPS eligible clinician from all quality and cost measures
calculated from administrative claims data if the clinician is granted
an exception for the respective performance categories based on extreme
and uncontrollable circumstances.
Beginning with the 2020 MIPS payment year, we propose that we would
reweight the quality, cost, and/or improvement activities performance
categories if a MIPS eligible clinician, group, or virtual group's
request for a reweighting assessment based on extreme and
uncontrollable circumstances is granted. We propose that MIPS eligible
clinicians could request a reweighting assessment if they believe
extreme and uncontrollable circumstances affect the availability and
applicability of measures for the quality, cost, and improvement
activities performance categories. To the extent possible, we would
seek to align the requirements for submitting a reweighting assessment
for extreme and uncontrollable circumstances with the requirements for
requesting a significant hardship exception for the advancing care
information performance category. For example, we propose to adopt the
same deadline (December 31, 2018 for the 2018 MIPS performance period)
for submission of a reweighting assessment (see section II.C.6.f. of
this proposed rule), and we would encourage the requests to be
submitted on a rolling basis. We propose the reweighting assessment
must include the nature of the extreme and uncontrollable circumstance,
including the type of event, date of the event, and length of time over
which the event took place, performance categories impacted, and other
pertinent details that impacted the ability to report on measures or
activities to be considered for reweighting of the quality, cost, or
improvement activities performance categories (for example, information
detailing how exactly the event impacted availability and applicability
of measures). If we finalize the policy to allow reweighting based on
extreme and uncontrollable circumstances beginning with the 2020 MIPS
payment year, we would specify the form and manner in which these
reweighting applications must be submitted outside of the rulemaking
process after the final rule is published.
For virtual groups, we propose to ask the virtual group to submit a
reweighting assessment for extreme and uncontrollable circumstances
similar to groups, and we would evaluate whether sufficient measures
and activities are applicable and available to the majority of TINs in
the virtual group. We are proposing that a majority of TINs in the
virtual group would need to be impacted before we grant an exception.
We still find it important to measure the performance of virtual group
members unaffected by an extreme and uncontrollable circumstance even
if some of the virtual group's TINs are affected.
We also seek comment on what additional factors we should consider
for virtual groups. This reweighting assessment due to extreme and
uncontrollable circumstances for the quality, cost, and improvement
activities would not be available to APM Entities in the APM scoring
standard for the following reasons. First, all MIPS eligible clinicians
scored under the APM scoring standard will automatically receive an
improvement activities category score based on the terms of their
participation in a MIPS APM and need not report anything for this
performance category. Second, the cost performance category has no
weight under the APM scoring standard. Finally, for the quality
performance category, each MIPS APM has its own rules related to
quality measures and we believe any decisions related to
[[Page 30144]]
availability and applicability of measures should reside within the
model. As noted in II.C.6.g.(2)(d) of this proposed rule, MIPS APM
entities would be able to request reweighting of the advancing care
information performance category.
If we finalize these proposals for reweighting the quality, cost,
and improvement activities performance categories based on extreme and
uncontrollable circumstances, then it would be possible that one or
more of these performance categories would not be scored and would be
weighted at zero percent of the final score for a MIPS eligible
clinician. We propose to assign a final score equal to the performance
threshold if fewer than two performance categories are scored for a
MIPS eligible clinician. This is consistent with our policy finalized
in the CY 2017 Quality Payment Program final rule that because the
final score is a composite score, we believe the intention of section
1848(q)(5) of the Act is for MIPS eligible clinicians to be scored
based on multiple performance categories (81 FR 77326 through 77328).
We request comment on our extreme and uncontrollable circumstances
proposals. We also seek comment on the types of the extreme and
uncontrollable circumstances we should consider for this policy given
the general parameters we describe in this section.
(d) Redistributing Performance Category Weights
In the CY 2017 Quality Payment Program final rule, we codified at
Sec. 414.1380(c)(2) that we will assign different scoring weights for
the performance categories if we determine there are not sufficient
measures and activities applicable and available to MIPS eligible
clinicians (81 FR 77327). We also finalized a policy to assign MIPS
eligible clinicians with only one scored performance category a final
score that is equal to the performance threshold, which means the
clinician would receive a MIPS payment adjustment factor of zero
percent for the year (81 FR 77326 through 77328). We are proposing in
section II.C.7.b.(2) of this proposed rule to refine this policy such
that a MIPS eligible clinician with fewer than 2 performance category
scores would receive a final score equal to the performance threshold.
This refinement is to account for our proposal in section
II.C.7.b.(3)(c) of this proposed rule for extreme and uncontrollable
circumstances which, if finalized, could result in a scenario where a
MIPS eligible clinician is not scored on any performance categories. We
refer readers to the CY 2017 Quality Payment Program final rule for a
description of our policies for redistributing the weights of the
performance categories (81 FR 77325 through 77329). For the 2020 MIPS
payment year, we propose to redistribute the weights of the performance
categories in a manner that is similar to the transition year. However,
we are also proposing new scoring policies to incorporate our proposals
for extreme and uncontrollable circumstances.
In section II.C.6.f. of this proposed rule, we are proposing to use
the authority in the last sentence of section 1848(o)(2)(D) of the Act,
as amended by section 4002(b)(1)(B) of the 21st Century Cures Act, as
the authority for certain policies under which we would assign a
scoring weight of zero percent for the advancing care information
performance category, and to amend Sec. 414.1380(c)(2) to reflect our
proposals. We are not, however, proposing substantive changes to the
policy established in the CY 2017 Quality Payment Program final rule to
redistribute the weight of the advancing care information performance
category to the other performance categories for the transition year
(81 FR 77325 through 77329).
For the 2020 MIPS payment year, if we assign a weight of zero
percent for the advancing care information performance category for a
MIPS eligible clinician, we propose to continue our policy from the
transition year and redistribute the weight of the advancing care
information performance category to the quality performance category
(assuming the quality performance category does not qualify for
reweighting). We believe redistributing the weight of the advancing
care information performance category to the quality performance
category (rather than redistributing to both the quality and
improvement activities performance categories) is appropriate because
MIPS eligible clinicians have more experience reporting quality
measures through the PQRS program, and measurement in this performance
category is more mature.
If we do not finalize our proposal at section II.C.6.d. of this
proposed rule to weight the cost performance category at zero percent
(which means the weight of the cost performance category is greater
than zero percent), then we propose to not redistribute the weight of
any other performance categories to the cost performance category. We
believe this is consistent with our policy of introducing cost
measurement in a deliberate fashion and recognition that clinicians are
more familiar with other elements of MIPS. In the rare and unlikely
scenario where a MIPS eligible clinician qualifies for reweighting of
the quality performance category percent score (because there are not
sufficient quality measures applicable and available to the clinician
or the clinician is facing extreme and uncontrollable circumstances)
and the MIPS eligible clinician is eligible to have the advancing care
information performance category reweighted to zero and the MIPS
eligible clinician has sufficient cost measures applicable and
available to have a cost performance category percent score that is not
reweighted, then we would redistribute the weight of the quality and
advancing care information performance categories to the improvement
activities performance category and would not redistribute the weight
to the cost performance category. If we finalize the cost performance
category weight at zero percent for the 2020 MIPS payment year, then we
would set the final score at the performance threshold because the
final score would be based on improvement activities which would not be
a composite of two or more performance category scores.
For the 2020 MIPS payment year, if we do not finalize the proposal
to set the cost performance category a zero percent weight, and if a
MIPS eligible clinician does not receive a cost performance category
percent score because there are not sufficient cost measures applicable
and available to the clinician or the clinician is facing extreme and
uncontrollable circumstances, we propose to redistribute the weight of
the cost performance category to the quality performance category. In
the rare scenarios where a MIPS eligible clinician does not receive a
quality performance category percent score because there are not
sufficient quality measures applicable and available to the clinician
or the clinician is facing extreme and uncontrollable circumstances, we
propose to redistribute the weight of the cost performance category
equally to the remaining performance categories that are not
reweighted.
In the rare event a MIPS eligible clinician is not scored on at
least one measure in the quality performance category because there are
not sufficient measures applicable and available or the clinician is
facing extreme and uncontrollable circumstances, we propose for the
2020 MIPS payment year to continue our policy from the transition year
and redistribute the 60 percent weight of the quality performance
category so that the performance category weights are 50
[[Page 30145]]
percent for the advancing care information performance category and 50
percent for the improvement activities performance category (assuming
these performance categories do not qualify for reweighting). While
clinicians have more experience reporting advancing care information
measures, we believe equal weighting to both the improvement activities
and advancing care information is appropriate for simplicity.
Additionally, in the absence of quality measures, we believe increasing
the relative weight of the improvement activities performance category
is appropriate because both improvement activities and advancing care
information have elements of quality and care improvement which are
important to emphasize. Should the cost performance category have
available and applicable measures and the cost performance category
weight is not zero, but either the improvement activities or advancing
care information performance category is reweighted to zero percent,
then we would redistribute the weight of the quality performance
category to the remaining performance category that is not weighted at
zero percent. We would not redistribute the weight to the cost
performance category.
We believe that all MIPS eligible clinicians will have sufficient
improvement activities applicable and available. It is possible that a
MIPS eligible clinician might face extreme and uncontrollable
circumstances that render the improvement activities not applicable or
available to the clinician; however, in that scenario, we believe it is
likely that the measures specified for the other performance categories
also would not be applicable or available to the clinician based on the
circumstances. In the rare event that the improvement activities
performance category would qualify for reweighting based on extreme and
uncontrollable circumstances, and the other performance categories
would not also qualify for reweighting, we propose to redistribute the
improvement activities performance category weight to the quality
performance category consistent with the redistribution policies for
the cost and advancing care information performance categories. Should
the cost performance category have available and applicable measures
and the cost performance category weight is not finalized at zero
percent, and the quality performance category is reweighted to zero
percent, then we would redistribute the weight of the improvement
activities performance category to the advancing care information
performance category.
Table 38 summarizes the potential reweighting scenarios based on
our proposals for the 2020 MIPS payment year should the cost
performance category be weighted at zero percent.
Table 38--Proposed Performance Category Redistribution Policies for the 2020 MIPS Payment Year if the Cost
Performance Category Weight Is Zero Percent
----------------------------------------------------------------------------------------------------------------
Reweight Reweight
scenario if no Reweight scenario if no
Weighting for advancing care scenario if no improvement
Performance category the 2020 MIPS information quality activities
payment year performance performance performance
(%) category score category category score
(%) percent score (%)
----------------------------------------------------------------------------------------------------------------
Quality......................................... 60 85 0 75
Cost............................................ 0 0 0 0
Improvement Activities.......................... 15 15 50 0
Advancing Care Information...................... 25 0 50 25
----------------------------------------------------------------------------------------------------------------
In response to our final policy to redistribute the advancing care
information performance category weight solely to the quality
performance category in the CY 2017 Quality Payment Program final rule
(81 FR 77327), we received some comments expressing concern that this
would place undue emphasis on the quality performance category.
Commenters expressed the belief that this policy would particularly
affect non-patient facing MIPS eligible clinicians who have limited
available measures, and would limit the ability to fairly compare
different specialties that are reweighted differently. One reason for
the discrepancy is that MIPS eligible clinicians that submit data to
the advancing care information performance category can readily achieve
a base score of 50 percent if they meet the requirements for the base
score measures, whereas the quality performance category does not start
at the same base. Commenters also expressed the belief that specialties
with few quality measures available to them will be unfairly impacted
by this reweighting policy, by putting a disproportionate weight on
just a few quality measures. Commenters suggested we redistribute the
weight of the advancing care information performance category to the
improvement activities performance category because the improvement
activities performance category allows for the most flexibility. One
commenter recommended redistributing the weight of the advancing care
information performance category to both the quality and improvement
activities performance categories.
We continue to have concerns about increasing the weight of the
improvement activities performance category, given that this
performance category is based on attestation only and is not connected
to a predecessor CMS program like the other MIPS performance
categories. However, based on the comments we received, we considered
an alternative approach for the 2020 MIPS payment year to redistribute
the weight of the advancing care information performance category to
the quality and improvement activities performance categories, to
minimize the impact of the quality performance category on the final
score. For this approach, we would redistribute 15 percent to the
quality performance category (60 percent + 15 percent = 75 percent) and
10 percent to the improvement activities performance category (15
percent + 10 percent = 25 percent). We considered redistributing the
weight of the advancing care information performance category equally
to the quality and improvement activities performance categories.
However, for simplicity, we wanted to redistribute the weights in
increments of 5 points. Because MIPS eligible clinicians have more
experience reporting quality measures and because these measures are
more mature, under
[[Page 30146]]
this alternative option, we would redistribute slightly more to the
quality performance category (15 percent vs. 10 percent). Should the
cost performance category have available and applicable measures and
the cost performance category weight is not finalized at zero percent
and the quality performance category is reweighted to zero percent,
then we would redistribute the weight of the advancing care information
performance category to the improvement activities performance
category. This alternative approach, assuming the cost performance
category weight is zero percent is detailed in Table 39.
Table 39--Alternative Option for Reweighting the Advancing Care
Information Performance Category for the 2020 MIPS Payment Year if the
Cost Performance Category Weight Is Zero Percent
------------------------------------------------------------------------
Reweight
scenario if no
Weighting for advancing care
Performance category the 2020 MIPS information
payment year performance
(%) category score
(%)
------------------------------------------------------------------------
Quality............................... 60 75
Cost.................................. 0 0
Improvement Activities................ 15 25
Advancing Care Information............ 25 0
------------------------------------------------------------------------
We invite comments on our proposal for weighting the performance
categories for the 2020 MIPS payment year and our alternative option
for reweighting the advancing care information performance category.
8. MIPS Payment Adjustments
a. Payment Adjustment Identifier and Final Score Used in Payment
Adjustment Calculation
(1) Payment Adjustment Identifier
For purposes of applying the MIPS payment adjustment under section
1848(q)(6)(E) of the Act, we finalized a policy in the CY 2017 Quality
Payment Program final rule to use a single identifier, TIN/NPI, for all
MIPS eligible clinicians, regardless of whether the TIN/NPI was
measured as an individual, group or APM Entity group (81 FR 77329
through 77330). In other words, a TIN/NPI may receive a final score
based on individual, group, or APM Entity group performance, but the
MIPS payment adjustment would be applied at the TIN/NPI level.
We are not proposing any changes to the MIPS payment adjustment
identifier.
(2) Final Score Used in Payment Adjustment Calculation
In CY 2017 Quality Payment Program final rule (81 FR 77330 through
77332), we finalized a policy to use a TIN/NPI's historical performance
from the performance period associated with the MIPS payment
adjustment. We also proposed the following policies, and, although we
received public comments on them and responded to those comments, we
inadvertently failed to state that we were finalizing these policies,
although it was our intention to do so. Thus, we clarify that the
following final policies apply beginning with the transition year. For
groups submitting data using the TIN identifier, we will apply the
group final score to all the TIN/NPI combinations that bill under that
TIN during the performance period. For individual MIPS eligible
clinicians submitting data using TIN/NPI, we will use the final score
associated with the TIN/NPI that is used during the performance period.
For eligible clinicians in MIPS APMs, we will assign the APM Entity
group's final score to all the APM Entity Participant Identifiers that
are associated with the APM Entity. For eligible clinicians that
participate in APMs for which the APM scoring standard does not apply,
we will assign a final score using either the individual or group data
submission assignments.
In the case where a MIPS eligible clinician starts working in a new
practice or otherwise establishes a new TIN that did not exist during
the performance period, there would be no corresponding historical
performance information or final score for the new TIN/NPI. In cases
where there is no final score associated with a TIN/NPI from the
performance period, we will use the NPI's performance for the TIN(s)
the NPI was billing under during the performance period. If the MIPS
eligible clinician has only one final score associated with the NPI
from the performance period, then we will use that final score. In the
event that an NPI bills under multiple TINs in the performance period
and bills under a new TIN in the MIPS payment year, we finalized a
policy of taking the highest final score associated with that NPI in
the performance period (81 FR 77332).
In some cases, a TIN/NPI could have more than one final score
associated with it from the performance period, if the MIPS eligible
clinician submitted duplicative data sets. In this situation, the MIPS
eligible clinician has not changed practices; rather, for example, a
MIPS eligible clinician has a final score for an APM Entity and a final
score for a group TIN. If a MIPS eligible clinician has multiple final
scores, the following hierarchy will apply. If a MIPS eligible
clinician is a participant in MIPS APM, then the APM Entity final score
would be used instead of any other final score. If a MIPS eligible
clinician has more than one APM Entity final score, we will apply the
highest APM Entity final score to the MIPS eligible clinician. If a
MIPS eligible clinician reports as a group and as an individual and not
as an APM Entity, we will calculate a final score for the group and
individual identifier and use the highest final score for the TIN/NPI
(81 FR 77332).
For a further description of our policies, we refer readers to the
CY 2017 Quality Payment Program final rule (81 FR 77330 through 77332).
In addition to the above policies from the CY 2017 Quality Payment
Program final rule, beginning with the 2020 MIPS payment year, we are
proposing to modify the policies to address the addition of virtual
groups. Section 1848(q)(5)(I)(i) of the Act provides that MIPS eligible
clinicians electing to be a virtual group must: (1) Have their
performance assessed for the quality and cost performance categories in
a manner that applies the combined performance of all the MIPS eligible
clinicians in the virtual group to each MIPS eligible clinician in the
virtual group for the applicable performance period; and (2) be scored
for the quality
[[Page 30147]]
and cost performance categories based on such assessment. Therefore,
when identifying a final score for payment adjustments, we must
prioritize a virtual group final score over other final scores such as
individual and group scores. Because we also wish to encourage movement
towards APMs, we will prioritize using the APM Entity final score over
any other score for a TIN/NPI, including a TIN/NPI that is in a virtual
group. If a TIN/NPI is in both a virtual group and a MIPS APM, we
propose to use the waiver authority for Innovation Center models under
section 1115A(d)(1) of the Act and the Shared Savings Program waiver
authority under section 1899(f) of the Act to waive section
1848(q)(5)(I)(i)(I) and (II) of the Act. As discussed in section
II.C.4.h. of this proposed rule, the use of waiver authority is to
avoid creating competing incentives between MIPS and the APM. We want
MIPS eligible clinicians to focus on the requirements of the APM to
ensure that the models produce valid results that are not confounded by
the incentives created by MIPS.
We also propose to modify our hierarchy to state that if a MIPS
eligible clinician is not in an APM Entity and is in a virtual group,
the MIPS eligible clinician would receive the virtual group final score
over any other final score. Our policies remain unchanged for TIN/NPIs
who are not in an APM Entity or virtual group.
We invite public comment on our proposals.
Table 40 illustrates the previously finalized and newly proposed
policies for determining which final score to use when more than one
final score is associated with a TIN/NPI.
Table 40--Hierarchy for Final Score When More Than One Final Score Is
Associated With a TIN/NPI
------------------------------------------------------------------------
Final score used to determine
Example payment adjustments
------------------------------------------------------------------------
TIN/NPI has more than one APM Entity The highest of the APM Entity
final score. final scores.
TIN/NPI has an APM Entity final score APM Entity final score.
that is not a virtual group score and
also has a group final score.
TIN/NPI has an APM Entity final score APM Entity final score.
and also has a virtual group score.
TIN/NPI has a virtual group score and Virtual group score.
an individual final score.
TIN/NPI has a group final score and an The highest of the group or
individual final score, but no APM individual final score.
Entity final score and is not in a
virtual group.
------------------------------------------------------------------------
Table 41 illustrates the previously finalized policies that apply
if there is no final score associated with a TIN/NPI from the
performance period, such as when a MIPS eligible clinician starts
working in a new practice or otherwise establishes a new TIN.
Table 41--No Final Score Associated With a TIN/NPI
------------------------------------------------------------------------
Final score
Performance TIN/NPI billing used to
MIPS eligible period final in MIPS payment determine
clinician (NPI 1) score year (yes/no) payment
adjustments
------------------------------------------------------------------------
TIN A/NPI 1.......... 90............. Yes (NPI 1 is 90 (Final score
still billing for TIN A/NPI
under TIN A in 1 from the
the MIPS performance
payment year). period).
TIN B/NPI 1.......... 70............. No (NPI 1 has n/a (no claims
left TIN B and are billed
no longer under TIN B/
bills under NPI 1).
TIN B in the
MIPS payment
year).
TIN C/NPI 1.......... n/a (NPI 1 was Yes (NPI 1 has 90 (No final
not part of joined TIN C score for TIN
TIN C during and is billing C/NPI 1, so
the under TIN C in use the
performance the MIPS highest final
period). payment year). score
associated
with NPI 1
from the
performance
period).
------------------------------------------------------------------------
b. MIPS Payment Adjustment Factors
For a description of the statutory background and further
description of our policies, we refer readers to the CY 2017 Quality
Payment Program final rule (81 FR 77332 through 77333).
We are not proposing any changes to these policies.
c. Establishing the Performance Threshold
Under section 1848(q)(6)(D)(i) of the Act, for each year of the
MIPS, the Secretary shall compute a performance threshold with respect
to which the final scores of MIPS eligible clinicians are compared for
purposes of determining the MIPS payment adjustment factors under
section 1848(q)(6)(A) of the Act for a year. The performance threshold
for a year must be either the mean or median (as selected by the
Secretary, and which may be reassessed every 3 years) of the final
scores for all MIPS eligible clinicians for a prior period specified by
the Secretary. Section 1848(q)(6)(D)(iii) of the Act outlines a special
rule for the initial 2 years of MIPS, which requires the Secretary,
prior to the performance period for such years, to establish a
performance threshold for purposes of determining the MIPS payment
adjustment factors under section 1848(q)(6)(A) of the Act and an
additional performance threshold for purposes of determining the
additional MIPS payment adjustment factors under section 1848(q)(6)(C)
of the Act, each of which shall be based on a period prior to the
performance period and take into account data available for performance
on measures and activities that may be used under the performance
categories and other factors determined appropriate by the Secretary.
We codified the term performance threshold at Sec. 414.1305 as the
numerical threshold for a MIPS payment year against which the final
scores of MIPS eligible clinicians are compared to determine the MIPS
payment adjustment factors. We codified at Sec. 414.1405(b) that a
performance threshold will be specified for each MIPS payment year. We
refer readers to the CY 2017 Quality Payment Program final rule for
further discussion
[[Page 30148]]
of the performance threshold (81 FR 77333 through 77338). In accordance
with the special rule set forth in section 1848(q)(6)(D)(iii) of the
Act, we finalized a performance threshold of 3 points for the
transition year (81 FR 77334 through 77338).
Our goal was to encourage participation and provide an opportunity
for MIPS eligible clinicians to become familiar with the MIPS Program.
