Practice Management Alert

Beware: Small practices are at risk of being hit hardest.

Every year, practices that accept Medicare brace for whatever turbulence the Centers for Medicare & Medicaid Services (CMS) might throw their way with the Medicare Physician Fee Schedule and other annual updates.

CMS gave providers some extra leeway in the early ’20s during the height of the COVID-19 pandemic and public health emergency. But now things are largely going back to “normal,” and CMS has quality reporting programs and other measures of provider accountability and transparency back in their sights.

Background: On Aug. 7, CMS published the calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) proposed rule in the Federal Register. Sandwiched in the MPFS proposals are changes to the Quality Payment Program (QPP), CMS’ value-based and cost-saving incentive payment program. CMS mentions that COVID-19 threw a wrench in its long-term plans for the QPP but hopes now to get “back on track with the trajectory we had planned before the PHE,” the agency says in a QPP fact sheet on the proposed rule.

Reminder: Medicare providers currently have a few routes to report their quality measures, depending on their level of participation:

• The Traditional Merit-Based Incentive Payment System (MIPS) is the original, basic pathway with four distinct performance categories (Cost, Improvement Activities, Quality, and Promoting Interoperability).
• The MIPS Value Pathways (MVPs) began in CY 2023 and are focused on offering providers reporting differentiation based on specialty and scope.
• The Alternative Payment Model (APM) Performance Pathway (APP) is an optional reporting route for MIPS-eligible clinicians who are in MIPS APMs.
• The Advanced APMs have special features (clinical area, care episode, or population), report at the highest levels, and allow providers to reach Qualifying Participant (QP) status. AAPMs are usually also MIPS APMs, too.

Among the many QPP proposals for CY 2024, CMS maintains its focus on improving digital health, promoting health equity across its programs, and bolstering patient access.

Check out these seven top actions on the table:

1. Watch the threshold to go up for the CY 2024 performance year/2026 payment year.

Raising the performance threshold by seven points from 75 to 82 points will provide stability and drive quality — and is much less than the “12-to-15-point increases in previous years,” CMS says. CMS also reasons that this “statutorily-required increase” will “provide practices with a greater return on their investment in MIPS participation by giving an opportunity to achieve a higher positive payment adjustment while also encouraging participation in Advanced Alternative Payment Models,” the agency says in a release.

However, the caveat is that CMS estimates more than half of MIPS-eligible clinicians will receive a negative payment adjustment due to the change — and that’s unacceptable, warns the American Medical Association (AMA) in a rule summary. “The AMA will strongly oppose increasing the threshold and is alarmed that CMS would propose an increase that results in a significant increase in physicians being penalized by MIPS, as the program has been largely paused since 2019 due to the significant disruptions caused by the COVID-19 pandemic.”

2. Align with CMS’ ‘Universal Foundation.’ Since the public health emergency (PHE), CMS has jump-started a plethora of new initiatives, including the “Universal Foundation” methodology, which focuses on aligning its various quality programs and making the experience more meaningful for both providers and patients. In a nutshell, “Universal Foundation” is “a core set of quality metrics across CMS programs to more effectively drive change,” the agency explains.

3. Find more MVP options. CMS already revealed that MVPs are the future of the QPP and proposes adding five more MVPs for CY 2024, which include the following:

• Focusing on Women’s Health;
• Quality Care for the Treatment of Ear, Nose, and Throat Disorders;
• Prevention and Treatment of Infectious Disorders Including Hepatitis C and HIV;
• Quality Care in Mental Health and Substance Use Disorders; and
• Rehabilitative Support for Musculoskeletal Care.

4. Beware possible MVP subgroup scoring changes. MIPS-eligible providers reporting MVPs have the option to report as a subgroup. Remember, “a subgroup is a subset of clinicians within a group (identified by a single Taxpayer Identification Number, or TIN) which contains at least 2 clinicians, 1 of whom is an individually eligible MIPS eligible clinician,” CMS reminds in MVP guidance.

CMS proposes to change the subgroup scoring methods starting in CY 2024 and would not calculate a facility-based score for subgroups. Confusingly, CMS would continue to calculate one for clinicians reporting under Traditional MIPS, attach the highest score, and factor that into the complex patient bonus, the rule indicates.

5. Explore modifications to 3 MIPS performance categories. Part of tweaking MIPS includes annual updates to the performance categories as the program moves forward. Here are the top changes in the Cost, Quality, and Improvement Activities categories:

• Cost: CMS proposes recalibrating the improvement scoring for the Cost category. The agency also wants to add five new episode-based Cost measures for CY 2024.
• Quality: There are lots of measures turnarounds proposed for CY 2024 that include introducing 14 new measures; nixing 12 old measures from the inventory; partially eliminating three measures; and changing 59 existing measures.
• Improvement Activities: Currently for CY 2023, there are 104 Improvement Activities, but for next year, CMS proposes adding five new ones, modifying one existing activity, and removing three others.

6. Beware these Promoting Interoperability category proposals. Due to its connection with 21st Century Cures Act provisions, the Promoting Interoperability category often has the most proposed changes and warrants its own place on the watchlist. For CY 2024, CMS aims to focus on digital health in the QPP, and that includes these proposed PI additions and revisions:

• Redefine the meaning of Certified EHR Technology across all QPP reporting platforms and align with other quality programs like the Medicare Shared Saving Program and the Promoting Interoperability Programs.
• Add new MIPS PI reporting standards and requirements for clinicians, QPs, and partial QPs in Accountable Care Organizations (ACOs) and filing under the APP pathway.
• Continue to offer automatic reweighting of the PI performance category to zero for social workers for CY 2024, but no longer offer the option to the other clinician types still receiving it for the CY 2023 performance period. Automatic reweighting for providers with special status — ASC-based, hospital-based, or non-patient facing clinicians and groups, or small practice clinicians — will remain intact.
• Change the PI performance category reporting period from 90 continuous days to 180 continuous days.
• Require a “yes” to the Safety Assurance Factors for EHR Resilience (SAFER) Guide measure.

7. Focus on health IT vendor proposal. CMS acknowledges that MIPS data accuracy is critical for success — and that, on occasion, health IT vendors’ mistakes in submitting data have “undercut the integrity of the MIPS program.” the agency says in the QPP fact sheet.