Practice Management Alert

CMS hints at more options for small practices and fewer headaches.

As Part B clinicians ramp up for Performance Year 2 of MACRA's Quality Payment Program (QPP), they can expect scaled-back measures and streamlined processes. The Center for Medicare and Medicaid Services' (CMS) new project, "Patients Over Paperwork," promises to decrease Medicare's administrative burdens, too - but don't get too excited. Critics suggest 2018's sunny forecast is just the calm before 2019's storm.

Background: CMS instituted its new payment program, QPP, in 2017, as mandated by MACRA, with two points of entry into the program - the basic Merit-Based Incentive Payment System (MIPS) or the higher-level Advanced Alternative Payment Models (APMs). Last year's opus for reporting in 2017, "Pick-Your-Pace," was replaced by "QPP Year 2" in CMS's final rule published last month in the Federal Register for eligible Medicare Part B clinicians for the 2018 reporting year.

Read the QPP final rule at: www.gpo.gov/fdsys/pkg/FR-2017-11-16/pdf/2017-24067.pdf.

Anticipate a Reduced Administration Overload

Stakeholders chimed in at every opportunity over the past 12 months, with more than 100 organizations and over 47,000 individuals offering input on ways to improve the QPP and reduce the burden of a completely new Medicare reimbursement system, the QPP Year 2 fact sheet suggests. The public's outcry shaped the final rule and caused CMS to implement a new initiative, "Patients Over Paperwork."

"During my visits with clinicians across the country, I've heard many concerns about the impact burdensome regulations have on their ability to care for patients," said Seema Verma, CMS Administrator, in a release on the final rule and new initiative. "These rules move the agency in a new direction and begin to ease that burden by strengthening the patient-doctor relationship, empowering patients to realize the value of their care over volume of tests, and encouraging innovation and competition within the American healthcare system."

MIPS Reporting Streamlined ... Temporarily

Eligible clinicians have "Patients Over Paperwork" to thank for changes to the low-volume threshold, the confirmation of virtual groups, disaster exceptions, and mid-year Advanced APM incentives, but that doesn't mean accurate MIPS reporting isn't essential. In fact, it's even more critical as CMS promises the stakes will increase substantially in 2019.

2018 participation:  "CMS finalized its proposed increases in the low-volume threshold from performance year one to performance year two," notes attorney Benjamin Fee, Esq. of Dorsey and Whitney LLP, in the DesMoines, Iowa, office. "The proposed change was a direct result offeedback CMS received from providers, particularly small and ruralproviders."

Despite the added confusion with the threshold increase, CMS did respond to practices' collective frustration instead of steamrolling over a year's worth of providers' complaints, adjusting the QPP Year 2 accordingly. "The new rule eases the burden of participation," explains Vinod Gidwani, founder and president of Currence Inc. in Skokie, Illinois (medcurrence.com). "The threshold is now $90,000 in allowed charges or 200 Medicare encounters annually. This reduces the number of physicians who must participate by about 14 percent."

But the changes are likely temporary, Gidwani warns. "CMS has stated that the 'training wheels' will come off in Year 3 and participation requirements will be tightened."

CMS Bags Some Requirements, Adds Others

Due to the aforementioned stakeholder commentary, CMS lessened requirements, particularly for small and underserved practices, but also added some, too. "The biggest takeaway from the QPP final rule is CMS's decision to continue many of the transition year policies from Performance Year 1 into Performance Year 2," Fee points out. "Essentially, CMS is pushing back its goal of full implementation to performance year 3 which begins January 1, 2019."

Don't let eased measures fool you; there's still a lot to do in 2018, say healthcare experts. "For example, the quality reporting period is increasing from 90 days to a full year," Fee cautions. "While I still think the final rule is less burdensome than what CMS originally planned for performance year 2, there are increased obligations that providers should be aware of."

Other changes that will be phased in for Year 2 and may greatly impact both your data and your income include:

• Cost Component: It will now be factored into the MIPS composite score. Originally, "the Cost component was supposedly not to be included in 2018," reminds Gidwani. "However, this is not true. The Cost component will have a 10 percent weighting in 2018."
• Performance Threshold:  A marked increase that goes from the current 3 points for the 2017 transition year to 15 points in 2018.
• Physician Compare: A gradual increase of eligible clinicians' QPP performance reviews for public scrutiny on Physician Compare.

Virtual groups realized: The "Virtual Group" option for sole providers and group practices of 10 or less to report their MIPS measures together virtually was confirmed in the QPP final rule and is a bonus for smaller practices - if they can sift through the Medicare minutia of the program and meet the deadline.

"CMS also finalized its proposal to include virtual groups as a participation option for Performance Year 2," Fee says. "I still don't think anyone, including CMS, has a good sense of how many individuals and small groups will take advantage of the virtual group participation option under MIPS.

"While the formal formation requirements are relatively minimal for virtual group participation, my sense is that few groups or practitioners who would be eligible for virtual group participation are even aware of the option," he adds.

"CMS did move the election deadline back for when a virtual group must notify CMS of its participation » » from December 1 to December 31 [2017]," Fee notes. "But I suspect the number of physicians participating in virtualgroups will be minimal for the upcoming performance year."

Find out more about virtual groups on page 14.

Nuts and bolts: Some other highlights of the final rule aim to assist struggling clinicians bridge the transition gap, while other QPP Year 2 promotions support the highest levels of quality care with encouragement to join in Medicare Shared Savings Programs (MSSP), Accountable Care Organization (ACOs), and more. Here's a short list of the top 2018 features:

• Small and rural providers got a boost with more flexibility and reduced burdens.
• The choice to use 2014 CEHRT instead of 2015 CEHRT, but with the offer of bonus points added to the MIPS score.
• Adjustments to the weight of the categories under the MIPS composite score.
• Advanced APMs qualifying risk percentage of 8 percent was extended for two more years.
• Eased pathways and reduced complexity to encourage Advanced APM participation.

Resource: To review the QPP Year 2 final rule fact sheet, visit: www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/QPP-Year-2-Final-Rule-Fact-Sheet.pdf.