We determined that it would have been inappropriate to set a
performance threshold that would result in downward adjustments to
payments for many clinicians who may not have had time to prepare
adequately to succeed under MIPS. By providing a pathway for many
clinicians to succeed under MIPS, we believed that we would encourage
early participation in the program, which may enable more robust and
thorough engagement with the program over time. We set the performance
threshold at a low number to provide MIPS eligible clinicians an
opportunity to achieve a minimum level of success under the program,
while gaining experience with reporting on the measures and activities
and becoming familiar with other program policies and requirements. We
believed if we set the threshold too high, using a new formula that is
unfamiliar and confusing to clinicians, many could be discouraged from
participating in the first year of the program, which may lead to lower
participation rates in future years. Additionally, we believed this
flexibility is particularly important to reduce the burden for MIPS
eligible clinicians in small or solo practices. We believed that active
participation of MIPS eligible clinicians in MIPS will improve the
overall quality, cost, and care coordination of services provided to
Medicare beneficiaries. In accordance with section 1848(q)(6)(D)(iii)
of the Act, we took into account available data regarding performance
on measures and activities, as well as other factors we determined
appropriate. We refer readers to 81 FR 77333 through 77338 for details
on our analysis. We also stated our intent to increase the performance
threshold in the 2020 MIPS payment year, and that, beginning in the
2021 MIPS payment year, we will use the mean or median final score from
a prior period as required by section 1848(q)(6)(D)(i) of the Act (81
FR 77338).
For the 2020 MIPS payment year, we again want to use the
flexibility provided in section 1848(q)(6)(D)(iii) to help transition
MIPS eligible clinicians to the 2021 MIPS payment year, when the
performance threshold will be the mean or median of the final scores
for all MIPS eligible clinicians from a prior period. We want to
encourage continued participation and the collection of meaningful data
by MIPS eligible clinicians. A higher performance threshold would help
MIPS eligible clinicians strive to achieve more complete reporting and
better performance and prepare MIPS eligible clinicians for the 2021
MIPS payment year. However, a performance threshold set too high could
also create a performance barrier, particularly for MIPS eligible
clinicians who did not previously participate in PQRS or the EHR
Incentive Programs. We have heard from stakeholders requesting that we
continue a low performance threshold and from stakeholders requesting
that we ramp up the performance threshold to help MIPS eligible
clinicians prepare for the 2021 MIPS payment year and to meaningfully
incentivize higher performance. Given our desire to provide a
meaningful ramp between the transition year's 3-point performance
threshold and the 2021 MIPS payment year performance threshold using
the mean or median of the final scores for all MIPS eligible clinicians
for a prior period, we are proposing to set the performance threshold
at 15 points for the 2020 MIPS payment year.
We propose a performance threshold of 15 points because it
represents a meaningful increase in performance threshold, compared to
3 points in the transition year, while maintaining flexibility for MIPS
eligible clinicians in the pathways available to achieve this
performance threshold. For example, submitting the maximum number of
improvement activities could qualify for a score for 15 points (40 out
40 possible points for the improvement activity which is worth 15
percent of the final score). The performance threshold could also be
met by full participation in the quality performance category: By
submitting all required measures with the necessary data completeness,
MIPS eligible clinicians would earn at least a quality performance
category percent score of 30 percent (which is 3 measure achievement
points out of 10 measure points for each required measure).
If the quality performance category is weighted at 60 percent, then
the quality performance category would be 30 percent x 60 percent x 100
which equals 18 points toward the final score and exceeds the
performance threshold. Finally, a MIPS eligible clinician could achieve
a final score of 15 points through an advancing care information
performance category score of 60 percent or higher (60 percent
advancing care information performance category score x 25 percent for
the advancing care information performance category weight x 100 equals
15 points towards the final score). We refer readers to section
II.C.8.g.(2) of this proposed rule for complete examples of how MIPS
eligible clinician could exceed the performance threshold. We believe
the proposed performance threshold would mitigate concerns from MIPS
eligible clinicians about participating in the program for the second
year. However, we remain concerned that moving from a performance
threshold of 15 points for the 2020 MIPS payment year to a performance
threshold of the mean or median of the final scores for all MIPS
eligible clinicians for a prior period for the 2021 MIPS payment year
may be a steep jump.
By the 2021 MIPS payment year, MIPS eligible clinicians would
likely need to submit most of the required information and perform well
on the measures and activities to receive a positive MIPS payment
adjustment. Therefore, we also seek comment on setting the performance
threshold either lower or higher than the proposed 15 points for the
2020 MIPS payment year. A performance threshold lower than the proposed
15 points for the 2020 MIPS payment year presents the potential for a
significant increase in the final score a MIPS eligible clinician must
earn to meet the performance threshold in the 2021 MIPS payment year,
as well as providing for a potentially smaller total amount of negative
MIPS payment adjustments upon which the total amount of the positive
MIPS payment adjustments would depend due to the budget neutrality
requirement under section 1848(q)(6)(F)(ii) of the Act. A performance
threshold higher than the proposed 15 points would increase the final
score required to receive a neutral MIPS payment adjustment, which may
be particularly challenging for small practices, even with the proposed
addition of the small practice bonus. A higher performance threshold
would also allow for potentially higher positive MIPS payment
adjustments for those who exceed the performance threshold.
We considered an alternative of setting a performance threshold of
6 points, which could be met by submitting two quality measures with
required data completeness or one high-weighted improvement activity.
While this lower performance threshold may provide a sharp increase to
the required performance threshold in MIPS payment year 2021 (the mean
or median of the final scores for all MIPS eligible clinicians for a
prior period), it would continue to reward clinicians for participation
in MIPS as they transition into the program.
[[Page 30149]]
We also considered an alternative of setting the performance
threshold at 33 points, which would require full participation both in
improvement activities and in the quality performance category (either
for a small group or for a large group that meets data completeness
standards) to meet the performance threshold. Such a threshold would
make the step to the required mean or median performance threshold in
MIPS payment year 2021 less steep, but could present further challenges
to clinicians who have not previously participated in legacy quality
reporting programs.
As required by section 1848(q)(6)(D)(iii) of the Act, for the
purposes of determining the performance threshold, we considered data
available for performance on measures and activities that may be used
under the MIPS performance categories. Specifically, we updated our
scoring model using 2019 MIPS payment year eligibility data from the
initial 12-month period to identify potential MIPS eligible clinicians
who are physicians (doctors of medicine, doctors of osteopathy,
chiropractors, dentists, optometrists, and podiatrists), nurse
practitioners, physician assistants, certified registered nurse
anesthetists, and clinical nurse specialists, and who exceeded the low-
volume threshold. We estimated newly enrolled Medicare clinicians who
would be excluded from MIPS by using clinicians (identified by NPI)
that have Part B charges in the eligibility file, but no Part B charges
in 2015. To exclude QPs from our scoring model, we used a preliminary
version of the file used for the predictive qualifying Alternative
Payment Model participants analysis made available on qpp.cms.gov on
June 2, 2017 and prepared using claims for services between January 1,
2016 through August 31, 2016. We assumed that all partial QPs would
participate in MIPS and included them in our scoring model.
We used 2014 and 2015 PQRS and 2015 VM data to estimate scores for
the quality performance category, using the published benchmarks for
the 2017 MIPS performance period. We used 2015 and 2016 Medicare and
Medicaid EHR Incentive files to estimate advancing care information
performance category scores. We also modeled an improvement activities
performance category score using assumptions based on prior PQRS and
EHR Incentive Program participation. We did not model any cost measures
as we proposed in section II.C.6.d.(2) of this proposed rule to weight
the cost performance category at zero percent. We refer readers to the
regulatory impact analysis in section V.C. of this proposed rule for a
detailed description of our scoring model and data sources.
Using 2015 PQRS data, we determined which of these MIPS eligible
clinicians participated in PQRS and estimated participation rates for
the MIPS quality performance category based on PQRS participation,
which is the performance category that accounts for the largest share
(a minimum of 60 percent) of the 2020 MIPS payment year final score. We
noted that 92.4 percent of the estimated MIPS eligible clinicians
submitted data to PQRS, but the participation rate was lower for MIPS
eligible clinicians in small practices at 69.7 percent. While we
believe many of the policies in this proposed rule and the technical
assistance for small practices would help increase participation, we
believe it is important to keep the performance threshold low so that
these small practices can learn to participate and perform well in MIPS
for future years without excessive financial risk.
We invite public comments on the proposal to set the performance
threshold at 15 points, and also seek comment on setting the
performance threshold at the alternative of 6 points or at 33 points
for the 2020 MIPS payment year.
We also seek public comments on principles and considerations for
setting the performance threshold beginning with the 2021 MIPS payment
year, which will be the mean or median of the final scores for all MIPS
eligible clinicians from a prior period.
d. Additional Performance Threshold for Exceptional Performance
Section 1848(q)(6)(D)(ii) of the Act requires the Secretary to
compute, for each year of the MIPS, an additional performance threshold
for purposes of determining the additional MIPS payment adjustment
factors for exceptional performance under paragraph (C). For each such
year, the Secretary shall apply either of the following methods for
computing the additional performance threshold: (1) The threshold shall
be the score that is equal to the 25th percentile of the range of
possible final scores above the performance threshold determined under
section 1848(q)(6)(D)(i) of the Act; or (2) the threshold shall be the
score that is equal to the 25th percentile of the actual final scores
for MIPS eligible clinicians with final scores at or above the
performance threshold for the prior period described in section
1848(q)(6)(D)(i) of the Act.
We codified at Sec. 414.1305 the definition of additional
performance threshold as the numerical threshold for a MIPS payment
year against which the final scores of MIPS eligible clinicians are
compared to determine the additional MIPS payment adjustment factors
for exceptional performance. We also codified at Sec. 414.1405(d) that
an additional performance threshold will be specified for each of the
MIPS payment years 2019 through 2024. We refer readers to the CY 2017
Quality Payment Program final rule for further discussion of the
additional performance threshold (81 FR 77338 through 77339).
Based on the special rule for the initial 2 years of MIPS in
section 1848(q)(6)(D)(iii) of the Act, for the transition year, we
decoupled the additional performance threshold from the performance
threshold and established the additional performance threshold at 70
points. We selected a 70-point numerical value for the additional
performance threshold, in part, because it would require a MIPS
eligible clinician to submit data for and perform well on more than one
performance category (except in the event the advancing care
information performance category is reweighted to zero percent and the
weight is redistributed to the quality performance category making the
quality performance category worth 85 percent of the final score).
Under section 1848(q)(6)(C) of the Act, a MIPS eligible clinician with
a final score at or above the additional performance threshold will
receive an additional MIPS payment adjustment factor and may share in
the $500,000,000 available for the year under section 1848(q)(6)(F)(iv)
of the Act. We believed these additional incentives should only be
available to those clinicians with very high performance on the MIPS
measures and activities. We took into account the data available and
the modeling described in section II.E.7.c.(1) of the CY 2017 Quality
Payment Program final rule in selecting the additional performance
threshold for the transition year (81 FR 77338 through 77339).
As we discussed in section II.C.8.c. of this proposed rule, we are
relying on the special rule under section 1848(q)(6)(D)(iii) of the Act
to establish the performance threshold at 15 points for 2020 MIPS
payment year. We are proposing to again decouple the additional
performance threshold from the performance threshold. Because we do not
have actual MIPS final scores for a prior performance period, if we do
not decouple the additional performance threshold from the performance
threshold, then we would have to set the additional performance
threshold at
[[Page 30150]]
the 25th percentile of possible final scores above the performance
threshold. With a performance threshold set at 15 points, the range of
total possible points above the performance threshold is 16 to 100
points. The 25th percentile of that range is 36.25 points, which is
barely more than one third of the possible 100 points in the MIPS final
score. We do not believe it would be appropriate to lower the
additional performance threshold to 36.25 points, as we do not believe
a final score of 36.25 points demonstrates exceptional performance by a
MIPS eligible clinician. We believe these additional incentives should
only be available to those clinicians with very high performance on the
MIPS measures and activities. Therefore, we are relying on the special
rule under section 1848(q)(6)(D)(iii) of the Act to set the additional
performance threshold at 70 points for the 2020 MIPS payment year,
which is higher than the 25th percentile of the range of the possible
final scores above the performance threshold.
We took into account the data available and the modeling described
in section II.C.8.c. of this proposed rule to estimate final scores for
the 2020 MIPS payment year. We believe 70 points is appropriate because
it requires a MIPS eligible clinician to submit data for and perform
well on more than one performance category (except in the event the
advancing care information measures are not applicable and available to
a MIPS eligible clinician). Generally, a MIPS eligible clinician could
receive a maximum score of 60 points for the quality performance
category, which is below the 70-point additional performance threshold.
In addition, 70 points is at a high enough level that MIPS eligible
clinicians must submit data for the quality performance category to
achieve this target. For example, if a MIPS eligible clinician gets a
perfect score for the improvement activities and advancing care
information performance categories, but does not submit quality
measures data, then the MIPS eligible clinician would only receive 40
points (0 points for quality + 15 points for improvement activities +
25 points for advancing care information), which is below the
additional performance threshold. We believe the additional performance
threshold at 70 points maintains the incentive for excellent
performance while keeping the focus on quality performance. Finally, we
believe keeping the additional performance threshold at 70 points
maintains consistency with the 2019 MIPS payment year which helps to
simplify the overall MIPS framework.
We invite public comment on these proposals. We also seek feedback
on whether we should raise the additional performance threshold to a
higher number which would in many instances require the use of an EHR
for those to whom the advancing care information performance category
requirements would apply. In addition, a higher additional performance
threshold would incentivize better performance and would also allow
MIPS eligible clinicians to receive a higher additional MIPS payment
adjustment.
We also seek public comment on which method we should use to
compute the additional performance threshold beginning with the 2021
MIPS payment year. Section 1848(q)(6)(D)(ii) of the Act requires the
additional performance threshold to be the score that is equal to the
25th percentile of the range of possible final scores above the
performance threshold for the year, or the score that is equal to the
25th percentile of the actual final scores for MIPS eligible clinicians
with final scores at or above the performance threshold for the prior
period described in section 1848(q)(6)(D)(i) of the Act. For example,
should we use the lower of the two options, which would result in more
MIPS eligible clinicians receiving an additional MIPS payment
adjustment for exceptional performance? Or should we use the higher of
the options, which would restrict the additional MIPS payment
adjustment for exceptional performance to those with the higher final
scores? Since a fixed amount is available for a year under section
1848(q)(6)(F)(iv) of the Act to fund the additional MIPS payment
adjustments, the more clinicians that receive an additional MIPS
payment adjustment, the lower the average clinician's additional MIPS
payment adjustment will be.
e. Scaling/Budget Neutrality
We codified at Sec. 414.1405(b)(3) that a scaling factor not to
exceed 3.0 may be applied to positive MIPS payment adjustment factors
to ensure budget neutrality such that the estimated increase in
aggregate allowed charges resulting from the application of the
positive MIPS payment adjustment factors for the MIPS payment year
equals the estimated decrease in aggregate allowed charges resulting
from the application of negative MIPS payment adjustment factors for
the MIPS payment year. We refer readers to the CY 2017 Quality Payment
Program final rule for further discussion of budget neutrality (81 FR
77339).
We are not proposing any changes to the scaling and budget
neutrality requirements as they are applied to MIPS payment adjustment
factors in this proposed rule.
f. Additional Adjustment Factors
We refer readers to the CY 2017 Quality Payment Program final rule
for further discussion of the additional MIPS payment adjustment factor
(81 FR 77339 through 77340). We are not proposing any changes to
determine the additional MIPS payment adjustment factors.
g. Application of the MIPS Payment Adjustment Factors
(1) Application to the Medicare Paid Amount
Section 1848(q)(6)(E) of the Act provides that for items and
services furnished by a MIPS eligible clinician during a year
(beginning with 2019), the amount otherwise paid under Part B for such
items and services and MIPS eligible clinician for such year, shall be
multiplied by 1 plus the sum of the MIPS payment adjustment factor
determined under section 1848(q)(6)(A) of the Act divided by 100, and
as applicable, the additional MIPS payment adjustment factor determined
under section 1848(q)(6)(C) of the Act divided by 100.
We codified at Sec. 414.1405(e) the application of the MIPS
payment adjustment factors. For each MIPS payment year, the MIPS
payment adjustment factor, and if applicable the additional MIPS
payment adjustment factor, are applied to Medicare Part B payments for
items and services furnished by the MIPS eligible clinician during the
year.
We are proposing to apply the MIPS payment adjustment factor, and
if applicable, the additional MIPS payment adjustment factor, to the
Medicare paid amount for items and services paid under Part B and
furnished by the MIPS eligible clinician during the year. This proposal
is consistent with the approach taken for the value-based payment
modifier (77 FR 69308 through 69310) and would mean that beneficiary
cost-sharing and coinsurance amounts would not be affected by the
application of the MIPS payment adjustment factor and the additional
MIPS payment adjustment factor. The MIPS payment adjustment applies
only to the amount otherwise paid under Part B for items and services
furnished by a MIPS eligible clinician during a year. Please refer to
the CY 2017 Quality Payment Program final rule at 81 FR 77340 and
section II.C.3.c.
[[Page 30151]]
of this proposed rule for further discussion and our proposals
regarding which Part B covered items and services would be subject to
the MIPS payment adjustment.
(2) Example of Adjustment Factors
Figure A provides an example of how various final scores would be
converted to an adjustment factor, and potentially an additional
adjustment factor, using the statutory formula and based on proposed
policies. In Figure A, the performance threshold is 15 points. The
applicable percentage is 5 percent for 2020. The adjustment factor is
determined on a linear sliding scale from zero to 100, with zero being
the lowest negative applicable percentage (negative 5 percent for the
2020 MIPS payment year), and 100 being the highest positive applicable
percentage. However, there are two modifications to this linear sliding
scale. First, there is an exception for a final score between zero and
one-fourth of the performance threshold (zero and 3.75 points based on
the proposed performance threshold for the 2020 MIPS payment year). All
MIPS eligible clinicians with a final score in this range would receive
the lowest negative applicable percentage (negative 5 percent for the
2020 MIPS payment year). Second, the linear sliding scale line for the
positive MIPS adjustment factor is adjusted by the scaling factor (as
discussed in section II.C.8.e. of this proposed rule). If the scaling
factor is greater than zero and less than or equal to 1.0, then the
adjustment factor for a final score of 100 would be less than or equal
to 5 percent. If the scaling factor is above 1.0, but less than or
equal to 3.0, then the adjustment factor for a final score of 100 would
be higher than 5 percent. Only those MIPS eligible clinicians with a
final score equal to 15 points (which is the performance threshold in
this example) would receive a neutral MIPS payment adjustment. Because
our proposed policies have set the performance threshold at 15 points,
we anticipate that the scaling factor would be less than 1.0 and the
payment adjustment for MIPS eligible clinicians with a final score of
100 points would be less than 5 percent.
Figure A of this proposed rule illustrates an example slope. In
this example, the scaling factor for the adjustment factor is 0.22,
which is much lower than 1.0. In this example, MIPS eligible clinicians
with a final score equal to 100 would have an adjustment factor of 1.10
percent (5 percent x 0.22).
The additional performance threshold is 70 points. An additional
adjustment factor of 0.5 percent starts at the additional performance
threshold and increases on a linear sliding scale up to 10 percent
times a scaling factor that is greater than zero and less than or equal
to 1.0. The scaling factor will be determined so that the estimated
aggregate increase in payments associated with the application of the
additional adjustment factors is equal to $500,000,000. In Figure A of
this proposed rule, the example scaling factor for the additional
adjustment factor is 0.183. Therefore, MIPS eligible clinicians with a
final score of 100 would have an additional adjustment factor of 1.83
percent (10 percent x 0.183). The total adjustment for a MIPS eligible
clinician with a final score equal to 100 would be 1 + 0.0110 + 0.0183
= 1.0293, for a total positive MIPS payment adjustment of 2.93 percent.
[[Page 30152]]
[GRAPHIC] [TIFF OMITTED] TP30JN17.005
The final MIPS payment adjustments would be determined by the
distribution of final scores across MIPS eligible clinicians and the
performance threshold. More MIPS eligible clinicians above the
performance threshold means the scaling factors would decrease because
more MIPS eligible clinicians receive a positive MIPS payment
adjustment. More MIPS eligible clinicians below the performance
threshold means the scaling factors would increase because more MIPS
eligible clinicians would have negative MIPS payment adjustments and
relatively fewer MIPS eligible clinicians receive positive MIPS payment
adjustments.
Table 42 illustrates the changes in payment adjustments from the
transition year to the 2020 MIPS payment year based on the proposals in
this proposed rule as well as the statutorily-required increase in the
applicable percent as required by section 1848(q)(6)(B) of the Act.
Table 42--Illustration of Point System and Associated Adjustments
Comparison Between Transition Year and the 2020 MIPS Payment Year
------------------------------------------------------------------------
Transition year 2020 MIPS payment year
------------------------------------------------------------------------
Final score
Final score points MIPS adjustment points MIPS adjustment
------------------------------------------------------------------------
0.0-0.75.............. Negative 4 0.0-3.75 Negative 5
percent. percent.
0.76-2.99............. Negative MIPS 3.76-14.99 Negative MIPS
payment payment
adjustment adjustment
greater than greater than
negative 4 negative 5
percent and percent and
less than 0 less than 0
percent on a percent on a
linear sliding linear sliding
scale. scale.
3.00.................. 0 percent 15.00 0 percent
adjustment. adjustment.
3.01-69.99............ Positive MIPS 15.01-69.99 Positive MIPS
payment payment
adjustment adjustment
greater than 0 greater than 0
percent on a percent on a
linear sliding linear sliding
scale scale
multiplied by multiplied by
a scaling a scaling
factor to factor to
preserve preserve
budget budget
neutrality. neutrality.
The linear .............. The linear
sliding scale sliding scale
ranges from ranges from
greater than 0 greater than 0
to 4 percent to 5 percent
for scores for scores
from 3.01 to from 15.01 to
100.00. 100.00.
[[Page 30153]]
70.00-100............. Positive MIPS 70.00-100 Positive MIPS
payment payment
adjustment on adjustment on
a linear a linear
sliding scale sliding scale
multiplied by multiplied by
a scaling a scaling
factor to factor to
preserve preserve
budget budget
neutrality AND neutrality AND
additional additional
MIPS payment MIPS payment
adjustment for adjustment for
exceptional exceptional
performance. performance.
(Additional (Additional
MIPS payment MIPS payment
adjustment adjustment
starting at starting at
0.5 percent 0.5 percent
and increasing and increasing
on a linear on a linear
sliding scale sliding scale
to 10 percent to 10 percent
multiplied by multiplied by
a scaling a scaling
factor.) factor.)
The linear .............. The linear
sliding scale sliding scale
ranges from ranges from
greater than 0 greater than 0
to 4 percent to 5 percent
for scores for scores
from 3.01 to from 15.01 to
100.00. 100.00.
------------------------------------------------------------------------
We have provided the following examples for the 2020 MIPS payment
year to demonstrate scenarios in which MIPS eligible clinicians can
achieve a final score at or above the performance threshold of 15
points.
Example 1: MIPS Eligible Clinician in Small Practice Submits 1 Quality
Measure and 1 Improvement Activity
In the example illustrated in Table 43, a MIPS eligible clinician
in a small practice reporting individually meets the performance
threshold by reporting one measure one time via claims and one medium-
weight improvement activity. The practice does not submit data for the
advancing care information performance category, but does submit a
significant hardship exception application which is approved;
therefore, the weight for the advancing care information performance
category is reweighted to the quality performance category due to
proposed reweighting policies discussed in section II.C.7.b,(3) of this
proposed rule. We also assume the small practice has a cost performance
category percent score of 50 percent, although the cost performance
category percent score will not contribute to the final score. Finally,
we assume the average HCC score for the beneficiaries seen by the MIPS
eligible clinician is 1.5.
