For nephrology, an easier path to MACRA

The fireworks started early this year in Washington. Not only did the Senate reveal a health care reform plan, but the Centers for Medicare & Medicaid Services also unveiled another highly anticipated document: the 2018 (Year 2) of the Quality Payment Program (QPP) rule.

This is the first rule that has been released since Trump appointed Health and Human Services Secretary Tom Price and CMS Administrator Seema Verma. Both Price and Verma have emphasized that they want to reduce reporting burdens and allow clinicians to focus on patient care. Does the 2018 proposed rule reflect that?

First, the good news…

Fewer physicians qualify. One of the biggest moves in the 2018 proposed rule was increasing the low-volume threshold to allow more clinicians to be exempt from the Merit-based Incentive Payment System, or MIPS. The low-volume threshold moves to < $90,000 part B allowed charges or < 200 part B patients. This threshold probably doesn’t affect a large majority of nephrologists out there, but it probably does affect the mid-levels. By upping the low-threshold numbers, CMS expects to exclude a total of 585,560 clinicians. This means 63% of clinicians that bill to Medicare will be exempt from MIPS.

To determine eligibility in the 2018 performance year, CMS will look at data from September 1, 2016, to August 31, 2017. If you meet the low threshold qualification, you are all set to skip MIPS. CMS will then come around a second time and look at data from September 1, 2017, to August 31, 2018, to identify additional clinicians who should be excluded.

But there are caveats.

You will not be excluded from MIPS (even if you qualify as a low-volume clinician) if your practice decides to report as a practice group.

CMS will re-evaluate your exemption each performance year.

The fee schedule is still frozen. If you are out of MIPS (and not in any risk-sharing model) you probably won’t see any type of Medicare pay increase. The only way to get paid more is to do more.

Virtual group participation option in 2018. If you are a solo practice or part of a small one, CMS is allowing you to band together to create a virtual group (regardless of location or specialty). Starting in 2018, solo practitioners or groups of 10 or fewer eligible clinicians can come together “virtually” with at least one other clinician or group to participate in MIPS. Things to consider include:

All eligible clinicians under the tax ID number would be part of the virtual group (including those who may have been individually exempt due to low volume).

Virtual groups that choose this participation option would need to make an election prior to the 2018 performance period.

Multiple submission methods per category. CMS is proposing to allow for multiple submission methods within a single MIPS category. This would allow clinicians to report using more than one reporting method (for example they can report quality data via their EHR and a registry—not just one or the other).

MIPS scoring changes. CMS is proposing to keep the weights for each category the same in 2018. Most notably, that means the “cost” category will still be set at 0% in 2018.

Quality category changes

We all know quality is the monster of MIPS. I was shocked (and quite disappointed) to see this category barely change. One change that nephrologists will see in the proposed rule is the creation of a nephrology specialty set. What does this mean? Not much, except that CMS is pointing out measures that may be good for a nephrologist to select.

Remember the criteria for this category:

Will award a minimum of 3 points for all measures submitted (as long as they meet the data completeness requirements).

Will only award 3 points for each measure submitted that does not have a benchmark. Pay close attention to this one when selecting a nephrology measure.

Will only award 3 points for measures that do not meet case requirements.

Will award 1 point for measures that do not meet data completeness requirements (small practices will continue to get 3 points).

CMS will set a cap of 6 points for selecting certain topped out measures. As always, choose your measures wisely. - by Diana Strubler