There are several special scoring rules which affect MIPS eligible
clinicians in a small practice:
3 measure achievement points for each quality measure even
if the measure does not meet data completeness standards. We refer
readers to section II.C.7.a.(2)(d) of this proposed rule for discussion
of this policy. Therefore, a quality measure submitted one time would
receive 3 points. Because the measure is submitted via claims, it does
not qualify for the end-to-end electronic reporting bonus, nor would it
qualify for the high-priority bonus because it is the only measure
submitted. However, because the MIPS eligible clinician does not meet
full participation requirements, the MIPS eligible clinician does not
qualify for improvement scoring. We refer you to section
II.C.7.a.(2)(i)(iii) of this proposed rule for a discussion on full
participation requirements. Therefore, the quality performance category
is (3 measure achievement points + zero measure bonus points)/60 total
available measure points + zero improvement percent score which is 5
percent.
The advancing care information performance category weight
is redistributed to quality so that the quality performance category
percent score is worth 85 percent of the final score. We refer you to
section II.C.7.b.(3)(d) of this proposed rule for a discussion of this
proposed policy.
MIPS eligible clinicians in small practices qualify for
special scoring for improvement activities so a medium weighted
activity is worth 20 points out of a total 40 possible points for the
improvement activities performance category. We refer you to section
II.C.6.e.(5) of this proposed rule for a discussion of this proposed
policy.
MIPS eligible clinicians in small practices qualify for
the 5 point small practice bonus which is applied to the final score.
We refer you to section II.C.7.b.(1)(c) of this proposed rule for a
discussion of this proposed policy.
This MIPS eligible clinician exceeds the performance threshold of
15 points (but does not exceed the additional performance threshold).
This score is summarized in Table 43.
Table 43--Scoring Example 1, MIPS Eligible Clinician in a Small Practice
----------------------------------------------------------------------------------------------------------------
Earned points
Performance category Performance score Category weight ([B]*[C]*100)
----------------------------------------------------------------------------------------------------------------
[A] [B]............................ [C]............................ [D]
----------------------------------------------------------------------------------------------------------------
Quality....................... 5%............................. 85%............................ 4.25
Cost.......................... 50%............................ 0%............................. 0
Improvement Activities........ 20 out of 40 points--50%....... 15%............................ 7.5
Advancing Care Information.... Missing........................ 0% (reweighted to quality)..... 0
---------------------------------------------------------------------------------
Subtotal (Before Bonuses). ............................... ............................... 11.75
----------------------------------------------------------------------------------------------------------------
Complex Patient Bonus......... ............................... ............................... 1.5
Small Practice Bonus.......... ............................... ............................... 5
---------------------------------------------------------------------------------
Final Score (not to exceed ............................... ............................... 18.25
100).
----------------------------------------------------------------------------------------------------------------
[[Page 30154]]
Example 2: Group Submission Not in a Small Group
In the example illustrated in Table 44, a MIPS eligible clinician
in a medium size practice participating in MIPS as a group meets 75
percent of the quality score and 100 percent for the advancing care
information and improvement activities performance categories. There
are many paths for a practice to receive a 75 percent score in the
quality performance category, so for simplicity we are assuming the
score has been calculated. Both the performance threshold and the
additional performance threshold are exceeded. Again, for simplicity,
we assume the average HCC score for the group is 1.5. In this example,
the group practice does not qualify for any special scoring, yet is
able to exceed the additional performance threshold and achieve the
additional adjustment factor.
Table 44--Scoring Example 2, MIPS Eligible Clinician in a Medium Practice
----------------------------------------------------------------------------------------------------------------
Category Earned points
Performance category Performance score weight ([B]*[C]*100)
----------------------------------------------------------------------------------------------------------------
[A] [B]..................................... [C] [D]
----------------------------------------------------------------------------------------------------------------
Quality............................... 75%..................................... 60% 45
Cost.................................. 50%..................................... 0% 0
Improvement Activities................ 40 out of 40 points--100%............... 15% 15
Advancing Care Information............ 100%.................................... 25% 25
-------------------------------------------------------------------------
Subtotal (Before Bonuses)......... ........................................ .............. 85
----------------------------------------------------------------------------------------------------------------
Complex Patient Bonus................. ........................................ .............. 1.5
Small Practice Bonus.................. ........................................ .............. 0
-------------------------------------------------------------------------
Final Score (not to exceed 100)... ........................................ .............. 86.5
----------------------------------------------------------------------------------------------------------------
Example 3: Non-Patient Facing MIPS Eligible Clinician
In the example illustrated in Table 45, an individual MIPS eligible
clinician that is non-patient facing and not in a small practice meets
50 percent of the quality score and 50 percent for 1 medium-weighted
for improvement activity. Again, there are many paths for a practice to
receive a 50 percent score in the quality performance category, so for
simplicity we are assuming the score has been calculated. Because the
MIPS eligible clinician is non-patient facing, they qualify for special
scoring for improvement activities, they receive 20 points (out of 40
possible points) for the medium weighted activity. Also, this
individual did not submit advancing care information measures and
qualifies for the automatic reweighting of the advancing care
information performance category to quality. The non-patient facing
MIPS eligible clinician has an average HCC score of 1.5, but as the
MIPS eligible clinician is not in a small practice, the MIPS eligible
clinician does not qualify for the small practice bonus.
In this example, the performance threshold is exceeded while the
additional performance threshold is not.
Table 45--Scoring Example 2, Non-Patient Facing MIPS Eligible Clinician
----------------------------------------------------------------------------------------------------------------
Category Earned points
Performance category Performance score weight ([B]*[C]*100)
----------------------------------------------------------------------------------------------------------------
[A] [B]..................................... [C] [D]
----------------------------------------------------------------------------------------------------------------
Quality............................... 50%..................................... 60% 30
Cost.................................. 50%..................................... 0% 0
Improvement Activities................ 20 out of 40 points for 1 medium weight 15% 7.5
activity--50%.
Advancing Care Information............ 0%...................................... 25% 0
-------------------------------------------------------------------------
Subtotal (Before Bonuses)......... ........................................ .............. 37.5
----------------------------------------------------------------------------------------------------------------
Complex Patient Bonus................. ........................................ .............. 1.5
Small Practice Bonus.................. ........................................ .............. 0
-------------------------------------------------------------------------
Final Score (not to exceed 100)... ........................................ .............. 39
----------------------------------------------------------------------------------------------------------------
We note that these examples are not intended to be exhaustive of
the types of participants nor the opportunities for reaching and
exceeding the performance threshold.
9. Review and Correction of MIPS Final Score
a. Feedback and Information To Improve Performance
(1) Performance Feedback
As we have stated previously in the CY 2017 Quality Payment Program
final rule (81 FR 77345), we will continue to engage in user research
with front-line clinicians to ensure we are providing the performance
feedback data in a user-friendly format, and that we are including the
data most relevant to clinicians. Any suggestions from user research
would be considered as we
[[Page 30155]]
develop the systems needed for performance feedback, which would occur
outside of the rulemaking process.
Over the past year, we have conducted numerous user research
sessions to determine what the community most needs in performance
feedback. In summary we have found the users want the following:
(1) To know as soon as possible how I am performing based on my
submitted data so that I have confidence that I performed the way I
thought I would.
(2) To be able to quickly understand how and why my payments will
be adjusted so that I can understand how my business will be impacted.
(3) To be able to quickly understand how I can improve my
performance so that I can increase my payment in future program years.
(4) To know how I am performing over time so I can improve the care
I am providing patients in my practice.
(5) To know how my performance compares to my peers.
Based on that research, we have already begun development of real-
time feedback on data submission and scoring where technically feasible
(some scoring requires all clinician data be submitted, and therefore,
cannot occur until the end of the submission period). By ``real-time''
feedback, we mean instantaneous feedback; for example, when a clinician
submits their data via our Web site or a third party submits data via
our Application Program Interface (API), they will know immediately if
their submission was successful.
We will continue to provide information for stakeholders who wish
to participate in user research via our education and communication
channels. Suggestions can also be sent via the ``Contact Us''
information on qpp.cms.gov. However, we note that suggestions provided
through this channel will not be considered comments on this proposed
rule. To submit comments on this proposed rule, please see the
explanation of how to submit such comments and relevant deadlines
explained at the beginning of this proposed rule.
(a) MIPS Eligible Clinicians
Under section 1848(q)(12)(A)(i) of the Act, we are at a minimum
required to provide MIPS eligible clinicians with timely (such as
quarterly) confidential feedback on their performance under the quality
and cost performance categories beginning July 1, 2017, and we have
discretion to provide such feedback regarding the improvement
activities and advancing care information performance categories.
Beginning July 1, 2018, we are proposing to provide performance
feedback to MIPS eligible clinicians and groups for the quality and
cost performance categories for the 2017 performance period, and if
technically feasible, for the improvement activities and advancing care
information performance categories. We propose to provide this
performance feedback at least annually, and as, technically feasible,
we would provide it more frequently, such as quarterly. If we are able
to provide it more frequently, we would communicate the expected
frequency to our stakeholders via our education and outreach
communication channels.
Based on public comments summarized and responded to in the CY 2017
Quality Payment Program final rule (81 FR 77347), we also propose that
the measures and activities specified for the CY 2017 performance
period (for all four MIPS performance categories), along with the final
score, would be included in the performance feedback provided on or
about July 1, 2018. We request comment on these proposals.
For cost measures, since we can measure performance using any 12-
month period of prior claims data, we request comment on whether it
would be helpful to provide more frequent feedback on the cost
performance category using rolling 12-month periods or quarterly
snapshots of the most recent 12-month period; how frequent that
feedback should be; and the format in which we should make it available
to clinicians and groups. In addition, as described in sections
II.C.6.b. and II.C.6.d. of this proposed rule, we intend to provide
cost performance feedback in the fall of 2017 and the summer of 2018 on
new episode-based cost measures that are currently under development by
CMS. With regard to the format of feedback on cost measures, we are
considering utilizing the parts of the Quality and Resource Use Reports
(QRURs) that user testing has revealed beneficial while making the
overall look and feel usable to clinicians. We request comment whether
that format is appropriate or if other formats or revisions to that
format should be used to provide performance feedback on cost measures.
(b) MIPS APMs
We are proposing that MIPS eligible clinicians who participate in
MIPS APMs would receive performance feedback in 2018 and future years
of the Quality Payment Program, as technically feasible. Please refer
to section II.C.6.g.(5) of this proposed rule for additional
information related to this proposal.
(c) Voluntary Clinician and Group Reporting
As noted in the CY 2017 Quality Payment Program final rule (81 FR
77071), eligible clinicians who are not included in the definition of a
MIPS eligible clinician during the first 2 years of MIPS (or any
subsequent year) may voluntarily report on measures and activities
under MIPS, but will not be subject to the payment adjustment. In the
final rule (81 FR 77346), we summarized public comments requesting that
eligible clinicians who are not required, but who voluntarily report on
measures and activities under MIPS, should receive the same access to
performance feedback as MIPS eligible clinicians, and indicated that we
would take the comments into consideration in the future development of
performance feedback. We propose to furnish performance feedback to
eligible clinicians and groups that do not meet the definition of a
MIPS eligible clinician but voluntarily report on measures and
activities under MIPS. We propose that this would begin with data
collected in performance period 2017, and would be available beginning
July 1, 2018. Based on user and market research, we believe that making
this information available would provide value in numerous ways. First,
it would help clinicians who are excluded from MIPS in the 2017
performance period, but who may be considered MIPS eligible clinicians
in future years, to prepare for participation in the Quality Payment
Program when there are payment consequences associated with
participation. Second, it would give all clinicians equal access to the
CMS claims and benchmarking data available in performance feedback. And
third, it would allow clinicians who may be interested in participating
in an APM to make a more informed decision.
We request comments on this proposal.
(2) Mechanisms
Under section 1848(q)(12)(A)(ii) of the Act, the Secretary may use
one or more mechanisms to make performance feedback available, which
may include use of a web-based portal or other mechanisms determined
appropriate by the Secretary. For the quality performance category,
described in section 1848(q)(2)(A)(i) of the Act, the feedback shall,
to the extent an eligible clinician chooses to participate in a data
registry for purposes of MIPS (including registries under sections
1848(k) and (m) of the Act), be provided based on
[[Page 30156]]
performance on quality measures reported through the use of such
registries. For any other performance category (that is, cost,
improvement activities, or advancing care information), the Secretary
shall encourage provision of feedback through qualified clinical data
registries (QCDRs) as described in section 1848(m)(3)(E) of the Act.
As previously stated in the CY 2017 Quality Payment Program final
rule (81 FR 77347 through 77349), we will use a CMS-designated system
as the mechanism for making performance feedback available, which we
expect will be a web-based application. We expect to use a new and
improved format for the next performance feedback, anticipated to be
released around July 1, 2018. It will be provided via the Quality
Payment Program Web site (qpp.cms.gov), and we intend to leverage
additional mechanisms, such as health IT vendors, registries, and QCDRs
to help disseminate data and information contained in the performance
feedback to eligible clinicians, where applicable.
We are also seeking comment on how health IT, either in the form of
an EHR or as a supplemental module, could better support the feedback
related to participation in the Quality Payment Program and quality
improvement in general. Specifically--
Are there specific health IT functionalities that could
contribute significantly to quality improvement?
Are there specific health IT functionalities that could be
part of a certified EHR technology or made available as optional health
IT modules in order to support the feedback loop related to Quality
Payment Program participation or participation in other HHS reporting
programs?
In what other ways can health IT support clinicians
seeking to leverage quality data reports to inform clinical improvement
efforts? For example, are there existing or emerging tools or resources
that could leverage an API to provide timely feedback on quality
improvement activities?
Are there opportunities to expand existing tracking and
reporting for use by clinicians, for example expanding the feedback
loop for patient engagement tools to support remote monitoring of
patient status and access to education materials?
We welcome public comment on these questions.
We intend to continue to leverage third party intermediaries as a
mechanism to provider performance feedback. In the CY 2017 Quality
Payment Program final rule (81 FR 77367 through 77386) we finalized
that at least 4 times per year, qualified registries and QCDRs will
provide feedback on all of the MIPS performance categories that the
qualified registry or QCDR reports to us (improvement activities,
advancing care information, and/or quality performance category). The
feedback should be given to the individual MIPS eligible clinician or
group (if participating as a group) at the individual participant level
or group level, as applicable, for which the qualified registry or QCDR
reports. The qualified registry or QCDR is only required to provide
feedback based on the MIPS eligible clinician's data that is available
at the time the performance feedback is generated. In regard to third
party intermediaries, we also noted we would look to propose ``real
time'' feedback as soon as it is technically feasible.
Per the policies finalized in the CY 2017 Quality Payment Program
final rule (81 FR 77367 through 77386), we continue to require
qualified registries and QCDRs, as well as encourage other third party
intermediaries (such as health IT vendors that submit data to us on
behalf of a MIPS eligible clinician or group), to provide performance
feedback to individual MIPS eligible clinicians and groups via the
third party intermediary with which they are already working. We also
understand that performance feedback is valuable to individual
clinicians and groups, and seek feedback from third party
intermediaries on when ``real-time'' feedback could be provided.
Additionally, we plan to continue to work with third party
intermediaries as we continue to develop the mechanisms for performance
feedback, to see where we may be able to develop and implement
efficiencies for the Quality Payment Program. We are exploring options
with an API, which could allow authenticated third party intermediaries
to access the same data that we use to provide confidential feedback to
the individual clinicians and groups on whose behalf the third party
intermediary reports for purposes of MIPS, in accordance with
applicable law, including, but not limited to, the HIPAA Privacy and
Security Rules. Our goal is to enable individual clinicians and groups
to more easily access their feedback via the mechanisms and
relationships they already have established. We are seeking comments on
this approach as we continue to develop performance feedback
mechanisms. We refer readers to section II.C.10. of this proposed rule
for additional information on Third Party Data Submission.
(3) Receipt of Information
Section 1848(q)(12)(A)(v) of the Act, states that the Secretary may
use the mechanisms established under section 1848(q)(12)(A)(ii) of the
Act to receive information from professionals. This allows for expanded
use of the feedback mechanism to not only provide feedback on
performance to MIPS eligible clinicians, but to also receive
information from professionals.
In the CY 2017 Quality Payment Program final rule (81 FR 77350), we
discussed that we intended to explore the possibility of adding this
feature to the CMS-designated system, such as a portal, in future years
under MIPS. Although we are not making any specific proposals at this
time, we are again seeking comment on the features that could be
developed for the expanded use of the feedback mechanism. This could be
a feature where eligible clinicians and groups can send their feedback
(for example, if they are experiencing issues accessing their data,
technical questions about their data, etc.) to us through the Quality
Payment Program Service Center or the Quality Payment Program Web site.
We appreciate that eligible clinicians and groups may have questions
regarding the Quality Payment Program information contained in their
performance feedback. To assist eligible clinicians and groups, we
intend to utilize existing resources, such as a helpdesk or offer
technical assistance, to help address questions with the goal of
linking these resource features to the Quality Payment Program Web site
and Service Center.
(4) Additional Information--Type of Information
Section 1848(q)(12)(B)(i) of the Act states that beginning July 1,
2018, the Secretary shall make available to MIPS eligible clinicians
information about the items and services for which payment is made
under Title 18 that are furnished to individuals who are patients of
MIPS eligible clinicians by other suppliers and providers of services.
This information may be made available through mechanisms determined
appropriate by the Secretary, such as the CMS-designated system that
would also provide performance feedback. Section 1848(q)(12)(B)(ii) of
the Act specifies that the type of information provided may include the
name of such providers, the types of items and services furnished, and
the dates that items and services were furnished. Historical data
regarding the total, and components of, allowed charges (and
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other figures as determined appropriate by the Secretary) may also be
provided.
We propose, beginning with the performance feedback provided around
July 1, 2018, to make available to MIPS eligible clinicians and
eligible clinicians information about the items and services for which
payment is made under Title 18 that are furnished to individuals who
are patients of MIPS eligible clinicians and eligible clinicians by
other suppliers and providers of services. We propose to include as
much of the following data elements as technically feasible: The name
of such suppliers and providers of services; the types of items and
services furnished and received; the dollar amount of services provided
and received; and the dates that items and services were furnished. We
propose that the additional information would include historical data
regarding the total, and components of, allowed charges (and other
figures as determined appropriate). We propose that this information be
provided on the aggregate level; with the exception of data on items
and services, as we could consider providing this data at the patient
level, if clinicians find that level of data to be useful, although we
note it may contain personally identifiable information and protected
health information. We propose the date range for making this
information available would be based on what is most helpful to
clinicians, such as the most recent data we have available, which as
technically feasible would be provided from a 3 to 12-month period. We
propose to make this information available via the Quality Payment
Program Web site, and as technically feasible, as part of the
performance feedback. Finally, because data on items and services
furnished is generally kept confidential, we propose that access would
be provided only after secure credentials are obtained. We request
comment on these proposals.
(5) Performance Feedback Template
As we have previously indicated (81 FR 77352), we intend to do as
much as we can of the development of the template for performance
feedback by working with the stakeholder community in a transparent
manner. We believe this will encourage stakeholder commentary and make
sure the result is the best possible format(s) for feedback.
To continue with our collaborative goal of working with the
stakeholder community, we seek comment on the structure, format,
content (for example, detailed goals, data fields, and elements) that
would be useful for MIPS eligible clinicians and groups to include in
performance feedback, including the data on items and services
furnished, as discussed above. Additionally, we understand the term
``performance feedback'' may not be meaningful to clinicians or groups
to clearly denote what this data might imply. Therefore, we seek
comment on what to term ``performance feedback.'' User testing to date
has provided some considerations for a name in the Quality Payment
Program, such as Progress Notes, Reports, Feedback, Performance
Feedback, or Performance Reports.
Any suggestions on the template to be used for performance feedback
or what to call ``performance feedback'' can be submitted to the
Quality Payment Program Web site at qpp.cms.gov.
b. Targeted Review
In the CY 2017 Quality Payment Program final rule (81 FR 77546), we
finalized at Sec. 414.1385 that MIPS eligible clinicians or groups may
request a targeted review of the calculation of the MIPS payment
adjustment factor under section 1848(q)(6)(A) of the Act and, as
applicable, the calculation of the additional MIPS payment adjustment
factor under section 1848(q)(6)(C) of the Act applicable to such MIPS
eligible clinician or group for a year. We note MIPS eligible
clinicians who are scored under the APM scoring standard described in
section II.C.6.g. of this proposed rule may request this targeted
review. Although we are not proposing any changes to the targeted
review process, we are providing information on the process that was
finalized in the CY 2017 Quality Payment Program final rule (81 FR
77353 through 77358).
(1) MIPS eligible clinicians and groups have a 60-day period to
submit a request for targeted review, which begins on the day we make
available the MIPS payment adjustment factor, and if applicable the
additional MIPS payment adjustment factor, for the MIPS payment year
and ends on September 30 of the year prior to the MIPS payment year or
a later date specified by us.
(2) We will respond to each request for targeted review timely
submitted and determine whether a targeted review is warranted.
Examples under which a MIPS eligible clinician or group may wish to
request a targeted review include, but are not limited to:
The MIPS eligible clinician or group believes that
measures or activities submitted to us during the submission period and
used in the calculations of the final score and determination of the
adjustment factors have calculation errors or data quality issues.
These submissions could be with or without the assistance of a third
party intermediary; or
The MIPS eligible clinician or group believes that there
are certain errors made by us, such as performance category scores were
wrongly assigned to the MIPS eligible clinician or group (for example,
the MIPS eligible clinician or group should have been subject to the
low-volume threshold exclusion and should not have received a
performance category score).
(3) The MIPS eligible clinician or group may include additional
information in support of their request for targeted review at the time
the request is submitted. If we request additional information from the
MIPS eligible clinician or group, it must be provided and received by
us within 30 days of the request. Non-responsiveness to the request for
additional information may result in the closure of the targeted review
request, although the MIPS eligible clinician or group may submit
another request for targeted review before the deadline.
(4) Decisions based on the targeted review are final, and there is
no further review or appeal.
c. Data Validation and Auditing
In the CY 2017 Quality Payment Program final rule (81 FR 77546
through 77547), we finalized at Sec. 414.1390(a) that we will
selectively audit MIPS eligible clinicians and groups on a yearly
basis. If a MIPS eligible clinician or group is selected for audit, the
MIPS eligible clinician or group will be required to do the following
in accordance with applicable law and timelines we establish:
(1) Comply with data sharing requests, providing all data as
requested by us or our designated entity. All data must be shared with
us or our designated entity within 45 days of the data sharing request,
or an alternate timeframe that is agreed to by us and the MIPS eligible
clinician or group. Data will be submitted via email, facsimile, or an
electronic method via a secure Web site maintained by us.
(2) Provide substantive, primary source documents as requested.
These documents may include: Copies of claims, medical records for
applicable patients, or other resources used in the data calculations
for MIPS measures, objectives, and activities. Primary source
documentation also may include verification of records for Medicare and
non-Medicare beneficiaries where applicable. We are not proposing any
changes to the requirements in section Sec. 414.1390(a).
We indicated in the CY 2017 Quality Payment Program final rule that
all
[[Page 30158]]
MIPS eligible clinicians and groups that submit data to us
electronically must attest to the best of their knowledge that the data
submitted to us is accurate and complete (81 FR 77362). We also
indicated in the final rule that attestation requirements would be part
of the submission process (81 FR 77360). We neglected to codify this
requirement in regulation text of the CY 2017 Quality Payment Program
final rule. Additionally, after further consideration since the final
rule, the requirement is more in the nature of a certification, rather
than an attestation. Thus, we are proposing to revise Sec. 414.1390 to
add a new paragraph (b) that requires all MIPS eligible clinicians and
groups that submit data and information to CMS for purposes of MIPS to
certify to the best of their knowledge that the data submitted to CMS
is true, accurate, and complete. We also propose that the certification
by the MIPS eligible clinician or group must accompany the submission.
We also indicated in the CY 2017 Quality Payment Program final rule
that if a MIPS eligible clinician or group is found to have submitted
inaccurate data for MIPS, we would reopen and revise the determination
in accordance with the rules set forth at Sec. Sec. 405.980 through
405.984 (81 FR 77362). We neglected to codify this policy in regulation
text of the CY 2017 Quality Payment Program final rule and further, we
did not include Sec. 405.986, which is also an applicable rule in our
reopening policy. We also finalized our approach to recoup incorrect
payments from the MIPS eligible clinician by the amount of any debts
owed to us by the MIPS eligible clinician and likewise, we would recoup
any payments from the group by the amount of any debts owed to us by
the group. Thus, we are proposing to revise Sec. 414.1390 to add a new
paragraph (c) that states we may reopen and revise a MIPS payment
determination in accordance with the rules set forth at Sec. Sec.
405.980 through 405.986.
In the CY 2017 Quality Payment Program, we also indicated that MIPS
eligible clinicians and groups should retain copies of medical records,
charts, reports and any electronic data utilized for reporting under
MIPS for up to 10 years after the conclusion of the performance period
(81 FR 77360). We neglected to codify this policy in regulation text of
the CY 2017 Quality Payment Program final rule. Thus, we are proposing
to revise Sec. 414.1390 to add a new paragraph (d) that states that
all MIPS eligible clinicians or groups that submit data and information
to CMS for purposes of MIPS must retain such data and information for a
period of 10 years from the end the MIPS Performance Period.
Finally, we indicated in the CY 2017 Quality Payment Program final
rule, that, in addition to recouping any incorrect payments, we intend
to use data validation and audits as an educational opportunity for
MIPS eligible clinicians and groups and we note that this process will
continue to include education and support for MIPS eligible clinicians
and groups selected for an audit.
10. Third Party Data Submission
In developing MIPS, our goal is to develop a program that is
meaningful, understandable, and flexible for participating MIPS
eligible clinicians. Flexible reporting options will provide eligible
clinicians with options to accommodate different practices and make
measurement meaningful. We believe that allowing eligible clinicians to
participate in MIPS through the use of third party intermediaries that
will collect or submit data on their behalf, will help us accomplish
our goal of implementing a flexible program. We strongly encourage all
third party intermediaries to work with their MIPS eligible clinicians
to ensure the data submitted are representative of the individual MIPS
eligible clinician's or group's overall performance for that measure or
activity.
For purposes of this section, we use the term third party to refer
to a qualified registry, QCDR, a health IT vendor or other third party
that obtains data from a MIPS eligible clinician's Certified Electronic
Health Record Technology, or a CMS approved survey vendor. In the CY
2017 Quality Payment Program final rule (81 FR 77363), we finalized at
Sec. 414.1400(a)(1) that MIPS data may be submitted by third party
intermediaries on behalf of a MIPS eligible clinician or group by: (1)
A qualified registry; (2) a QCDR; (3) a health IT vendor; or (4) a CMS
approved survey vendor. Additionally, we finalized at Sec.
414.1400(a)(3) that third party intermediaries must meet all the
criteria designated by us as a condition of their qualification or
approval to participate in MIPS as a third party intermediary. Lastly,
as finalized at Sec. 414.1400(a)(3)(ii), all submitted data must be
submitted in the form and manner specified by us.
We are proposing to revise Sec. 414.1400(a)(1) to state that MIPS
data may be submitted by third party intermediaries on behalf of an
individual MIPS eligible clinician, group, or virtual group. See
section II.C.4. of this rule for more information related to virtual
groups.
Additionally, we believe it is important that the MIPS data
submitted by third party intermediaries is true, accurate, and
complete. To that end, we are proposing to add a requirement at Sec.
414.1400(a)(5) stating that all data submitted to CMS by a third party
intermediary on behalf of a MIPS eligible clinician, group or virtual
group must be certified by the third party intermediary to the best of
its knowledge as true, accurate, and complete. We also propose that
this certification occur at the time of the submission and accompany
the submission. We solicit comments on this proposal.
As more clinicians participate in value based payment arrangements
with multiple payers, we believe third-party intermediaries will play
an important role in calculating quality measures, reporting once to
all payers, and sharing actionable feedback to clinicians. A robust
ecosystem of third-party intermediaries would more reliably calculate
measures using data across clinical practices caring for the same
patients and reduce burden by streamlining reporting to all payers and
offering timely feedback to clinicians that is easier to act on in
addressing gaps in care. Third-party intermediaries can also take the
burden off clinical practices by integrating various types of health
care data, including administrative data from payers, other utilization
data, cost data, and clinical data derived from health IT systems, to
provide front-line clinicians and others with a comprehensive view of
the cost and quality of the care they are delivering.
We are continuing to explore how we can further encourage those
third-party intermediaries that provide comprehensive data services to
support eligible clinicians participating in both MIPS and APMs. For
instance, should we consider implementing additional incentives for
eligible clinicians to use a third-party intermediary which has
demonstrated substantial participation from additional payers and/or
other clinical data sources across practices caring for a cohort of
Medicare beneficiaries within a given geographic area? Should these
incentives also include expectations that structured, standardized data
be shared with third party intermediaries? Should there be additional
refinements to the approach to qualifying third party intermediaries
which evaluate the degree to which these intermediaries can deliver
longitudinal information on a patient to participating clinicians, for
example, a
[[Page 30159]]
virtual care team of primary and specialty physicians? Should there be
a special designation for registries that would convey the availability
of longitudinal clinical data for robust measurement and feedback? We
seek comment on these and other ideas which can further advance the
role of intermediaries and reduce clinician burden by enabling a
streamlined reporting and feedback system.
a. Qualified Clinical Data Registries (QCDRs)
In the CY 2017 Quality Payment Program final rule (81 FR 77364), we
finalized the definition and capabilities of a QCDR. We are not
proposing any changes to the definition or the capabilities of a QCDR
in this proposed rule, and refer readers to the CY 2017 Quality Payment
Program final rule for a detailed discussion of the definition and
capabilities of a QCDR.
(1) Establishment of an Entity Seeking To Qualify as a QCDR
In the CY 2017 Quality Payment Program final rule (81 FR 77365), we
finalized the criteria to establish an entity seeking to qualify as a
QCDR. We are not proposing any changes to the criteria in this proposed
rule, and refer readers to the CY 2017 Quality Payment Program final
rule for the criteria to qualify as a QCDR.
(2) Self-Nomination Period
In the CY 2017 Quality Payment Program final rule (81 FR 77365
through 77366), we finalized the self-nomination period for the 2018
performance period and for future years of the program to be from
September 1 of the year prior to the applicable performance period
until November 1 of the same year. As an example, the self-nomination
period for the 2018 performance period will begin on September 1, 2017,
and will end on November 1, 2017. Entities that desire to qualify as a
QCDR for the purposes of MIPS for a given performance period will need
to self-nominate for that year and provide all information requested by
us at the time of self-nomination. Having qualified as a QCDR in a
prior year does not automatically qualify the entity to participate in
MIPS as a QCDR in subsequent performance periods. Furthermore, prior
performance of the QCDR (when applicable) will be taken into
consideration in approval of their self-nomination. For example, a QCDR
may choose not to continue participation in the program in future
years, or the QCDR may be precluded from participation in a future year
due to multiple data or submission errors as noted below. Finally,
QCDRs may want to update or change the measures or services or
performance categories they intend to provide. We believe an annual
self-nomination process is the best process to ensure accurate
information is conveyed to MIPS eligible clinicians and accurate data
is submitted to MIPS.
However, we do understand that some QCDRs have no changes to the
measure and/or activity inventory they offer to their clients and
intend to participate in the MIPS for many years. Because of this, we
are proposing, beginning with the 2019 performance period, a simplified
process in which existing QCDRs in good standing may continue their
participation in MIPS, by attesting that the QCDR's approved data
validation plan, cost, measures, activities, services, and performance
categories offered in the previous year's performance period of MIPS
have minimal or no changes and will be used for the upcoming
performance period. Specifically, existing QCDRs in good standing may
attest during the self-nomination period that they have no changes to
their approved self-nomination application from the previous year of
MIPS. In addition, the existing QCDRs may decide to make minimal
changes to their approved self-nomination application from the previous
year, which would be submitted by the QCDR for CMS review and approval
by the close of the self-nomination period. Minimal changes may include
limited changes to their performance categories, adding or removing
MIPS quality measures, and adding or updating existing services and/or
cost information. Existing QCDRs in good standing, may also submit for
CMS review and approval, substantive changes to measure specifications
for existing QCDR measures that were approved the previous year, or
submit new QCDR measures for CMS review and approval without having to
complete the entire self-nomination application process, which is
required to be completed by a new QCDR. By attesting that certain
aspects of their approved application from the previous year have not
changed, existing QCDRs in good standing would be spending less time
completing the entire self-nomination form, as was previously required
on a yearly basis. We are proposing such a simplified process to reduce
the burden of self-nomination for those existing QCDRs who have
previously participated in MIPS, and are in good standing (not on
probation or disqualified, as described below) and to allow for
sufficient time for us to review data submissions and to make
determinations on the standing of the QCDRs. We note that substantive
changes to existing QCDR measure specifications or any new QCDR
measures would have to be submitted for CMS review and approval by the
close of the self-nomination period. This proposed process will allow
existing QCDRs in good standing to avoid completing the entire
application annually, as is required in the existing process, and in
alignment with the existing timeline. We request comments on this
proposal. In the development of this proposal, we had reviewed the
possibility of offering a multi-year approval, where QCDRs would be
approved for a 2-year increment of time. We are concerned that
utilizing a multi-year approval process in which QCDRs would be
approved for 2 continuous years using the same fixed services they had
for the first year, would not provide the QCDR with the flexibility to
add or remove services and/or measures or activities based on their
QCDR capabilities for the upcoming program year. Furthermore, another
concern with a multi-year approval process is the concern for those
QCDRs who perform poorly during the first year, and who should be
placed on probation or disqualified (as described below). We request
comments on this alternative.
We finalized to require other information (described below) of
QCDRs at the time of self-nomination. If an entity becomes qualified as
a QCDR, they will need to sign a statement confirming this information
is correct prior to listing it on their Web site. Once we post the QCDR
on our Web site, including the services offered by the QCDR, we will
require the QCDR to support these services or measures for its clients
as a condition of the entity's qualification as a QCDR for purposes of
MIPS. Failure to do so will preclude the QCDR from participation in
MIPS in the subsequent year.
For future years, beginning with the 2018 performance period, we
are proposing that self-nomination information must be submitted via a
web-based tool, and to eliminate the submission method of email. We
will provide further information on the web-based tool at
www.qpp.cms.gov. We request comments on this proposal.
(3) Information Required at the Time of Self-Nomination
In the CY 2017 Quality Payment Program final rule (81 FR 77366
through 77367), we finalized the information a QCDR must provide to us
at the time of self-nomination. We are proposing to replace the term
non-MIPS measures
[[Page 30160]]
with QCDR measures for future program years, beginning with the 2018
performance period. We note that although we are proposing a change in
the term referring to such measures, we are not proposing any other
changes to the information a QCDR must provide to us at the time of
self-nomination finalized in the CY 2017 Quality Payment Program final
rule. We refer readers to the CY 2017 Quality Payment Program final
rule for specific information requirements.
(4) QCDR Criteria for Data Submission
In the CY 2017 Quality Payment Program final rule (81 FR 77367
through 77374), we finalized that a QCDR must perform specific
functions to meet the criteria for data submission. While we are not
proposing any changes to the criteria for data submission in this
proposed rule, we would like to note the following as clarifications to
existing criteria. Specifically, a QCDR--
Must have in place mechanisms for the transparency of data
elements and specifications, risk models, and measures. That is, we
expect that the QCDR measures, and their data elements (that is,
specifications) comprising these measures be listed on the QCDR's Web
site unless the measure is a MIPS measure, in which case the
specifications will be posted by us. QCDR measure specifications should
be provided at a level of detail that is comparable to what is posted
by us on the CMS Web site for MIPS quality measures specifications.
Approved QCDRs may post the MIPS quality measure
specifications on their Web site, if they so choose. If the MIPS
quality measure specifications are posted by the QCDRs, they must
replicate exactly the same as the MIPS quality measure specifications
posted on the CMS Web site.
Enter into and maintain with its participating MIPS
eligible clinicians an appropriate Business Associate agreement that
complies with the HIPAA Privacy and Security Rules. Ensure that the
Business Associate agreement provides for the QCDR's receipt of
patient-specific data from an individual MIPS eligible clinician or
group, as well as the QCDR's disclosure of quality measure results and
numerator and denominator data or patient specific data on Medicare and
non-Medicare beneficiaries on behalf of MIPS eligible clinicians and
groups.
Must provide timely feedback at least 4 times a year, on
all of the MIPS performance categories that the QCDR will report to us.
We refer readers to section II.C.9.a. of this proposed rule for
additional information on third party intermediaries and performance
feedback.
For purposes of distributing performance feedback to MIPS
eligible clinicians, we encourage QCDRs to assist MIPS eligible
clinicians in the update of their email addresses in CMS systems--
including PECOS and the Identity and Access System--so that they have
access to feedback as it becomes available on www.qpp.cms.gov and have
documentation from the MIPS eligible clinician authorizing the release
of his or her email address.
As noted in the CY 2017 Quality Payment Program final rule (81 FR
77370), we will on a case-by-case basis allow QCDRs and qualified
registries to request review and approval for additional MIPS measures
throughout the performance period. We would like to explain that this
flexibility would only apply for MIPS measures; QCDRs will not be able
to request additions of any new QCDR measures throughout the
performance period. QCDRs will not be able to retire any measures they
are approved for during the performance period. Should a QCDR encounter
an issue regarding the safety or change in evidence for a measure
during the performance period, they must inform CMS of said issue and
indicate whether they will or will not be reporting on the measure, and
we will review measure issues on a case-by-case basis. Any measures
QCDRs wish to retire would need to be retained until the next annual
self-nomination process and applicable performance period.
(5) QCDR Measure Specifications Criteria
In the CY 2017 Quality Payment Program final rule (81 FR 77374
through 77375), we specified at Sec. 414.1400(f) that the QCDR must
provide specific QCDR measures specifications criteria. We generally
intend to apply a process similar to the one used for MIPS measures to
QCDR measures that have been identified as topped out. We are not
proposing any changes to the QCDR measure specifications criteria as
finalized in the CY2017 Quality Payment Program final rule. We would
like to note that for QCDR quality measures, we encourage alignment
with our measures development plan, but will consider all QCDR measures
submitted by the QCDR. For MIPS measures, we would also like to note
that CMS expects that a QCDR reporting on MIPS measures retain and use
the MIPS specifications as they exist for the performance period.
We would like to clarify that we will likely not approve retired
measures that were previously in one of CMS's quality programs, such as
the Physician Quality Reporting System (PQRS) program, if proposed as
QCDR measures. This includes measures that were retired due to being
topped out (as defined in section II.C.6.c.(2) of this proposed rule)
due to high-performance or measures retired due to a change in the
evidence supporting the use of the measure.
We seek comment for future rulemaking, on requiring QCDRs that
develop and report on QCDR measures, must fully develop and test (that
is, conduct reliability and validity testing) their QCDR measures, by
the time of submission of the new measure during the self-nomination
process.
Beginning with the 2018 performance period and for future program
years, we propose that QCDR vendors may seek permission from another
QCDR to use an existing measure that is owned by the other QCDR. If a
QCDR would like report on an existing QCDR measure that is owned by
another QCDR, they must have permission from the QCDR that owns the
measure that they can use the measure for the performance period.
Permission must be granted at the time of self-nomination, so that the
QCDR that is using the measure can include the proof of permission for
CMS review and approval for the measure to be used in the performance
period. The QCDR measure owner (QCDR vendor) would still own and
maintain the QCDR measure, but would allow other approved QCDRs to
utilize their QCDR measure with proper notification. This proposal will
help to harmonize clinically similar measures and limit the use of
measures that only slightly differ from another. We invite comments on
this proposal.
We would like to clarify from the CY 2017 Quality Payment Program
final rule (81 FR 77375) that the QCDR must publicly post the measure
specifications no later than 15 calendar days following our approval of
these measures specifications for each QCDR measure it intends to
submit for MIPS.
We refer readers to the CY 2017 Quality Payment Program final rule
for the QCDR measure specifications criteria.
(6) Identifying QCDR Quality Measures
In the CY 2017 Quality Payment Program final rule (81 FR 77375
through 77377), we finalized the definition and types of QCDR quality
measures for purposes of QCDRs submitting data for the MIPS quality
performance category. We are not proposing any changes to the criteria
on how to identify QCDR quality measures in this proposed rule. We
would like to clarify that QCDRs are not limited to reporting on QCDR
measures,
[[Page 30161]]
and may also report on MIPS measures as indicated above in the QCDR
data submission criteria section.
(7) Collaboration of Entities To Become a QCDR
In the CY 2017 Quality Payment Program final rule (81 FR 77377), we
finalized policy on the collaboration of entities to become a QCDR. We
are not proposing any changes to this policy in this proposed rule, and
would refer readers to the CY 2017 Quality Payment Program final rule
for the criteria.
In response to the CY 2017 Quality Payment Program final rule,
commenters recommended that we work with QCDRs to determine a more
reasonable cycle for self-nomination, measure selection, and reporting
because the current process is burdensome. Commenters also recommended
that we not disqualify QCDRs that do not have the capability to allow
MIPS eligible clinicians to report across all performance categories
using only one submission mechanism, and noted that the ability for
QCDRs to report their own measures allows MIPS eligible clinicians the
ability to implement measures that are more clinically meaningful and
up-to-date than those measures that may be available in the MIPS
measure set. We would like to note that we are proposing above, a
simplified self-nomination and measure selection process available to
existing QCDRs that are in good standing, beginning in the third year
of the Quality Payment Program. We would also like to explain that
QCDRs are not required to report on all performance categories across
the MIPS program, and would not be disqualified for not being able to
report data across on performance categories only using one mechanism.
We thank the commenters for their support with regards to allowing
QCDRs to nominate and report on QCDR measures that may be specialty
related. We thank the commenters for their feedback and will take their
comments into consideration in future rule making.
b. Health IT Vendors That Obtain Data From MIPS Eligible Clinicians'
Certified EHR Technology (CEHRT)
In the CY 2017 Quality Payment Program final rule 81 FR 77382, we
finalized definitions and criteria around health IT vendors that obtain
data from MIPS eligible clinicians CEHRT. We note that, for this
proposed rule, a health IT vendor that serves as a third party
intermediary to collect or submit data on behalf MIPS eligible
clinicians may or may not also be a ``health IT developer.'' Under the
ONC Health IT Certification Program (Program), (80 FR 62604), a health
IT developer constitutes a vendor, self-developer, or other entity that
presents health IT for certification or has health IT certified under
the Program. The use of ``health IT developer'' is consistent with the
use of the term ``health IT'' in place of ``EHR'' or ``EHR technology''
under the Program (see 80 FR 62604; and section II.C.6.f. of this
proposed rule). Throughout this proposed rule, we use the term ``health
IT vendor'' to refer to entities that support the health IT
requirements of a clinician participating in the Quality Payment
Program.
We are not proposing any changes to this policy in this proposed
rule, and would refer readers to the CY 2017 Quality Payment Program
final rule for the criteria. However we seek comment for future
rulemaking regarding the potential shift to seeking alternatives which
might fully replace the QRDA III format in the Quality Payment Program
in future program years.
c. Qualified Registries
In the CY 2017 Quality Payment Program final rule (81 FR 77382
through 77386), we finalized the definition and capability of qualified
registries. We are not proposing any changes to the definition or the
capabilities of qualified registries in this final rule, and refer
readers to the CY 2017 Quality Payment Program final rule for the
detailed definition and capabilities of a qualified registry.
(1) Establishment of an Entity Seeking To Qualify as a Registry
In the CY 2017 Quality Payment Program final rule (81 FR 77383), we
finalized the requirements for the establishment of an entity seeking
to qualify as a registry. We are not proposing any changes to the
criteria regarding the establishment of an entity seeking to qualify as
a registry criteria in this proposed rule, and refer readers to the
final rule for the criteria for establishing an entity seeking to
qualify as a registry.
(2) Self-Nomination Period
For the 2018 performance period, and for future years of the
program, we finalized at Sec. 414.1400(g) a self-nomination period
from September 1 of the year prior to the applicable performance
period, until November 1 of the same year. For example, for the 2018
performance period, the self-nomination period would begin on September
1, 2017, and end on November 1, 2017. Entities that desire to qualify
as a qualified registry for purposes of MIPS for a given performance
period will need to provide all requested information to us at the time
of self-nomination and would need to self-nominate for that performance
period. Having previously qualified as a qualified registry does not
automatically qualify the entity to participate in subsequent MIPS
performance periods. Furthermore, prior performance of the qualified
registry (when applicable) will be taken into consideration in approval
of their self-nomination. For example, a qualified registry may choose
not to continue participation in the program in future years, or the
qualified registry may be precluded from participation in a future
year, due to multiple data or submission errors as noted below. As
such, we believe an annual self-nomination process is the best process
to ensure accurate information is conveyed to MIPS eligible clinicians
and accurate data is submitted to MIPS.
However, we do understand that some qualified registries have no
changes to the measures and/or activity inventory they offer to their
clients and intend to participate in MIPS for many years. Because of
this, we are proposing, beginning with the 2019 performance period, a
simplified process in which existing qualified registries in good
standing may continue their participation in MIPS by attesting that the
qualified registry's approved data validation plan, cost, approved MIPS
quality measures, services, and performance categories offered in the
previous year's performance period of MIPS have minimal or no changes
and will be used for the upcoming performance period. Specifically,
existing qualified registries in good standing may attest during the
self-nomination period that they have no changes to their approved
self-nomination application from the previous year of MIPS. In
addition, the existing qualified registry may decide to make minimal
changes to their self-nomination application from the previous year,
which would be submitted by the qualified registry for CMS review and
approval by the close of the self-nomination period. Minimal changes
may include limited changes to their performance categories, adding or
removing MIPS quality measures, and adding or updating existing
services and/or cost information. By attesting that certain aspects of
their approved application from the previous year have not changed,
existing qualified registries will be spending less time completing the
entire self-nomination form, as was previously required on a yearly
basis. We are proposing such a simplified process to reduce the burden
of self-
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nomination for those existing qualified registries who have previously
participated in MIPS, and are in good standing (not on probation or
disqualified, as described below) and to allow for sufficient time for
us to review data submissions and to make determinations on the
standing of qualified registries. This proposed process will allow
existing qualified registries in good standing to avoid completing the
entire application annually, as is required in the existing process,
and in alignment with the existing timeline. We request comments on
this proposal. In the development of this proposal, we had reviewed the
possibility of offering a multi-year approval, where qualified
registries would be approved for a 2-year increment of time. We are
concerned that utilizing a multi-year approval process in which
qualified registries would be approved for 2 continuous program years
using the same fixed services they had for the first year, would not
provide the qualified registry with the flexibility to add or remove
services and or measures based on their capabilities for the upcoming
program year. Furthermore, another concern with a multi-year approval
process is the concern for those qualified registries who perform
poorly during the first year, who should be placed on probation or
disqualified (as described below). We are proposing that this process
be conducted on a yearly basis, from September 1 of the year prior to
the applicable performance period until November 1 of the same year,
starting in 2018, aligning with the annual self-nomination period in
order to ensure that only those qualified registries who are in good
standing utilize this process. We believe that this annual process will
provide qualified registries with the flexibility to make minor changes
to their services should they wish to do so. We request comments on
this proposal. We also seek comment to potentially allow for qualified
registries to utilize a multi-year approval process, in which they
would be approved for a continuous 2-year increment since qualified
registries can only make minor changes (for example, including a
performance category, or a MIPS quality measure, all of which are
already considered a part of the MIPS program).
We finalized to require further information of qualified registries
at the time of self-nomination. If an entity becomes qualified as a
qualified registry, they would need to sign a statement confirming this
information is correct prior to us listing their qualifications on
their Web site. Once we post the qualified registry on our Web site,
including the services offered by the qualified registry, we would
require the qualified registry to support these services/measures for
its clients as a condition of the entity's qualification as a qualified
registry for purposes of MIPS. Failure to do so will preclude the
qualified registry from participation in MIPS in the subsequent
performance year.
For the 2018 performance period and beyond, we are proposing that
self-nomination information must be submitted via a web-based tool, and
to eliminate the submission method of email. We will provide further
information on the web-based tool at www.qpp.cms.gov. We request
comments on this proposal.
(3) Information Required at the Time of Self-Nomination
We finalized in the CY 2017 Quality Payment Program final rule (81
FR 77384) that a qualified registry must provide specific information
to us at the time of self-nomination. We are not proposing any changes
to the information required at the time of self-nomination in this
proposed rule, and refer readers to the final rule for specific
information requirements.
(4) Qualified Registry Criteria for Data Submission
In the CY 2017 Quality Payment Program final rule (81 FR 77386), we
finalized the criteria for qualified registry data submission. We are
not proposing any changes to the data submission criteria in this
proposed rule, and refer readers to the final rule for specific
criteria regarding qualified registry data submission. We would like to
note two clarifications to the existing criteria:
Enter into and maintain with its participating MIPS
eligible clinicians an appropriate Business Associate agreement that
complies with the HIPAA Privacy and Security Rules. Ensure that the
Business Associate agreement provides for the Qualified Registry's
receipt of patient-specific data from an individual MIPS eligible
clinician or group, as well as the Qualified Registry's disclosure of
quality measure results and numerator and denominator data or patient
specific data on Medicare and non-Medicare beneficiaries on behalf of
individual MIPS eligible clinicians and groups.
We had finalized that timely feedback be provided at least
four times a year, on all of the MIPS performance categories that the
qualified registry will report to us. We refer readers to section
II.C.9.a. of this proposed rule for additional information on third
party intermediaries and performance feedback.
We had received comments in response to the CY 2017 Quality Payment
Program final rule from commenters who expressed concern that the 3
percent acceptable error rate for qualified registries is too low.
Commenters recommended we analyze reporting for the transition year and
increase the error rate to 5 percent at the minimum because qualified
registries may make a small number of errors given that 2017 is the
first year of MIPS and that removing qualified registries due to a low
error threshold could hurt clinicians. We thank the commenters for
their feedback and will take the comments into consideration in future
rulemaking.
As indicated in the CY 2017 Quality Payment Program final rule (81
FR 77370), we will on a case-by-case basis allow qualified registries
to request review and approval for additional MIPS measures throughout
the performance period. Any new measures that are approved by us will
be added to the information related to the qualified registry on the
CMS Web site, as technically feasible. We anticipate only being able to
update this information on the Web site on a quarterly basis, as
technically feasible.
d. CMS-Approved Survey Vendors
In the CY 2017 Quality Payment Program final rule (81 FR 77386), we
finalized the definition, criteria, required forms, and vendor business
requirements needed to participate in MIPS as a survey vendor. We refer
readers to the CY 2017 Quality Payment Program final rule for specific
details on requirements. We have heard from some groups that it would
be useful to have a final list of CMS-approved survey vendors to inform
their decision on whether or not to participate in the CAHPS for MIPS
survey. Therefore, beginning with the 2018 performance period and for
future program years, we propose to remove the April 30th survey vendor
application deadline because this deadline is within the timeframe of
when groups can elect to participate in the CAHPS for MIPS survey. In
order to provide a final list of CMS-approved survey vendors earlier in
the timeframe during which groups can elect to participate in the CAHPS
for MIPS survey, an earlier vendor application deadline would be
necessary. This could be accomplished by having a rolling application
period, where vendors would be able to submit an application by the end
of the first quarter. However, in addition to
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submitting a vendor application, vendors must also complete vendor
training and submit a Quality Assurance Plan and we need to allow
sufficient time for these requirements as well. Therefore, we propose
for the Quality Payment Program Year 2 and future years that the vendor
application deadline would be January 31st of the applicable
performance year or a later date specified by CMS. This proposal would
allow us to adjust the application deadline beyond January 31st on a
year to year basis, based on program needs. We will notify vendors of
the application deadline to become a CMS-approved survey vendor through
additional communications and postings. We request comments on this
proposal and other alternatives that would allow us to provide a final
list of CMS-approved survey vendors early in the timeframe during which
groups can elect to participate in the CAHPS for MIPS survey.
e. Probation and Disqualification of a Third Party Intermediary
At Sec. 414.1400(k), we finalized the process for placing third
party intermediaries on probation and for disqualifying such entities
for failure to meet certain standards established by us (81 FR 77386).
Specifically, we proposed that if at any time we determine that a third
party intermediary (that is, a QCDR, health IT vendor, qualified
registry, or CMS-approved survey vendor) has not met all of the
applicable criteria for qualification, we may place the third party
intermediary on probation for the current performance period or the
following performance period, as applicable.
In addition, we finalized that we require a corrective action plan
from the third party intermediary to address any deficiencies or issues
and prevent them from recurring. We finalized that the corrective
action plan must be received and accepted by us within 14 days of the
CMS notification to the third party intermediary of the deficiencies or
probation. Failure to comply with these corrective action plan
requirements would lead to disqualification from MIPS for the
subsequent performance period.
We finalized for probation to mean that, for the applicable
performance period, the third party intermediary must meet all
applicable criteria for qualification and approval and also must submit
a corrective action plan for remediation or correction of any
deficiencies identified by CMS that resulted in the probation (81 FR
77548).
In addition, we finalized that if the third party intermediary has
data inaccuracies including (but not limited to) TIN/NPI mismatches,
formatting issues, calculation errors, data audit discrepancies
affecting in excess of 3 percent (but less than 5 percent) of the total
number of MIPS eligible clinicians or groups submitted by the third
party intermediary, we would annotate the listing of qualified third
party intermediaries on the CMS Web site, noting that the third party
intermediary furnished data of poor quality and would place the entity
on probation for the subsequent performance period.
Further, we finalized if the third party intermediary does not
reduce their data error rate below 3 percent for the subsequent
performance period, the third party intermediary would continue to be
on probation and have their listing on the CMS Web site continue to
note the poor quality of the data they are submitting for MIPS for one
additional performance period. After 2 years on probation, the third
party intermediary would be disqualified for the subsequent performance
period. Data errors affecting in excess of 5 percent of the MIPS
eligible clinicians or groups submitted by the third party intermediary
may lead to the disqualification of the third party intermediary from
participation for the following performance period. In placing the
third party intermediary on probation; we would notify the third party
intermediary of the identified issues, at the time of discovery of such
issues.
In addition, we finalized that if the third party intermediary does
not submit an acceptable corrective action plan within 14 days of
notification of the deficiencies and correct the deficiencies within 30
days or before the submission deadline--whichever is sooner, we may
disqualify the third party intermediary from participating in MIPS for
the current performance period or the following performance period, as
applicable.
We note that MIPS eligible clinicians are ultimately responsible
for the data that are submitted by their third party intermediaries and
expect that MIPS eligible clinicians and groups should ultimately hold
their third party intermediaries accountable for accurate reporting. We
will consider cases of vendors leaving the marketplace during the
performance period on a case by case basis, but would note that we will
not consider cases prior to the performance period. We would however,
need proof that the MIPS eligible clinician had an agreement in place
with the vendor at the time of their withdrawal from the marketplace.
We are not proposing any changes to the process of probation and
disqualification of a third party intermediary in this proposed rule.
Commenters on the final rule requested that we provide
opportunities for MIPS eligible clinicians and groups that discover an
issue with their third party intermediary to change reporting methods
and/or third party intermediaries without restriction on the eligible
clinicians. We thank the commenters for their feedback and will take
the comments into consideration in future rulemaking.
f. Auditing of Third Party Intermediaries Submitting MIPS Data
In the CY 2017 Quality Payment Program final rule (81 FR 77389), we
finalized at Sec. 414.1400(j) that any third party intermediary (that
is, a QCDR, health IT vendor, qualified registry, or CMS-approved
survey vendor) must comply with the following procedures as a condition
of their qualification and approval to participate in MIPS as a third
party intermediary:
(1) The entity must make available to us the contact information of
each MIPS eligible clinician or group on behalf of whom it submits
data. The contact information will include, at a minimum, the MIPS
eligible clinician or group's practice phone number, address, and if
available, email;
(2) The entity must retain all data submitted to us for MIPS for a
minimum of 10 years; and
(3) For the purposes of auditing, we may request any records or
data retained for the purposes of MIPS for up to 6 years and 3 months.
We are proposing to change Sec. 414.1400(j)(2) to clarify that the
entity must retain all data submitted to us for purposes of MIPS for a
minimum of 10 years from the end of the MIPS performance period.
11. Public Reporting on Physician Compare
This section contains the approach for public reporting on
Physician Compare for the CY 2018 Quality Payment Program final rule,
including MIPS, APMs, and other information as required by the MACRA
and building on the MACRA public reporting policies previously
finalized (81 FR 77390 through 77399).
Physician Compare draws its operating authority from section
10331(a)(1) of the Affordable Care Act. As required by section
10331(a)(1) of the Affordable Care Act, by January 1, 2011, we
developed a Physician Compare
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Internet Web site with information on physicians enrolled in the
Medicare program under section 1866(j) of the Act, as well as
information on other EPs who participate in the PQRS under section 1848
of the Act. More information about Physician Compare can be accessed on
the Physician Compare Initiative Web site at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/physician-compare-initiative/.
The first phase of Physician Compare was launched on December 30,
2010 (http://www.medicare.gov/physiciancompare). Since the initial
launch, Physician Compare has been continually improved and more
information has been added. In December 2016, the site underwent a
complete user-informed, evidenced-based redesign to further enhance
usability and functionality on both desktop computers and mobile
devices and to begin to prepare the site for the inclusion of more data
as required by the MACRA.
Currently, Web site users can view information about approved
Medicare clinicians, such as: Name; Medicare primary and secondary
specialties; practice locations; group affiliations; hospital
affiliations that link to the hospital's profile on Hospital Compare as
available; Medicare assignment status; education; residency; and,
American Board of Medical Specialties (ABMS), American Osteopathic
Association (AOA), and American Board of Optometry (ABO) board
certification information. For groups, users can view group names,
specialties, practice locations, Medicare assignment status, and
affiliated clinicians. In December 2016, we also added indicators on
the results page to show those clinicians and groups that had
performance scores available to view. We also included an indicator on
profile pages to show those Medicare clinicians and groups that
satisfactorily or successfully participated in a CMS quality program to
indicate their commitment to quality.
Consistent with section 10331(a)(2) of the Affordable Care Act,
Physician Compare phased in public reporting of performance scores that
provide comparable information on quality and patient experience
measures for reporting periods beginning January 1, 2012. To the extent
that scientifically sound measures are developed and are available,
Physician Compare is required to include, to the extent practicable,
the following types of measures for public reporting: Measures
collected under PQRS and an assessment of efficiency, patient health
outcomes, and patient experience, as specified. The first set of
quality measures were publicly reported on Physician Compare in
February 2014. Currently, Physician Compare publicly reports 91 group-
level measures collected through either the Web Interface or registry
for groups participating in 2015 under the PQRS, 19 quality measures
for ACOs participating in the 2015 Shared Savings Program or Pioneer
ACO program, and 90 individual clinician-level measures collected
either through claims or registry for individual EPs participating in
2015 under the PQRS. In addition, 31 total individual clinician-level
Qualified Clinical Data Registry (QCDR) non-PQRS measures are publicly
available either through Physician Compare profile pages or 2015 QCDR
Web sites. A complete history of public reporting on Physician Compare
is detailed in the CY 2016 PFS final rule (80 FR 71117 through 71122).
As finalized in the CY 2015 and CY 2016 PFS final rules (79 FR
67547 and 80 FR 70885, respectively), Physician Compare will continue
to expand public reporting. This expansion includes publicly reporting
both individual eligible professional (now referred to as eligible
clinician) and group-level QCDR measures starting with 2016 data
available for public reporting in late 2017, as well as the inclusion
of a benchmark and 5-star rating in late 2017 based on 2016 data (80 FR
71125 and 71129), among other additions.
This expansion will continue under the MACRA. Sections
1848(q)(9)(A) and (D) of the Act facilitate the continuation of our
phased approach to public reporting by requiring the Secretary to make
available on the Physician Compare Web site, in an easily
understandable format, individual MIPS eligible clinician and group
performance information, including:
The MIPS eligible clinician's final score;
The MIPS eligible clinician's performance under each MIPS
performance category (quality, cost, improvement activities, and
advancing care information);
Names of eligible clinicians in Advanced APMs and, to the
extent feasible, the names of such Advanced APMs and the performance of
such models; and,
Aggregate information on the MIPS, posted periodically,
including the range of final scores for all MIPS eligible clinicians
and the range of the performance of all MIPS eligible clinicians for
each performance category.
Initial plans to publicly report this performance information on
Physician Compare were finalized in the CY 2017 Quality Payment Program
final rule (81 FR 77390). The proposals related to each of these
requirements for year 2 of the Quality Payment Program are addressed
below in this section.
Section 1848(q)(9)(B) of the Act also requires that this
information indicate, where appropriate, that publicized information
may not be representative of the eligible clinician's entire patient
population, the variety of services furnished by the eligible
clinician, or the health conditions of individuals treated. The
information mandated for Physician Compare under section 1848(q)(9) of
the Act will generally be publicly reported consistent with sections
10331(a)(2) and 10331(b) of the Affordable Care Act, and like all
measure data included on Physician Compare, will be comparable. In
addition, section 10331(b) of the Affordable Care Act requires that we
include, to the extent practicable, processes to ensure that data made
public are statistically valid, reliable, and accurate, including risk
adjustment mechanisms used by the Secretary. In addition to the public
reporting standards identified in the Affordable Care Act--
statistically valid and reliable data that are accurate and
comparable--we have established a policy that, as determined through
user testing, the data we disclose generally should resonate with and
be accurately interpreted by Web site users to be included on Physician
Compare profile pages. Together, we refer to these conditions as the
Physician Compare public reporting standards (80 FR 71118 through
71120). Section 10331(d) of the Affordable Care Act also requires us to
consider input from multi-stakeholder groups, consistent with sections
1890(b)(7) and 1890A of the Act. We continue to receive general input
from stakeholders on Physician Compare through a variety of means,
including rulemaking and different forms of stakeholder outreach (for
example, Town Hall meetings, Open Door Forums, webinars, education and
outreach, Technical Expert Panels, etc.).
In addition, section 1848(q)(9)(C) of the Act requires the
Secretary to provide an opportunity for MIPS eligible clinicians to
review the information that will be publicly reported prior to such
information being made public. This is generally consistent with
section 10331(a)(2) of the Affordable Care Act, under which we have
established a 30-day preview period for all measurement performance
data that allows physicians and other eligible clinicians to view
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their data as it will appear on the Web site in advance of publication
on Physician Compare (80 FR 77392). Section 1848(q)(9)(C) of the Act
also requires that MIPS eligible clinicians be able to submit
corrections for the information to be made public. We finalized a
policy to extend the current Physician Compare 30-day preview period
for MIPS eligible clinicians starting with data from the 2017 MIPS
performance period, which is available for public reporting in late
2018. Therefore, we finalized a 30-day preview period in advance of the
publication of data on Physician Compare (81 FR 77392).
We will coordinate data review and any relevant data resubmission
or correction between Physician Compare and the four performance
categories of MIPS. All data available for public reporting--measure
rates, scores, and attestations, etc.--are available for review and
correction during the targeted review process, which will begin at
least 30 days in advance of the publication of new data. Data under
review is not publicly reported until the review is complete. All
corrected measure rates, scores, and attestations submitted as part of
this process are available for public reporting. The technical details
of the process are communicated directly to affected MIPS eligible
clinicians and groups and detailed outside of rulemaking with specifics
made public on the Physician Compare Initiative page on www.cms.gov and
communicated through Physician Compare and other CMS listservs (81 FR
77391).
In addition, section 1848(q)(9)(D) of the Act requires that
aggregate information on the MIPS be periodically posted on the
Physician Compare Web site, including the range of final scores for all
MIPS eligible clinicians and the range of performance for all MIPS
eligible clinicians for each performance category.
Lastly, section 104(e) of the MACRA requires the Secretary to make
publicly available, on an annual basis, in an easily understandable
format, information for physicians and, as appropriate, other eligible
clinicians related to items and services furnished to people with
Medicare, and to include, at a minimum:
Information on the number of services furnished under Part
B, which may include information on the most frequent services
furnished or groupings of services;
Information on submitted charges and payments for Part B
services; and,
A unique identifier for the physician or other eligible
clinician that is available to the public, such as an NPI.
The information is further required to be made searchable by at
least specialty or type of physician or other eligible clinician;
characteristics of the services furnished (such as, volume or groupings
of services); and the location of the physician or other eligible
clinician.
In accordance with section 104(e) of the MACRA, we finalized a
policy in the CY 2016 PFS final rule (80 FR 71130) to add utilization
data to the Physician Compare downloadable database. Utilization data
is currently available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html. This information is integrated
on the Physician Compare Web site via the downloadable database each
year using the most current data, starting with the 2016 data, targeted
for initial release in late 2017 (80 FR 71130). Not all available data
will be included. The specific HCPCS codes included are to be
determined based on analysis of the available data, focusing on the
most used codes. Additional details about the specific HCPCS codes that
are included in the downloadable database will be provided to
stakeholders in advance of data publication. All data available for
public reporting--on the public-facing Web site pages or in the
downloadable database--are available for review during the 30-day
preview period.
We propose to revise the public reporting regulation at Sec.
414.1395(a), to more completely and accurately reference the data
available for public reporting on Physician Compare. We propose to
modify Sec. 414.1395(a) to remove from the heading and text references
to ``MIPS'' and ``public Web site'' and instead reference ``Quality
Payment Program'' and ``Physician Compare''. Specifically, proposed
Sec. 414.1395(a) reads as follows: ``Public reporting of eligible
clinician and group Quality Payment Program information. For each
program year, CMS posts on Physician Compare, in an easily
understandable format, information regarding the performance of
eligible clinicians or groups under the Quality Payment Program.'' We
also propose to add paragraphs (b), (c), and (d) at Sec. 414.1395, to
capture previously established policies for Physician Compare relating
to the public reporting standards, first year measures, and the 30-day
preview period. Specifically, at proposed Sec. 414.1395(b), we propose
that, with the exception of data that must be mandatorily reported on
Physician Compare, for each program year, we rely on the established
public reporting standards to guide the information available for
inclusion on Physician Compare. The public reporting standards require
data included on Physician Compare to be statistically valid, reliable,
and accurate; be comparable across reporting mechanisms; and, meet the
reliability threshold. And, to be included on the public facing profile
pages, the data must also resonate with Web site users, as determined
by CMS. At proposed Sec. 414.1395(c), we propose to codify our policy
regarding first year measures: ``For each program year, CMS does not
publicly report any first year measure, meaning any measure in its
first year of use in the quality and cost performance categories. After
the first year, CMS reevaluates measures to determine when and if they
are suitable for public reporting.'' At proposed Sec. 414.1395(d), we
propose to specify the 30-day preview period rule: ``For each program
year, CMS provides a 30-day preview period for any clinician or group
with Quality Payment Program data before the data are publicly reported
on Physician Compare.''
We believe section 10331 of the Affordable Care Act supports the
overarching goals of the MACRA by providing the public with quality
information that will help them make informed decisions about their
health care, while encouraging clinicians to improve the quality of
care they provide to their patients. In accordance with section 10331
of the Affordable Care Act, section 1848(q)(9) of the Act, and section
104(e) of the MACRA, we plan to continue to publicly report performance
information on Physician Compare. As such, we propose the inclusion of
the following information on Physician Compare.
a. Final Score, Performance Categories, and Aggregate Information
Sections 1848(q)(9)(A) and (D) of the Act require that we publicly
report on Physician Compare the final score for each MIPS eligible
clinician, performance of each MIPS eligible clinician for each
performance category, and periodically post aggregate information on
the MIPS, including the range of final scores for all MIPS eligible
clinicians and the range of performance of all the MIPS eligible
clinicians for each performance category. We finalized such data for
public reporting on Physician Compare for the transition year (81 FR
77393), and we are now proposing to add these data each year to
Physician Compare for each MIPS eligible clinician or group, either on
the profile pages or in the downloadable
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database, as technically feasible. Statistical testing and user
testing, as well as consultation of the Physician Compare Technical
Expert Panel, will determine how and where these data are best reported
on Physician Compare. As the MACRA requires that this information be
available for public reporting on Physician Compare, we are proposing
to include it each year moving forward, as technically feasible. We
request comment on this proposal to publicly report on Physician
Compare the final score for each MIPS eligible clinician or group,
performance of each MIPS eligible clinician or group for each
performance category, and periodically post aggregate information on
the MIPS, including the range of final scores for and the range of
performance of all the MIPS eligible clinicians or groups for each
performance category, as technically feasible.
A detailed discussion of proposals related to each performance
category of MIPS data follows.
b. Quality
As detailed in the CY 2017 Quality Payment Program final rule (81
FR 77395), and consistent with the existing policy that makes all
current PQRS measures available for public reporting, we finalized a
decision to make all measures under the MIPS quality performance
category available for public reporting on Physician Compare in the
transition year of the Quality Payment Program, as technically
feasible. This included all available measures reported via all
available submission methods, and applied to both MIPS eligible
clinicians and groups.
Also consistent with current policy, although all measures will be
available for public reporting, not all measures will be made available
on the public-facing Web site profile pages. As explained in the CY
2017 Quality Payment Program final rule (81 FR 77394), providing too
much information can overwhelm Web site users and lead to poor decision
making. Therefore, consistent with section 1848(q)(9)(A)(i)(II) of the
Act, all measures in the quality performance category that meet the
statistical public reporting standards will be included in the
downloadable database, as technically feasible. We also finalized a
policy that a subset of these measures will be publicly reported on the
Web site's profile pages, as technically feasible, based on Web site
user testing. Statistical testing and user testing will determine how
and where measures are reported on Physician Compare. In addition, we
adopted our existing policy of not publicly reporting first year
measures, meaning new measures that have been in use for less than 1
year, regardless of submission method used, for this MIPS quality
performance category. After a measure's first year in use, we will
evaluate the measure to see if and when the measure is suitable for
public reporting (81 FR 77395).
Currently, there is a minimum sample size requirement of 20
patients for performance data to be included on Physician Compare. We
previously sought comment on moving away from this requirement and
moving to a reliability threshold for public reporting. In general,
commenters supported a minimum reliability threshold. As a result, we
finalized instituting a minimum reliability threshold for public
reporting data on Physician Compare starting with 2017 data available
for public report in late 2018 and each year moving forward (81 FR
77395).
The reliability of a measure refers to the extent to which the
variation in the performance rate is due to variation in quality of
care as opposed to random variation due to sampling. Statistically,
reliability depends on performance variation for a measure across
entities, the random variation in performance for a measure within an
entity's panel of attributed patients, and the number of patients
attributed to the entity. High reliability for a measure suggests that
comparisons of relative performance across entities, such as eligible
clinicians or groups, are likely to be stable and consistent, and that
the performance of one entity on the quality measure can confidently be
distinguished from another. We will conduct analyses to determine the
reliability of the data collected and use this to calculate the minimum
reliability threshold for the data. Once an appropriate minimum
reliability threshold is determined, we will only publicly report those
performance rates for any given measure that meet the minimum
reliability threshold. We note that reliability standards for public
reporting and reliability for scoring need not align; reliability for
public reporting is unique because, for example, public reporting
requires ensuring additional protections to maintain confidentiality.
In addition, because publicly reported measures can be compared across
clinicians and across groups, it is particularly important for the most
stringent reliability standards to be in place to ensure differences in
performance scores reflect true differences in quality of care to
promote accurate comparisons by the public. For further information on
reliability as it relates to scoring of cost measures see section
II.C.7.a.(3) of this proposed rule.
In the CY 2017 Quality Payment Program final rule, we established
that we will include the total number of patients reported on each
measure in the downloadable database to facilitate transparency and
more accurate understanding and use of the data (81 FR 77395). We will
begin publishing the total number of patients reported on each measure
in the downloadable database with 2017 data available for public
reporting in late 2018 and for each year moving forward.
Understanding that we will continue our policies to not publicly
report first year quality measures, that we will only report those
measures that meet the reliability threshold and meet the public
reporting standards, and include the total number of patients reported
on for each measure in the downloadable database, we are again
proposing to make all measures under the MIPS quality performance
category available for public reporting on Physician Compare, as
technically feasible. This would include all available measures
reported via all available submission methods for both MIPS eligible
clinicians and groups, for 2018 data available for public reporting in
late 2019, and for each year moving forward, these data are required by
the MACRA to be available for public reporting on Physician Compare,
continuing to publicly report these data ensures continued transparency
and provides people with Medicare and their caregivers valuable
information they can use to make informed health care decisions. We
request comment on this proposal.
In addition, we seek comment on expanding the patient experience
data available for public reporting on Physician Compare. Currently,
the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for
MIPS survey is available for groups to report under the MIPS. This
patient experience survey data is highly valued by patients and their
caregivers as they evaluate their health care options. However, in
testing with patient and caregivers, they regularly ask for more
information from patients like them in their own words. Patients
regularly request we include narrative reviews of clinicians and groups
on the Web site. The Agency for Healthcare Research and Quality (AHRQ)
is fielding a beta version of the CAHPS Patient Narrative Elicitation
Protocol (https://www.ahrq.gov/cahps/surveys-guidance/item-sets/elicitation/index.html). This includes five open-ended questions
designed to be added to the Clinician &
[[Page 30167]]
Groups CAHPS survey, which CAHPS for MIPS is molded after. These five
questions have been developed and tested to work to capture patient
narratives in a scientifically grounded and rigorous way, setting it
apart from other patient narratives collected by various health systems
and patient rating sites. More scientifically rigorous patient
narrative data would not only greatly benefit patients, but it would
also greatly aid clinicians and groups as they work to assess how their
patients experience care. We are seeking comment on potentially public
reporting these five open-ended questions for the CAHPS for MIPS survey
on Physician Compare as a consideration in future rulemaking. We direct
readers to the Quality Performance Criteria in section II.C.6.b.(3)(a)
of this proposed rule for additional information related to seeking
comment on adding these questions to the CAHPS for MIPS survey.
c. Cost
Consistent with section 1848(q)(9)(A)(i)(II) of the Act, we
finalized in the CY 2017 Quality Payment Program final rule a decision
to make all measures under the MIPS cost performance category available
for public reporting on Physician Compare (81 FR 77396). This included
all available measures reported via all available submission methods,
and applied to both MIPS eligible clinicians and groups. However, as
noted in the final rule, we may not have data available for public
reporting in the transition year of the Quality Payment Program for the
cost performance category (2017 data available for public reporting in
late 2018).
As discussed in the final rule (81 FR 77395), cost data are
difficult for patients to understand and, as a result, publicly
reporting these measures could lead to significant misinterpretation
and misunderstanding. For this reason, we are again proposing to
include on Physician Compare a sub-set of cost measures that meet the
public reporting standards, either on profile pages or in the
downloadable database, if technically feasible, for 2018 data available
for public reporting in late 2019, and for each year moving forward.
These data are required by the MACRA to be available for public
reporting on Physician Compare, but we want to ensure we only share
those cost measures that can help patients and caregivers make informed
health care decisions on profile pages. For transparency purposes, the
cost measures that meet all other public reporting standards would be
included in the downloadable database. Statistical testing and Web site
user testing would determine how and where measures are reported on
Physician Compare to minimize passing the complexity of these measures
on to patients and to ensure those measures included are accurately
understood and correctly interpreted. Under this proposal, we note that
the policies we previously mentioned regarding first year measures, the
minimum reliability threshold, and all public reporting standards would
apply. This proposal applies to all available measures reported via all
available submission methods, and applies to both MIPS eligible
clinicians and groups. We request comment on this proposal.
d. Improvement Activities
Consistent with section 1848(q)(9)(A)(i)(II) of the Act, we
finalized a decision to make all activities under the MIPS improvement
activities performance category available for public reporting on
Physician Compare (81 FR 77396). This included all available
improvement activities reported via all available submission methods,
and applied to both MIPS eligible clinicians and groups.
Consistent with the policy finalized for the transition year, we
are again proposing to include a subset of improvement activities data
on Physician Compare that meet the public reporting standards, either
on the profile pages or in the downloadable database, if technically
feasible, for 2018 data available for public reporting in late 2019,
and for each year moving forward. This again includes all available
activities reported via all available submission methods, and applies
to both MIPS eligible clinicians and groups. For those eligible
clinicians or groups that successfully meet the improvement activities
performance category requirements this information may be posted on
Physician Compare as an indicator. This information is required by the
MACRA to be available for public reporting on Physician Compare, but
the improvement activities performance category is a new field of data
for Physician Compare so concept and Web site user testing is still
needed to ensure these data are understood by stakeholders. Therefore,
we again propose that statistical testing and user testing would
determine how and where improvement activities are reported on
Physician Compare.
For the transition year, we proposed to exclude first year
activities from public reporting. First year activities are any
improvement activities in their first year of use. Starting with year 2
(2018 data available for public reporting in late 2019), we propose
publicly reporting first year activities if all other reporting
criteria are satisfied. This evolution in our Quality Payment Program
public reporting plan provides an opportunity to make more valuable
information public given that completion of or participation in
activities the first year they are available is different from
reporting first year quality or cost measures. Clinicians and groups
can learn from the first year of quality and cost data, understand why
their performance rate is what it is, and take time to improve. A
waiting period for indicating completion or participation in an
improvement activity is unlikely to produce the same benefit. We
request comments on these proposals.
e. Advancing Care Information
Since the beginning of the EHR Incentive Programs in 2011,
participant performance data has been publicly available in the form of
public use files on the CMS Web site. In the 2015 EHR Incentive
Programs final rule (80 FR 62901), we addressed comments requesting
that we not only continue this practice but also include a wider range
of information on participation and performance. In that rule, we
stated our intent to publish the performance and participation data on
Stage 3 objectives and measures of meaningful use in alignment with
quality programs which utilize publicly available performance data such
as Physician Compare. At this time there is only an indicator on
Physician Compare profile pages to show that an eligible clinician
successfully participated in the current Medicare EHR Incentive
Program.
As MIPS will include advancing care information as one of the four
MIPS performance categories, we decided, consistent with section
1848(q)(9)(i)(II) of the Act, to include more information on an
eligible clinician's or group's performance on the objectives and
measures of meaningful use on Physician Compare for the transition year
(81 FR 77387). An important consideration was that to meet the public
reporting standards, the data added to Physician Compare must resonate
with Medicare patients and their caregivers. Testing to date has shown
that people with Medicare value the use of certified EHR technology and
see EHR use as something that if used well can improve the quality of
their care. In addition, we believe the inclusion of indicators for
clinicians and groups who achieve high
[[Page 30168]]
performance in key care coordination and patient engagement activities
provide significant value for patients and their caregivers as they
make health care decisions.
Consistent with our transition year final policy, and understanding
the value of this information to Web site users, we are again proposing
to include an indicator on Physician Compare for any eligible clinician
or group who successfully meets the advancing care information
performance category, as technically feasible. Also, as technically
feasible, we propose to include additional indicators, including but
not limited to, objectives, activities, or measures specified in
section II.C.6.f. of this proposed rule, such as, identifying if the
eligible clinician or group scores high performance in patient access,
care coordination and patient engagement, or health information
exchange. These proposals would apply to 2018 data available for public
reporting in late 2019, and for each year moving forward, as this
information is required by the MACRA to be available for public
reporting on Physician Compare. We also propose that any advancing care
information objectives, activities, or measures would need to meet the
public reporting standards applicable to data posted on Physician
Compare, either on the profile pages or in the downloadable database.
This would include all available objectives, activities, or measures
reported via all available submission methods, and would apply to both
MIPS eligible clinicians and groups. Statistical testing and Web site
user testing would determine how and where objectives and measures are
reported on Physician Compare. As with improvement activities, we are
also proposing to allow first year advancing care information
objectives, activities, and measures to be available for public
reporting starting in year 2 (2018 data available for public reporting
in late 2019). Again, especially if we are including an indicator over
a performance rate, the benefits of waiting 1 year are not the same and
thus, we believe it is more important to make more information
available for public reporting as the Quality Payment Program matures.
We request comment on these proposals.
f. Achievable Benchmark of Care (ABCTM)
Benchmarks are important to ensuring that the quality data
published on Physician Compare are accurately understood. A benchmark
allows Web site users to more easily evaluate the information published
by providing a point of comparison between groups and between
clinicians. In an effort to find the best possible methodology for
Physician Compare, we embarked on a year-long information gathering and
stakeholder outreach effort in advance of the CY 2016 PFS rule process.
We reached out to stakeholders, including specialty societies, consumer
advocacy groups, physicians and other clinicians, measure experts, and
quality measure specialists, as well as other CMS Quality Programs.
Based on this outreach and the recommendation of our Technical Expert
Panel, we proposed and ultimately finalized (80 FR 71129) a decision to
publicly report on Physician Compare an item, or measure-level,
benchmark using the Achievable Benchmark of Care (ABCTM)
\21\ methodology annually based on the PQRS performance rates most
recently available by reporting mechanism. As a result, in late 2017,
we expect to publicly report a benchmark based on the 2016 PQRS
performance rates for each measure by each available reporting
mechanism. The specific measures the benchmark will be calculated for
will be determined once the data are available and analyzed. As with
all data, the benchmark will only be applied to those measures deemed
to meet the established public reporting standards.
---------------------------------------------------------------------------
\21\ Kiefe CI, Weissman NW., Allison JJ, Farmer R, Weaver M,
Williams OD. Identifying achievable benchmarks of care: concepts and
methodology. International Journal of Quality Health Care. 1998 Oct;
10(5):443-7.
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We believe ABCTM is a well-tested, data-driven
methodology that allows us to account for all of the data collected for
a quality measure, evaluate who the top performers are, and then use
that to set a point of comparison for all of those groups or clinicians
who report the measure.
ABCTM starts with the pared-mean, which is the mean of
the best performers on a given measure for at least 10 percent of the
patient population--not the population of reporters. To find the pared-
mean, we will rank order physicians or groups (as appropriate per the
measure being evaluated) in order from highest to lowest performance
score. We will then subset the list by taking the best performers
moving down from best to worst until we have selected enough reporters
to represent 10 percent of all patients in the denominator across all
reporters for that measure.
We finalized that the benchmark would be derived by calculating the
total number of patients in the highest scoring subset receiving the
intervention or the desired level of care, or achieving the desired
outcome, and dividing this number by the total number of patients that
were measured by the top performing doctors. This would produce a
benchmark that represents the best care provided to the top 10 percent
of patients by measure, by reporting mechanism.
An Example: A clinician reports on how many patients with diabetes
she has given foot exams. There are four steps to establishing the
benchmark for this measure.
(1) We look at the total number of patients with diabetes for all
clinicians who reported this diabetes measure.
(2) We rank clinicians that reported this diabetes measure from
highest performance score to lowest performance score to identify the
set of top clinicians who treated at least 10 percent of the total
number of patients with diabetes.
(3) We count how many of the patients with diabetes who were
treated by the top clinicians also got a foot exam.
(4) This number is divided by the total number of patients with
diabetes who were treated by the top clinicians, producing the
ABCTM benchmark.
To account for low denominators, ABCTM suggests the
calculation of an adjusted performance fraction (AFP) using a Bayesian
Estimator or use of another statistical methodology. After analysis, we
have determined that the use of a beta binomial model adjustment is
most appropriate for the type of data we are working with. The beta
binomial method moves extreme values toward the average for a given
measure, while the Bayesian Estimator moves extreme values toward 50
percent. Using the beta binomial method is a more methodologically
sophisticated approach to address the issue of extreme values based on
small sample sizes. This ensures that all clinicians are accounted for
and appropriately figured in to the benchmark.
The benchmarks for Physician Compare developed using the
ABCTM methodology will be based on the current year's data,
so the benchmark will be appropriate regardless of the unique
circumstances of data collection or the measures available in a given
reporting year. We also finalized (80 FR 71129) a decision to use the
ABCTM methodology to generate a benchmark which will be used
to systematically assign stars for the Physician Compare 5-star rating.
The details of how the benchmark will be specifically used to determine
the 5-star categories for all applicable measures is being determined
in close collaboration with stakeholders, CMS programs, measure
experts, and the Physician Compare
[[Page 30169]]
Technical Expert Panel. We expect to publicly report the benchmark and
5-star rating for the first time on Physician Compare in late 2017
using the 2016 PQRS performance scores for both clinicians and groups.
As a result of stakeholder feedback asking that we consider one
consistent approach for benchmarking and parsing the data based on the
benchmark across the Quality Payment Program, we did consider an
alternative approach. We reviewed the benchmark and decile breaks being
used to assign points and determine payment under MIPS (see
II.C.7.a.(2)(b) of this proposed rule). This approach was not
considered ideal for public reporting for several reasons. A primary
concern was that the decile approach when used for public reporting
would force a star rating distribution inconsistent with the raw
distribution of scores on a given measure. If applied to star ratings,
there would need to be an equal distribution of clinicians in each of
the star rating categories.
Using the ABCTM methodology for the benchmark sets the
5-star rating at the performance rate that is the best achievable rate
in the current clinical climate based on the current set of measures
and the current universe of reporters. The star ratings are then
derived from there consistent with the raw score distribution. In this
way, if the majority of clinicians performed well on a measure, the
majority would receive a high star rating. If we used the decile
approach some clinicians would be reported as having a ``low'' star
rating despite their relative performance on the measure.
It is not always ideal to use the same methodology across the
program as scoring for payment purposes may be designed in a somewhat
different way that may incorporate factors that are not necessarily as
applicable for public reporting, while the key consideration for public
reporting is that the methodology used best helps patients and
caregivers easily interpret the data accurately. Testing with Web site
users has shown that the star rating based on the ABCTM
benchmark helps patients and caregivers interpret the data accurately.
ABCTM has been historically well received by the
clinicians and entities it is measuring because the benchmark
represents quality while being both realistic and achievable; it
encourages continuous quality improvement; and, it is shown to lead to
improved quality of care.22 23 24 Appreciating this and the
support this methodology received in previous rulemaking and throughout
our outreach process to date, we are again proposing to use the
ABCTM methodology to determine a benchmark for the quality,
cost, improvement activities, and advancing care information data, as
feasible and appropriate, by measure and by reporting mechanism for
each year of the Quality Payment Program, starting with the transition
year data (2017 data available for public reporting in late 2018). We
are also proposing to use this benchmark to determine a 5-star rating
for each MIPS measure, as feasible and appropriate. As previously
finalized, only those measures that meet the public reporting standards
would be considered and the benchmark would be based on the most
recently available data. The details of how the benchmark will
translate to the 5-star rating will be determined in consultation with
stakeholders.
---------------------------------------------------------------------------
\22\ Kiefe CI, Weissman NW., Allison JJ, Farmer R, Weaver M,
Williams OD. Identifying achievable benchmarks of care: concepts and
methodology. International Journal of Quality Health Care. 1998 Oct;
10(5):443-7.
\23\ Kiefe CI, Allison JJ, Williams O, Person SD, Weaver MT,
Weissman NW. Improving Quality Improvement Using Achievable
Benchmarks For Physician Feedback: A Randomized Controlled Trial.
JAMA. 2001;285(22):2871-2879.
\24\ Wessell AM, Liszka HA, Nietert PJ, Jenkins RG, Nemeth LS,
Ornstein S. Achievable benchmarks of care for primary care quality
indicators in a practice-based research network. American Journal of
Medical Quality 2008 Jan-Feb;23(1):39-46.
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We believe that displaying the appropriate and relevant MIPS data
in this user-friendly format provides more opportunities to present
these data to people with Medicare in a way that is most likely to be
accurately understood and interpreted. We request comment on these
proposals.
g. Voluntary Reporting
In CY 2017 Quality Payment Program proposed rule (81 FR 28291), we
solicited comment on the advisability and technical feasibility of
including on Physician Compare data voluntarily reported by eligible
clinicians and groups that are not subject to MIPS payment adjustments,
such as exempt clinician types and those clinicians practicing through
Rural Health Centers (RHCs), Federally Qualified Health Centers
(FQHCs), etc., to be addressed through separate notice-and-comment
rulemaking.
Overall, comments received were favorable. Stakeholders generally
support clinicians and groups being permitted to have data available
for public reporting when submitting these data voluntarily under MIPS.
As a result, we are now proposing that starting with year 2 of the
Quality Payment Program (2018 data available for public reporting in
2019) and for each year moving forward, to make available for public
reporting all data submitted voluntarily across all MIPS performance
categories, regardless of submission method, by clinician and groups
not subject to the MIPS payment adjustments, as technically feasible.
If a clinician or group chooses to submit quality, cost,
improvement activity, or advancing care information, these data would
become available for public reporting. However, because these data
would be submitted voluntarily, we propose that during the 30-day
preview period these clinicians and groups would have the option to opt
out of having their data publicly reported on Physician Compare. If
clinicians and groups do not actively opt out at this time, their data
would be available for inclusion on Physician Compare if the data meet
all previously stated public reporting standards and the minimum
reliability threshold. As clinicians and groups not required to report
under MIPS, particularly in the first years of the Quality Payment
Program, are taking additional steps to show their commitment to
quality care, we want to ensure they have the opportunity to report
their data and have it included on Physician Compare. We request
comment on this proposal.
h. APM Data
Section 1848(q)(9)(A)(ii) of the Act requires us to publicly report
names of eligible clinicians in Advanced APMs and, to the extent
feasible, the names and performance of Advanced APMs. We see this as an
opportunity to continue to build on the ACO reporting we are now doing
on Physician Compare. At this time, if a clinician or group submitted
quality data as part of an ACO, there is an indicator on the
clinician's or group's profile page indicating this. In this way, it is
known which clinicians and groups took part in an ACO. Also, currently,
all ACOs have a dedicated page on the Physician Compare Web site to
showcase their data. For the transition year of the Quality Payment
Program, we decided to use this model as a guide as we add APM data to
Physician Compare. Specifically, we finalized a policy to indicate on
eligible clinician and group profile pages of Physician Compare when
the eligible clinician or group is participating in an APM (81 FR
77398). We also finalized a decision to link eligible clinicians and
groups to their APM's data, as technically feasible, through Physician
Compare. The finalized policy provides the opportunity to publicly
report data for
[[Page 30170]]
both Advanced APMs and APMs that are not considered Advanced APMs for
the transition year, as technically feasible.
At the outset, APMs will be very new concepts for Medicare patients
and their caregivers. In these early years, indicating who participated
in APMs and testing language to accurately explain that to Web site
users provides useful and valuable information as we continue to evolve
Physician Compare. As we come to understand how to best explain this
concept to patients and their caregivers, we can continue to assess how
to most fully integrate these data on the Web site. Understanding this
and understanding the value of adding APM data to Physician Compare, we
are again proposing to publicly report names of eligible clinicians in
Advanced APMs and the names and performance of Advanced APMs and APMs
that are not considered Advanced APMs related to the Quality Payment
Program starting with year 2 (2018 data available for public reporting
in late 2019), and for each year moving forward, as technically
feasible. In addition, we again propose to continue to find ways to
more clearly link clinicians and groups and the APMs they participate
in on Physician Compare, as technically feasible. We request comment on
these proposals.
i. Stratification by Social Risk Factors
We understand that social risk factors such as income, education,
race and ethnicity, employment, disability, community resources, and
social support play a major role in health. One of our core objectives
is to improve the outcomes of people with Medicare, and we want to
ensure that complex patients, as well as those with social risk factors
receive excellent care. In addition, we seek to ensure that all
clinicians are treated as fairly as possible within all CMS programs.
In the CY 2017 Quality Payment Program final rule (81 FR 77395), we
noted that we would review the first of several reports by the Office
of the Assistant Secretary for Planning and Evaluation (ASPE).\25\ In
addition, we have been reviewing the report of the National Academies
of Sciences, Engineering, and Medicine on the issue of accounting for
social risk factors in CMS programs. ASPE's first report, as required
by the Improving Medicare Post-Acute Care Treatment (IMPACT) Act, was
released on December 21, 2016, and analyzed the effects of social risk
factors of people with Medicare on clinician performance under nine
Medicare value-based purchasing programs. A second report due October
2019 will expand on these initial analyses, supplemented with non-
Medicare datasets to measure social risk factors. The National
Academies of Sciences, Engineers, and Medicine released its fifth and
final report on January 10, 2017, and provided various potential
methods for accounting for social risk factors, including stratified
public reporting, as well as recommended next steps.\26\
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\25\ ASPE, ``Report to Congress: Social Risk Factors and
Performance Under Medicare's Value-Based Purchasing Programs.'' 21
Dec 2016. Available at https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-under-medicares-value-based-purchasing-programs.
\26\ National Academies of Sciences, Engineering, and Medicine.
2017. Accounting for social risk factors in Medicare payment.
Washington, DC: The National Academies Press.
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As we continue to consider the analyses and recommendations from
these and any future reports, we look forward to working with
stakeholders in this process. Therefore, we seek comment only on
accounting for social risk factors through public reporting on
Physician Compare. Specifically, we seek comment on stratified public
reporting by risk factors and ask for feedback on which social risk
factors or indicators should be used and from what sources. Examples of
social risk factor indicators include but are not limited to dual
eligibility/low-income subsidy, race and ethnicity, social support, and
geographic area of residence. We also seek comment on the process for
accessing or receiving the necessary data to facilitate stratified
reporting. Finally, we seek comment on whether strategies such as
confidential reporting of stratified rates using social risk factor
indicators should be considered in the initial years of the Quality
Payment Program in lieu of publicly reporting stratified performance
rates for quality and cost measures under the MIPS on Physician
Compare. We seek comment only on these items for possible consideration
in future rulemaking.
j. Board Certification
Finally, we propose adding additional Board Certification
information to the Physician Compare Web site. Board Certification is
the process of reviewing and certifying the qualifications of a
physician or clinician by a board of specialists in the relevant field.
We currently include ABMS, AOA, and ABO data as part of clinician
profiles on Physician Compare. We appreciate that there are additional,
well respected boards that are not included in the ABMS, AOA, and ABO
data currently available on Physician Compare that represent clinicians
and specialties represented on the Web site. Such board certification
information is of interest to users as it provides additional
information to use to evaluate and distinguish between clinicians on
the Web site, which can help in making an informed health care
decision. The more data of immediate interest that is included on
Physician Compare, the more users will come to the Web site and find
quality data that can help them make informed decisions. Please note we
are not endorsing any particular boards.
Another board, the American Board of Wound Medicine and Surgery
(ABWMS), has shown interest in being added to Physician Compare and
have demonstrated that they have the data to facilitate inclusion of
this information on the Web site. We believe this board fills a gap for
a specialty that is not currently covered by the ABMS, so we propose to
add ABWMS Board Certification information to Physician Compare.
Additionally, for all years moving forward, for any board that
would like to be considered to be added to the Physician Compare Web
site, we propose to establish a process for reviewing interest from
these boards as it is brought to our attention on a case-by-case basis,
and selecting boards as possible sources of additional board
certification information for Physician Compare. We further propose
that, for purposes of CMS's selection, the board would need to
demonstrate that it: Fills a gap in currently available board
certification information listed on Physician Compare, can make the
necessary data available, and if appropriate, can make arrangements and
enter into agreements to share the needed information for inclusion on
Physician Compare. We propose that boards contact the Physician Compare
support team at [email protected] to indicate interest and
initiate the review and discussion process. Once decisions are made,
they will be communicated via the CMS.gov Physician Compare initiative
Web page and via the Physician Compare listserv. We request comments on
these proposals.
D. Overview of the APM Incentive
1. Overview
Section 1833(z) of the Act requires that an incentive payment be
made to QPs for participation in Advanced APMs. In the CY 2017 Quality
Payment Program final rule (81 FR 77399 through 77491), we finalized
policies relating to the following topics:
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Beginning in 2019, if an eligible clinician participated
sufficiently in an Advanced APM during the QP Performance Period, that
eligible clinician may become a QP for the year. Eligible clinicians
who are QPs are excluded from the MIPS reporting requirements in the
performance year and payment adjustment for the payment year.
For years from 2019 through 2024, QPs receive a lump sum
incentive payment equal to 5 percent of their prior year's payments for
Part B covered professional services. Beginning in 2026, QPs receive a
higher update under the PFS for the year than non-QPs.
For 2019 and 2020, eligible clinicians may become QPs only
through participation in Advanced APMs.
For 2021 and later, eligible clinicians may become QPs
through a combination of participation in Advanced APMs and Other Payer
Advanced APMs (which we refer to as the All-Payer Combination Option).
In this proposed rule, we discuss proposals for clarifications and
modifications to some of the policies that we previously finalized, and
provide additional details and proposals regarding the All-Payer
Combination Option.
2. Terms and Definitions
As we continue to develop the Quality Payment Program, we have
identified the need to propose additions, deletions, and changes to
some of the previously finalized definitions. A list of these
definitions is available in the CY 2017 Quality Payment Program final
rule (81 FR 77537 through 77540).
As we discuss in section II.D.6.d.(2)(a) of this proposed rule, we
propose to change the timeframe of the QP Performance Period under the
All-Payer Combination Option so that it would begin on January 1 and
end on June 30 of the calendar year that is 2 years prior to the
payment year. We propose to add the definition of All-Payer QP
Performance Period using this timeframe. We also propose to add the
definition of Medicare QP Performance Period, which would begin on
January 1 and end on August 31 of the calendar year that is 2 years
prior to the payment year. We would replace the definition we
established in the CY 2017 Quality Payment Program final rule for QP
Performance Period with the definitions of All-Payer QP Performance
Period and Medicare QP Performance Period. To update the regulation to
incorporate this proposal, we also propose to remove ``QP Performance
Period'' each time it occurs in our regulations and replace it with
either ``All-Payer QP Performance Period'' or ``Medicare QP Performance
Period'' as relevant. As we discuss in section II.D.6.d.(3)(a) of this
proposed rule, we propose to make QP determinations under the All-Payer
Combination Option at the eligible clincian level only. In connection
with our proposals to calculate Threshold Scores for QP determinations
under the All-Payer Combination Option, we do not anticipate having or
receiving information about attributed beneficiaries as we do under the
Medicare Option. This is because, under the All-Payer Combination
Option, APM Entities or eligible clinicians would only submit aggregate
payment and patient data. We would not have anything similar to a
Participation List or an Affiliated Practitioner List for Other Payer
Advanced APMs. Therefore, we are proposing to change the definition of
attributed beneficiary so that it only applies to Advanced APMs, not to
Other Payer Advanced APMs. We seek comment on these proposals.
We seek comment on these terms, including how we have defined the
terms, the relationship between terms, any additional terms that we
should formally define to clarify the explanation and implementation of
this program, and potential conflicts with other terms we use in
similar contexts. We also seek comment on the naming of the terms and
whether there are ways to name or describe their relationships to one
another that make the definitions more distinct and easier to
understand. For instance, we would consider options for a framework of
definitions that might more intuitively distinguish between APMs and
Other Payer Advanced APMs and between APMs and Advanced APMs.
3. Regulation Text Changes
a. Clarifications and Corrections
We propose to revise the definition of APM Entity in the regulation
at Sec. 414.1305 to clarify that a ``payment arrangement with a non-
Medicare payer'' is an other payer arrangement as defined in Sec.
414.1305. We propose to make technical changes to the definition of
Medicaid APM in Sec. 414.1305 to clarify that these arrangements must
meet the Other Payer Advanced APM criteria set forth in Sec. 414.1420,
and not just the criteria under Sec. 414.1420(a) as provided under the
current definition.
To consolidate our regulations and avoid unnecessarily defining a
term, we propose to remove the defined term for Advanced APM Entity in
Sec. 414.1305 and to replace ``Advanced APM Entity'' where it appears
throughout the regulations with ``APM Entity.'' We also propose to make
this substitution in the definitions of Affiliated Practitioner and
Attributed Beneficiary in Sec. 414.1305. Similarly, we propose to
replace ``Advanced APM Entity group'' with ``APM Entity group'' where
it appears throughout our regulations. We note that these proposed
changes are technical, and would not have a substantive effect on our
policies.
We propose technical changes to correct the references in the first
sentence of the regulation at Sec. 414.1415 to refer to the financial
risk standard under paragraph (c)(1) or (2) and the nominal amount
standard under paragraph (c)(3) or (4). Due to typographical errors,
the current regulation refers to paragraphs (d)(1) through (4), and
there is no paragraph (d) in this section. We also propose to correct
typographical errors in Sec. 414.1420(a)(3)(i), (ii), (d) and (d)(1).
In Sec. 414.1420(d), we propose to correct the reference to the
``nominal risk standard'' to instead refer to the ``nominal amount
standard.'' We propose technical, non-substantive clarifications in
Sec. Sec. 414.1425(a)(1) through (3), 414.1425(b)(2), and 414.1435(d).
We also propose to correct a typographical error in Sec. 414.1460(b)
to refer to participation ``during a Medicare QP Performance Period''
instead of ``during the QP Performance Periods.''
b. Changes to Sec. 414.1460
We propose to reorganize and revise the monitoring and program
integrity provisions at Sec. 414.1460. We propose changes to
paragraphs (a), (b), and (d) in this section of the proposed rule as
these policies apply to both the Medicare Option and the All-Payer
Combination Option. We discuss proposed changes to paragraph (c) of
Sec. 414.1460 in sections II.D.6.c.(7) and II.D.6.d.(4) of this
proposed rule, and changes to paragraph (e) of Sec. 414.1460 in
sections II.D.6.c.(7)(b) and II.D.6.d.(4)(c), as the policies in these
paragraphs only apply to the All-Payer Combination Option.
We finalized in the CY 2017 Quality Payment Program final rule at
Sec. 414.1460(d) that for any QPs who are terminated from an Advanced
APM or found to be in violation of any federal, state, or tribal
statute, regulation, or binding guidance during the QP Performance
Period or Incentive Payment Base Period or terminated after these
periods as a result of a violation occurring during either period we
may rescind such eligible clinician's QP determinations and, if
necessary, recoup
[[Page 30172]]
part or all of any such eligible clinician's APM Incentive Payment or
deduct such amount from future payments to such individuals. We also
finalized that we may reopen and recoup any payments that were made in
error (81 FR 77555). We recognize that rescinding QP determinations and
reopening and recouping APM Incentive Payments are separate policies
and for this reason, we propose to reorganize Sec. 414.1460 so that
paragraph (b) sets forth our policy on rescinding QP determinations and
paragraph (d) sets forth our policy on reopening and recouping APM
Incentive Payments. We propose to revise Sec. 414.1460(b) to provide
when we may rescind a QP determination. In addition, we propose to
remove the last sentence of Sec. 414.1460(d), which provides that an
APM Incentive Payment will be recouped if an audit reveals a lack of
support for attested statements provided by eligible clinicians and APM
Entitles. We believe that this provision is duplicative of the
immediately preceding sentence, which permits us to reopen and recoup
any erroneous payments in accordance with existing procedures set forth
at Sec. Sec. 405.980 through 405.986 and 405.370 through 405.379. We
propose to codify our recoupment policy at Sec. 414.1460(d)(2), which
provides that we may reopen, revise, and recoup an APM Incentive
Payment that was made in error in accordance with procedures similar to
those set forth at Sec. Sec. 405.980 through 405.986 and 405.370
through 405.379 or as established under the relevant APM.
In the CY 2017 Quality Payment Program final rule, we indicated at
Sec. 414.1460(b) that CMS may reduce or deny an APM Incentive Payment
to eligible clinicians who are terminated by APMs or whose APM Entities
are terminated by APMs for non-compliance with all Medicare conditions
of participation or the terms of the relevant Advanced APMs in which
they participate during the QP Performance Period. We also finalized at
Sec. 414.1460(a) that for QPs who CMS determines are not in compliance
with all Medicare conditions of participation and the terms of the
relevant Advanced APMs in which they participate during the QP
Performance Period, there may be a reduction or denial of the APM
Incentive Payment. We propose to consolidate our policy on reducing and
denying APM Incentive Payments and redesignate it to Sec.
414.1460(d)(1). Thus, we propose to remove provisions regarding
reducing and denying APM Incentive Payments from paragraphs (a) and (b)
of Sec. 414.1460, and revise paragraph (d) to discuss when CMS may
reduce or deny an APM Incentive Payment to an eligible clinician. We
solicit comment on these proposals.
4. Advanced APMs
a. Overview
In the CY 2017 Quality Payment Program final rule (81 FR 77408), we
finalized the criteria that define an Advanced APM based on the
requirements set forth in sections 1833(z)(3)(C) and (D) of the Act. An
Advanced APM is an APM that:
Requires its participants to use certified EHR technology
(CEHRT) (See 81 FR 77409-44414);
Provides for payment for covered professional services
based on quality measures comparable to measures under the quality
performance category under MIPS (See 81 FR 77414-77418); and
Either requires its participating APM Entities to bear
financial risk for monetary losses that are in excess of a nominal
amount, or the APM is a Medical Home Model expanded under section
1115A(c) of the Act (See 81 FR 77418-77431).
APMs may offer multiple options or tracks with variations in CEHRT
use requirements, quality-based payments, and the level of financial
risk; or multiple tracks designed for different types of participant
organizations, and we finalized in the CY 2017 Quality Payment Program
final rule (81 FR 77406) that we will consider different tracks or
options within an APM separately for purposes of making Advanced APM
determinations.
b. Bearing Financial Risk for Monetary Losses
In the CY 2017 Quality Payment Program final rule (81 FR 77418), we
divided the discussion of this criterion into two main elements: (1)
What it means for an APM Entity to bear financial risk for monetary
losses under an APM); and (2) what levels of risk we would consider to
be in excess of a nominal amount. For each of these elements, we
established a generally applicable standard and a Medical Home Model
standard.
As we discussed in the CY 2017 Quality Payment Program final rule,
we believe that it is important to maintain the distinction between
Medical Home Models and other APMs because we believe that Medical Home
Models are categorically different than other types of APMs, as
supported by specific provisions in the statute enabling unique
treatment of Medical Home Models. Also, Medical Home Model participants
tend to be smaller in size and have lower Medicare revenues relative to
total Medicare spending than other APM Entities, which affects their
ability to bear substantial risk, especially in relation to total cost
of care. We believe that the meaning of nominal financial risk varies
according to context, and that smaller practices participating in
Medical Home Models, as a category, experience risk differently than
much larger, multispecialty focused organizations do. Historically,
Medical Home Model participants have not been required to bear
financial risk, which means the assumption of any new financial risk
presents a new challenge for these entities (81 FR 77420-77421). For
these reasons, we finalized special standards for Medical Home Models
that are exceptions to the generally applicable financial risk and
nominal amount standards.
(1) Medical Home Model Eligible Clinician Limit
In the CY 2017 Quality Payment Program final rule, we finalized
that beginning in the 2018 Medicare QP Performance Period, the Medical
Home Model financial risk standard would only apply to APM Entities
that participate in Medical Home Models and that have fewer than 50
eligible clinicians in the organization through which the APM Entity is
owned and operated (81 FR 77430). Under this policy, in a Medical Home
Model that otherwise meets the criteria to be an Advanced APM, the
Medical Home Model financial risk standard would be applicable only for
those APM Entities owned and operated by organizations with fewer than
50 eligible clinicians. We note this policy does not apply to Medical
Home Models expanded under section 1115A of the Act.
We are proposing to exempt from this requirement any APM Entities
enrolled in Round 1 of the Comprehensive Primary Care Plus Model
(CPC+).
We finalized the Medical Home Model eligible clinician limit after
practices applied and signed agreements with CMS to participate in CPC+
Round 1. As such, practices applying to participate in CPC+ Round 1
were not necessarily aware of the eligible clinician limit policy and
will have already participated in CPC+ for one year without this
requirement applying to them by the beginning of CY 2018. Thus, to
permit continued and uninterrupted testing of CPC+ in existing regions,
we believe it is necessary to exempt practices participating in CPC+
Round 1 from this requirement. Additionally, since in future all APM
Entities would know about this requirement prior to their
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enrollment and in order to ensure that large APM entities that are able
to bear more risk enroll in such higher risk models, we are also
proposing that CPC+ participants who enroll in the future (for example,
in CPC+ Round 2) will not be exempt from this requirement. While this
creates a small difference between the incentives for large APM
Entities in different cohorts to participate in CPC+, we believe an APM
Entity should seek to enroll in an APM, including an Advanced APM,
primarily based on the framework of that APM itself, rather than the
possibility of other associated payments such as the Advanced APM
incentive payment. Additionally, we note that any eligible clinicians
in APM Entities participating in CPC+ that do not achieve QP status for
the year would be scored under MIPS using the APM scoring standard,
meaning minimal additional burden would be required for such MIPS
eligible clinicians.
We seek comment on these proposals.
(2) Nominal Amount of Risk
We finalized in the CY 2017 Quality Payment Program final rule (81
FR 77427) that an APM would meet the generally applicable nominal
amount standard if, under the terms of the APM, the total annual amount
that an APM Entity potentially owes us or foregoes is equal to at
least:
For QP Performance Periods in 2017 and 2018, 8 percent of
the average estimated total Medicare Parts A and B revenue of
participating APM Entities (the revenue-based standard); or
For all QP Performance Periods, 3 percent of the expected
expenditures for which an APM Entity is responsible under the APM (the
benchmark-based standard).
We also finalized in the CY 2017 Quality Payment Program final rule
(81 FR 77428) that to be an Advanced APM, a Medical Home Model must
require that the total annual amount that an Advanced APM potentially
owes us or foregoes under the Medical Home Model be at least the
following amounts in a given performance year:
In 2017, 2.5 percent of the APM Entity's total Medicare
Parts A and B revenue.
In 2018, 3 percent of the APM Entity's total Medicare
Parts A and B revenue.
In 2019, 4 percent of APM Entity's total Medicare Parts A
and B revenue.
In 2020 and later, 5 percent of the APM Entity's total
Medicare Parts A and B revenue.
Both the generally applicable and Medical Home Model revenue-based
nominal amount standards state the standard in terms of average
estimated total Medicare Parts A and B revenue of participating APM
Entities. We recognize that this language may be ambiguous as to
whether it is intended to include payments to all providers and
suppliers in an APM Entity or only payments directly to the APM Entity
itself. To eliminate this potential ambiguity, we propose to amend
Sec. Sec. 414.1415(c)(3)(i)(A) and (c)(4)(i)(A) through (D) to more
clearly define the generally applicable revenue-based nominal amount
standard and the Medical Home Model revenue-based nominal amount
standard as a percentage of the average estimated total Medicare Parts
A and B revenue of providers and suppliers in participating APM
Entities. Under this proposed policy, when assessing whether an APM
meets the generally applicable revenue-based nominal amount standard,
where total risk under the model is not expressly defined in terms of
revenue, we would calculate the estimated total Medicare Parts A and B
revenue of providers and suppliers at risk for each APM Entity. We
would then calculate an average of all the estimated total Medicare
Parts A and B revenue of providers and suppliers at risk for each APM
Entity, and if that average estimated total Medicare Parts A and B
revenue at risk for all APM Entities was equal to or greater than 8
percent, the APM would satisfy the generally applicable revenue-based
nominal amount standard.
We request comment on this proposal.
(a) Generally Applicable Revenue-Based Nominal Amount Standard
In the CY 2017 Quality Payment Program final rule we finalized the
amount of the generally applicable revenue-based nominal amount
standard for the first two QP Performance Periods only, and we sought
comment on what the revenue-based nominal amount standard should be for
the third and subsequent QP Performance Periods. Specifically, we
sought comment on: (1) Setting the revenue-based standard for 2019 and
later at up to 15 percent of revenue; or (2) setting the revenue-based
standard at 10 percent so long as risk is at least equal to 1.5 percent
of expected expenditures for which an APM Entity is responsible under
an APM (81 FR 77427).
Many commenters requested that we not raise the revenue-based
nominal amount standard for 2019 and beyond. Some commenters stated
that maintaining the 8 percent revenue-based nominal amount standard
for 2019 would allow for stability and predictability for eligible
clinicians participating in certain APMs. Other commenters noted that
increasing the revenue-based nominal amount standard may reduce or
discourage eligible clinicians from participating in Advanced APMs and
that the added complexity of requiring that a 10 percent revenue-based
standard also be equivalent to at least 1.5 percent of expected
expenditures would be confusing for participants and other
stakeholders. A few commenters suggested that we only consider
increasing the revenue-based nominal amount standard after we review
how the finalized standard affects participation in Advanced APMs.
We agree that maintaining the revenue-based nominal amount standard
at 8 percent of the average estimated total Medicare Parts A and B
revenue of providers and suppliers in participating APM Entities would
provide stability and clarity for eligible clinicians and APM Entities.
We also continue to believe that 8 percent of the average estimated
total Medicare Parts A and B revenue of providers and suppliers in
participating APM Entities represents a reasonable standard to
determine what constitutes a more than nominal amount of financial
risk. We believe that the continued testing and evaluation of APMs with
two-sided risk will yield critical information about the best way to
structure financial incentives and financial risk, and this information
may have bearing on what constitutes a more than nominal amount of
risk. Therefore, we will continue to evaluate the revenue-based nominal
amount standard in light of participation in Advanced APMs before
considering any increase in later years.
After considering public comments submitted on the potential
options for increasing the revenue-based nominal amount standard for
Medicare QP Performance Periods 2019 and later, we propose to maintain
the current revenue-based nominal amount standard at 8 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities for the 2019 and 2020
Medicare QP Performance Periods, and to address the standard for
Medicare QP Performance Periods after 2020 through subsequent
rulemaking. We seek comment on whether we should consider either a
lower or higher revenue-based nominal amount standard for the 2019 and
2020 Medicare QP Performance Periods, and on the amount and structure
of the revenue-based nominal amount standard for Medicare QP
Performance Periods 2021 and later.
[[Page 30174]]
We also seek comment on whether we should consider a different,
potentially lower, revenue-based nominal amount standard only for small
practices and those in rural areas that are not participating in a
Medical Home Model for the 2019 and 2020 Medicare QP Performance
Periods. For the purposes of the Quality Payment Program, we use the
definition of small practices and rural areas in Sec. 414.1305.
Specifically, we seek comment on whether such a standard should apply
only to small and, or rural practices that are participants in an APM,
or also small and, or rural practices that join larger APM Entities in
order to participate in APMs. We also seek comment on how we should
decide where a practice is located in order to determine whether it is
operating in a rural area as rural area is defined in Sec. 414.1305 of
our regulations. We believe that a different, potentially lower,
revenue-based nominal amount standard for the 2019 and 2020 Medicare QP
Performance Periods specifically for small practices and those in rural
areas that are not participating in a Medical Home Model may allow for
their increased participation in Advanced APMs, which may help increase
the quality and coordination of care beneficiaries receive as a result.
We believe such a standard should not apply to small and, or rural
practices participating in a Medical Home Model because participants in
Medical Home Models with fewer than 50 eligible clinicians in their
parent organization benefit from the lower Medical Home Model nominal
amount standard. We also note that such a standard may have certain
disadvantages, including reducing the likelihood that potential
Advanced APMs will ultimately result in reductions in the growth of
Medicare expenditures and increasing the complexity of the generally
applicable nominal amount standard.
(b) Medical Home Model Nominal Amount Standard
In the CY 2017 Quality Payment Program final rule, we finalized
that if the financial risk arrangement under the Medical Home Model is
not based on revenue (for example, it is based on total cost of care or
a per beneficiary per month dollar amount), we will make a
determination for the APM based on the risk under the Medical Home
Model compared to the average estimated total Parts A and B revenue of
its participating APM Entities using the most recently available data
(81 FR 77428).
We received comments suggesting that few APM Entities in Medical
Home Models have had experience with financial risk, and that many
would be financially challenged to provide sufficient care or even
remain a viable business if they were faced with the kinds of
substantial disruptions in revenue that can accompany financial risk
arrangements. Some commenters indicated that taking on the level of
risk required under our finalized policy would still represent an
increase in total risk that is too great in magnitude and premature for
the many APM Entities in Medical Home Models that have little
experience with financial risk.
We recognize these concerns, however, we still believe that a final
Medical Home Model nominal amount standard of 5 percent is the
appropriate target for the standard, and that ultimately setting the
standard at 5 percent of Parts A and B revenue of providers and
suppliers in participating APM Entities would strike the appropriate
balance to reflect the meaning of ``nominal'' in the Medical Home Model
context. We continue to believe that the meaning of the term
``nominal'' depends on the situation in which it is applied, so it is
appropriate to consider the characteristics of Medical Home Models and
their participating APM Entities in setting the nominal amount standard
for Medical Home Models.
We have reconsidered the incremental annual increases in the
nominal amount standard that we finalized to occur over several years
from 2.5 percent to 5 percent. We recognize that establishing an even
more gradual increase in risk for Medical Home Models with a lower risk
floor for the 2018 Medicare QP Performance Period may be better suited
to the circumstances of many APM Entities in Medical Home Models that
have little experience with risk. We also reiterate, as we note for the
generally applicable nominal amount standard, that the terms and
conditions in the particular APM govern the actual risk that
participants experience; the nominal amount standard merely sets a
floor on the level of risk required for the APM to be considered an
Advanced APM. To that end, we believe a small reduction of risk in the
Medical Home Model nominal amount standard beginning in the 2018
Medicare QP Performance Period, along with a more gradual progression
toward the 5 percent nominal amount standard, would allow for greater
flexibility at the APM level in setting financial risk thresholds that
would encourage more participation in Medical Home Models and be more
sustainable for the type of APM Entities that would potentially
participate in Medical Home Models.
Therefore, we are proposing that to be an Advanced APM, a Medical
Home Model must require that the total annual amount that an APM Entity
potentially owes us or foregoes under the Medical Home Model be at
least the following:
For Medicare QP Performance Period 2018, 2 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
For Medicare QP Performance Period 2019, 3 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
For Medicare QP Performance Period 2020, 4 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
For Medicare QP Performance Periods 2021 and later, 5
percent of the average estimated total Medicare Parts A and B revenue
of all providers and suppliers in participating APM Entities.
We seek comment on this proposal.
c. Summary of Proposals
In summary, we are making the following proposals in this section:
We are proposing to amend our regulation at Sec.
414.1415(c)(3)(i)(A) and (c)(4)(i)(A) through (D) to more clearly
define the generally applicable revenue-based nominal amount standard
and the Medical Home Model revenue-based nominal amount standard as a
percentage of the average estimated total Medicare Parts A and B
revenue of all providers and suppliers in participating APM Entities.
We are proposing to amend our regulation at Sec.
414.1415(c)(2) to any APM Entities enrolled in an Advanced APM
qualifying under the Medical Home Model standard as of January 1, 2017,
to exempt Round 1 of the CPC+ Model from the requirement that beginning
in the 2018 Medicare QP Performance Period, the Medical Home Model
financial risk standard applies only to an APM Entity that is
participating in a Medical Home Model if it has fewer than 50 eligible
clinicians in its parent organization.
We are proposing to amend our regulation at Sec.
414.1415(c)(3)(i)(A) to provide that the generally applicable revenue-
based nominal amount standard remain at 8 percent of the average
estimated total Medicare Parts A and B revenue of providers and
suppliers in participating APM Entities for the 2019 and 2020 Medicare
QP Performance Periods, and to address the standard for Medicare QP
Performance Periods after 2020 through subsequent rulemaking.
[[Page 30175]]
We are proposing to amend our regulation at Sec.
414.1415(c)(4)(i)(A) through (D) to provide that, to be an Advanced
APM, a Medical Home Model must require that the total annual amount
that an APM Entity potentially owes us or foregoes under the Medical
Home Model be at least the following amounts:
++ For Medicare QP Performance Period 2018, 2 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
++ For Medicare QP Performance Period 2019, 3 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
++ For Medicare QP Performance Period 2020, 4 percent of the
average estimated total Medicare Parts A and B revenue of all providers
and suppliers in participating APM Entities.
++ For Medicare QP Performance Periods 2021 and later, 5 percent of
the average estimated total Medicare Parts A and B revenue of all
providers and suppliers in participating APM Entities.
5. Qualifying APM Participant (QP) and Partial QP Determination
We finalized policies relating to QP and Partial QP determinations
in the CY 2017 Quality Payment Program final rule (See 81 FR 77433
through 77450).
We finalized that the QP Performance Period will run from January 1
through August 31 of the calendar year that is 2 years prior to the
payment year (81 FR 77446). As we discuss in section II.D.6.(d)(2)(a)of
this proposed rule, we propose to refer to this time period for the
Medicare Option as the Medicare QP Performance Period.
a. Advanced APMs Starting or Ending During a Medicare QP Performance
Period
We acknowledge that there may be Advanced APMs that start after
January 1 of the Medicare QP Performance Period for a year. There may
also be Advanced APMs that end prior to the August 31 end of the
Medicare QP Performance Period for a year. By ``start'' and ``end,'' in
this context, we mean that the period of active testing of the model
starts or ends such that there is no opportunity for any APM Entity to
participate in the Advanced APM before it starts, or to participate in
it after it ends. We consider the active testing period to mean the
dates within the performance period specific to the model, which is
also the time period for which we consider payment amounts or patient
counts through the Advanced APM when we make QP determinations. An
Advanced APM is in active testing if APM Entities are furnishing
services to beneficiaries and those services will count toward the APM
Entity's performance in the Advanced APM. Active testing does not
include, for example, the period of time after an APM Entity has
stopped furnishing services to beneficiaries under the terms of the
Advanced APM but is waiting for calculation or receipt of a
performance-based payment. We note that we tie this policy to the
timeframe during which APM Entities, rather than eligible clinicians,
participate in an Advanced APM. To the extent the participation of APM
Entities and eligible clinicians is not the same, we believe it is more
appropriate and consistent with other policies relating to the APM
incentive, and to APMs in general, to base the active testing period
for an APM on the activities of the APM Entities because they are the
participants directly subject to the terms of the Advanced APM,
including the specified performance period for the Advanced APM. For
example, in a model like CJR, where we identify eligible clinicians for
QP determinations based on the Affiliated Practitioner List, it would
be possible for APM Entities to be participating in active testing of
the Advanced APM without any Affiliated Practitioners for a period of
time. In that case, we would consider the dates the APM Entities were
able to be in active testing for CJR, as opposed to the dates when
eligible clinicians began participating as Affiliated Practitioners. If
a specific APM Entity joins an Advanced APM after the January 1 start
and before the August 31 end of a Medicare QP Performance Period, but
other APM Entities participate during the entire Medicare QP
Performance Period (from January 1 through August 31), then we would
consider the Advanced APM to be in active testing for the entire
Medicare QP Performance Period.
For example, the performance period for an Advanced APM may start
on May 1, which is after the first QP determination date (March 31) and
before the second QP determination date (June 30) during the Medicare
QP Performance Period. If we were to calculate Threshold Scores in such
an Advanced APM using data in the denominator for all attribution-
eligible beneficiaries from January through June 30, which would
include data for the period before the Advanced APM is actively tested,
the APM Entities, or, as applicable, individual eligible clinicians in
that Advanced APM, are less likely to achieve a QP threshold on either
the June 30 or the final August 31 determination date for the year.
This outcome would be a direct result of our operational decisions to
begin the performance period for the Advanced APM on May 1, which is
outside of the control of both the participating APM Entities and
eligible clinicians. As such, participants in Advanced APMs that start
or end during the Medicare QP Performance Period for the year could be
disadvantaged for purposes of QP determinations. This is because the
numerator of the Threshold Score calculation would include payment
amounts or patient counts from only the period before the QP
determination date during which the Advanced APM was actively tested,
while the denominator would include payment amounts or patient counts
for the entire Medicare QP performance period up to the QP
determination date.
We propose to modify our policies regarding the timeframe(s) for
which payment amount and patient count data are included in the QP
payment amount and patient count threshold calculations for Advanced
APMs that start after January 1 or end before August 31 in a given
Medicare QP Performance Period. In these situations, we would calculate
QP Threshold Scores using only data in the numerator and denominator
for the dates that APM Entities were able to participate in active
testing of the Advanced APM, per the terms of the Advanced APM, so long
as APM Entities were able to participate in the Advanced APM for 60 or
more continuous days during the Medicare QP Performance Period. We
propose to add this policy at Sec. 414.1425(c)(6) of our regulations.
The QP Threshold Score would be calculated at the APM Entity level or
the Affiliated Practitioner level as set forth in Sec. 414.1425(b);
this change would not affect our established policy as to which list of
eligible clinicians, the Participation List or Affiliated Practitioner
List, would be used.
This proposed change would not affect how we make QP and Partial QP
determinations for eligible clinicians who participate in multiple
Advanced APMs as set forth by Sec. Sec. 414.1425(c)(4) and
414.1425(d)(2). We propose to make those calculations using the full
Medicare QP Performance Period even if the eligible clinician
participates in one or more Advanced APMs that start or end during the
Medicare QP Performance Period. We believe that this policy
appropriately reflects the participation of the individual eligible
clinician in multiple Advanced APMs and is consistent with our general
framework for making QP determinations. For these QP determinations, we
would include
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patients or payments through all Advanced APMs the eligible clinician
participates in for a Medicare QP Performance Period, including any
Advanced APMs that are in active testing for less than 60 continuous
days. This policy accounts for the eligible clinician's flexibility in
participating in Advanced APMs while combining that participation to
potentially meet the QP threshold.
With the exception of QP determinations for individual eligible
clinicians who participate in multiple Advanced APMs, we believe it is
appropriate to require that an Advanced APM must be actively tested for
a minimum of 60 continuous days during the Medicare QP Performance
Period in order for the payment amount or patient count data to be
considered for purposes of QP determinations for the year because it is
important that the QP determination be based on a measure of meaningful
participation in an Advanced APM. For example, if an Advanced APM
started on August 30, we do not believe a QP determination made based
on only 2 days of payment amount or patient count data in the numerator
and denominator would reflect a meaningful assessment of participation
in an Advanced APM. We have chosen a minimum of 60 continuous days
because it is the shortest amount of time between two snapshot dates:
June 30 and August 31. We believe this amount of time is sufficient for
purposes of measuring participation in an Advanced APM. We seek comment
on whether it would be more appropriate to require that the Advanced
APM be in active testing for at least 90 days, since 90 days is the
shortest possible length of time we would use to make a QP
determination (if the QP determination is based on January 1 through
March 31).
Under this proposal, we would make QP determinations for all QP
determination snapshot dates that fall after the Advanced APM meets the
minimum time requirement of 60 continuous days, whether the Advanced
APM starts or ends during the Medicare QP Performance Period. We would
not make a QP or Partial QP determination for participants in Advanced
APMs that are not actively tested for a period of at least 60
continuous days during the Medicare QP Performance Period. For example,
for an Advanced APM that starts its performance period on June 1, we
would not make any QP Threshold Score calculations for the June 30
snapshot date because the Advanced APM would not yet have been actively
tested for 60 consecutive days. We would wait until the August 31
snapshot date because this would be the first snapshot where the
Advanced APM was active for 60 or more continuous days. The QP
determination would be made based on payment amounts or patient counts
from the June 1 start date to August 31 in both the numerator and the
denominator. For an Advanced APM that starts on or before January 1 and
ends active testing on June 1, we would make QP determinations on each
snapshot date, but those determinations would be made based only on
payment amounts or patient counts from January 1 to June 1. Although
the Advanced APM would not be actively tested between June 30 and
August 31, we would still make another QP Threshold Score calculation
for APM Entities or eligible clinicians who had not met the QP
Threshold in case the additional time for claims run out would give us
more accurate information. For an Advanced APM that started on August
30 of a year, we would not make a QP determination for that year
because the APM would not be actively tested for 60 continuous days
during the Medicare QP Performance Period.
We believe that this proposal allows us to properly measure
performance in Advanced APMs without penalizing APM Entities or
eligible clinicians for start or end dates that are wholly outside of
their control. We believe this policy is needed to match the data used
to assess Advanced APM participation for purposes of the APM incentive
payment with the timeframe during which the Advanced APM is actively
tested and to accurately reflect the participation of APM Entities and
eligible clinicians. This proposed policy would not apply to Other
Payer Advanced APMs because eligible clinicians have more control over
the start and end dates of payment arrangements with Other Payers, such
as through contract negotiations, than they do over our start and end
dates, which we exclusively determine.
This proposed policy would not apply to APM Entities that had the
opportunity to participate in the Advanced APM track of an APM during
the entire Medicare QP Performance Period, but did not do so until
partway through the Medicare QP Performance Period. For example,
Oncology Care Model (OCM), has two risk tracks: One-sided and two-sided
risk. Only the two-sided risk track is an Advanced APM. APM Entities
participating in OCM now have the opportunity to change their risk
track from one-sided to two-sided risk, to take effect on either
January 1 or July 1 of the applicable calendar year. Applying this
proposed policy to OCM, an APM Entity participating in OCM that
requests two-sided risk to take effect beginning on July 1, 2018, would
be considered a participant in and Advanced APM as of July 1, but would
be subject to a QP determination based on payment and patient count
data for the full Medicare QP Performance Period because that APM
Entity had the opportunity to elect two-sided risk beginning on January
1, 2018. In this scenario, the APM Entity has control over its
participation in an Advanced APM, and could choose to be in the
Advanced APM for the full Medicare QP Performance Period.
We clarify that this proposed policy for Advanced APMs that start
or end during the Medicare QP Performance Period does not apply to the
CEHRT Track (Track 1) of the Comprehensive Care for Joint Replacement
Model (CJR) because we have determined that Track 1 of CJR is an
Advanced APM for the 2017 QP Performance Period. Therefore, we will
include episodes ending on or after January 1, 2017 in QP
determinations as set forth in our regulations at Sec. 414.1425.
b. Participation in Multiple Advanced APMs
We propose to edit Sec. 414.1425(c)(4) and (d)(4) to better
reflect our intended policy for QP determinations and Partial QP
determinations for eligible clinicians who are included in more than
one APM Entity group and none of the APM Entity groups in which the
eligible clinician is included meets the corresponding QP or Partial QP
threshold, or who are Affiliated Practitioners. As we explained in the
CY 2017 Quality Payment Program final rule (81 FR 77446-7), eligible
clinicians may become QPs through any of the assessments conducted for
the three snapshot dates: March 31, June 30, and August 31. If the APM
Entity group meets the QP threshold under this first assessment, then
all eligible clinicians in the APM Entity group will be QPs unless the
APM Entity's participation in the Advanced APM is voluntarily or
involuntarily terminated before the end of the Medicare QP Performance
Period, or in the event of eligible clinician or APM Entity program
integrity violation. We stated these same procedures apply to the QP
determination made for individual eligible clinicians on an APM
Entity's Affiliated Practitioner List or individual eligible clinicians
in multiple Advanced APMs whose APM Entity groups did not meet the QP
threshold.
We propose to amend our regulation to make clear that under Sec.
414.1425(c)(4), if an eligible clinician is a determined to be a QP
based on
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participation in multiple Advanced APMs, but any of the APM Entities in
which the eligible clinician participates voluntarily or involuntarily
terminates from the Advanced APM before the end of the Medicare QP
Performance Period, the eligible clinician is not a QP. We propose to
make the same clarification for Partial QP determinations under Sec.
414.1425(d)(4). These clarifying edits specify that this policy applies
within the context of QP and Partial QP determinations based on
participation in multiple Advanced APMs, not all QP determinations.
Accordingly, for example, if an eligible clinician is a QP through
participation in both of two Advanced APMs under Sec. 414.1425(b)(1),
and one APM Entity voluntarily or involuntarily terminates from one of
those Advanced APMs, the eligible clinician is still a QP. However, if
the eligible clinician is a QP through participation in multiple
Advanced APMs under Sec. 414.1425(c)(4), and any APM Entity that
eligible clinician participates in that counts towards the QP
determination voluntarily or involuntarily terminates, the eligible
clinician is no longer a QP. We seek comment on these proposals.
c. Summary of Proposals
In summary, we are making the following proposals in this section:
We propose to calculate QP Threshold Scores for Advanced
APMs that are actively tested continuously for a minimum of 60 days
during the Medicare QP Performance Period and start or end during the
Medicare QP Performance Period using only the dates that APM Entities
were able to participate in the Advanced APM per the terms of the
Advanced APM, not the full Medicare QP Performance Period.
We propose to make QP determinations under Sec.
414.1425(c)(4), for eligible clinicians participating in multiple
Advanced APMs using the full Medicare QP Performance Period even if the
eligible clinician participates in one or more Advanced APMs that start
or end during the Medicare QP Performance Period.
We propose to amend our regulation to make clear that
under Sec. 414.1425(c)(4), if an eligible clinician is determined to
be a QP based on participation in multiple Advanced APMs, but any of
the APM Entities in which the eligible clinician participates
voluntarily or involuntarily terminates from the Advanced APM before
the end of the Medicare QP Performance Period, the eligible clinician
is not a QP.
6. All-Payer Combination Option
a. Overview
Section 1833(z)(2)(B)(ii) of the Act requires that beginning in
payment year 2021, in addition to the Medicare Option, eligible
clinicians may become QPs through the Combination All-Payer and
Medicare Payment Threshold Option, which we refer to as the All-Payer
Combination Option. In the CY 2017 Quality Payment Program final rule
(81 FR 77459), we finalized our overall approach to the All-Payer
Combination Option. The Medicare Option focuses on participation in
Advanced APMs, and we make determinations under this option based on
Medicare Part B covered professional services attributable to services
furnished through an APM Entity. The All-Payer Combination Option does
not replace or supersede the Medicare Option; instead, it would allow
eligible clinicians to become QPs by meeting the QP thresholds through
a pair of calculations that assess Medicare Part B covered professional
services furnished through Advanced APMs, and a combination of both
Medicare Part B covered professional services furnished through
Advanced APMs and services furnished through Other Payer Advanced APMs.
We finalized that beginning in payment year 2021, we will conduct QP
determinations sequentially so that the Medicare Option is applied
before the All-Payer Combination Option (81 FR 77438). An eligible
clinician only needs to be a QP under either the Medicare Option or the
All-Payer Combination Option to be a QP for the payment year. The All-
Payer Combination Option encourages eligible clinicians to participate
in payment arrangements with payers other than Medicare that have
payment designs that satisfy the Other Payer Advanced APM criteria. It
also encourages sustained participation in Advanced APMs across
multiple payers.
We finalized that the QP determinations under the All-Payer
Combination Option are based on payment amounts or patient counts as
illustrated in Tables 46, 47, and Figures K1 and K2 (See 81 FR 77460
through 77461). We also finalized that, in making QP determinations, we
will use the Threshold Score that is most advantageous to the eligible
clinician toward achieving QP status for the year, or if QP status is
not achieved, Partial QP status for the year (81 FR 77475).
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Unlike the Medicare Option, where we have access to all of the
information necessary to determine whether an APM meets the criteria to
be an Advanced APM, we cannot identify whether an other payer
arrangement meets the criteria to be an Other Payer Advanced APM
without receiving the required information from an external source.
Similarly, we do not have the necessary payment amount and patient
count information to determine under the All-Payer Combination Option
whether an eligible clinician meets the payment amount or patient count
threshold to be a QP without receiving the required information from an
external source.
We finalized the process that eligible clinicians can use to seek a
QP determination under the All-Payer Combination Option (81 FR 77478
through 77480):
The eligible clinician submits to CMS sufficient
information on all relevant payment arrangements with other payers;
Based upon that information CMS determines that at least
one of those payment arrangements is an Other Payer Advanced APM; and
The eligible clinician meets the relevant QP thresholds by
having sufficient payments or patients attributed to a combination of
participation in Other Payer Advanced APMs and Advanced APMs.
We address the following topics in this section of the proposed
rule: (1) Other Payer Advanced APM Criteria; (2) Determination of Other
Payer Advanced APMs; and (3) Calculation of All-Payer Combination
Option Threshold Scores and QP Determinations.
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b. Other Payer Advanced APM Criteria
(1) In General
Our goal is to align the Advanced APM criteria under the Medicare
Option and the Other Payer Advanced APM criteria under the All-Payer
Combination Option as permitted by statute and as feasible and
appropriate. We believe this alignment will help simplify the Quality
Payment Program and encourage participation in Other Payer Advanced
APMs.
In the CY 2017 Quality Payment Program final rule, we finalized
that, in general, an other payer arrangement with any payer other than
traditional Medicare, including Medicare Health Plans, which include
Medicare Advantage, Medicaid-Medicaid Plans, 1876 and 1833 Cost Plans,
and Programs of All Inclusive Care for the Elderly (PACE) plans, will
be an Other Payer Advanced APM if it meets all three of the following
criteria:
The other payer arrangement requires at least 50 percent
of participating eligible clinicians in each APM Entity (or each
hospital if hospitals are the APM participants) to use Certified EHR
Technology (CEHRT) to document and communicate clinical care (81 FR
77464 through 77465);
The other payer arrangement requires that quality measures
comparable to measures under the MIPS quality performance category
apply, which means measures that are evidence-based, reliable and
valid; and, if available, at least one measure must be an outcome
measure (81 FR 77466); and
The other payer arrangement either: (1) Requires APM
Entities to bear more than nominal financial risk if actual aggregate
expenditures exceed expected aggregate expenditures (under either the
generally applicable or Medicaid Medical Home Model standards for
nominal amount of financial risk, as applicable); or (2) is a Medicaid
Medical Home Model that meets criteria comparable to Medical Home
Models expanded under section 1115A(c) of the Act (81 FR 77466 through
77467).
(2) Other Payer Medical Home Models
In the CY 2017 Quality Payment Program final rule we finalized
definitions of Medical Home Model and Medicaid Medical Home Model at
Sec. 414.1305. The statute does not define ``medical homes,'' but
sections 1848(q)(5)(C)(i), 1833(z)(2)(B)(iii)(II)(cc)(BB),
1833(z)(2)(C)(iii)(II)(cc)(BB), and 1833(z)(3)(D)(ii)(II) of the Act
make medical homes an instrumental piece of the Quality Payment
Program.
We recognize that there may be medical homes that are operated by
other payers that may be appropriately considered medical home models
under the All-Payer Combination Option. Examples of these arrangements
may include those aligned with the Comprehensive Primary Care Plus
(CPC+) model. Therefore, we seek comment on whether we should define
the term Other Payer Medical Home Model as an other payer arrangement
that is determined by CMS to have the following characteristics:
The other payer arrangement has a primary care focus with
participants that primarily include primary care practices or
multispecialty practices that include primary care physicians and
practitioners and offer primary care services. For the purposes of this
provision, primary care focus means the inclusion of specific design
elements related to eligible clinicians practicing under one more of
the following Physician Specialty Codes: 01 General Practice; 08 Family
Medicine; 11 Internal Medicine; 16 Obstetrics and Gynecology; 37
Pediatric Medicine; 38 Geriatric Medicine; 50 Nurse Practitioner; 89
Clinical Nurse Specialist; and 97 Physician Assistant;