Final Quality Payment Program Rule Released With Changes That Affect Primary Care in 2020

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Final rule includes transition from MIPS to new MIPS Value Pathway starting in 2021

Dec. 6, 2019 (ACP) – While the American College of Physicians is cautiously optimistic about the future of Medicare's new Merit-based Incentive Payment System (MIPS) Value Pathway (MVP) and its potential to reduce burden on physicians participating in MIPS, it continues to advocate for additional support for primary care and improved performance measurement.

The Centers for Medicare & Medicaid Services (CMS) recently released the 2020 Quality Payment Program final rule, which lays out a broad plan to transition from the existing MIPS to the new MVP starting in 2021. The MVP aims to improve upon several shortcomings of MIPS by reducing clinician burden, streamlining the performance categories, and providing more consistent performance feedback.

“ACP appreciates the improvements to MIPS that were a direct response to previous ACP advocacy efforts,” said Dr. Robert McLean, ACP's president. “We will be analyzing the changes more closely to ensure they are implemented in a way that will truly enhance performance measurement while strengthening the patient-physician relationship.”

After pushback from ACP and other stakeholders about the proposed timeline including a mandatory transition to the MVP in 2021, CMS now plans to offer a transition or trial period. Many details regarding the overall structure and implementation are still outstanding. CMS intends to “co-develop” the MVP over the course of the next year in close collaboration with stakeholders.

“CMS was responsive to our request that they consider implementing the MVP via a trial or transition period, and we will encourage them to follow through with this approach. It will help to reduce any unintended consequences that can occur when such a significant change is implemented quickly,” said Shari Erickson, ACP's vice president for governmental affairs and medical practice. “We're also pleased that CMS seems intent on getting stakeholder feedback, which will be critical to a smooth rollout, and we look forward to representing the voice of internists in those conversations.”

In addition to the planned transition to MVP, CMS proposed several other more immediate changes to the existing MIPS framework that will affect primary care physicians starting in 2020:

  • The weight of the Cost Category, one of the four performance categories that collectively comprise a clinician's total MIPS score, will remain at 15 percent instead of rising to 20 percent as CMS had earlier proposed. This will give clinicians more time to familiarize themselves with significant changes to the category. These changes include 10 new episode-based measures and two redeveloped claims-based measures that attribute total per-capita costs and Medicare spending per beneficiary to individual clinicians or groups. The redeveloped measures are an improvement over flawed measures that were carried over from past programs. However, ACP continues to object to attributing broad-based downstream costs, particularly at the individual clinician level, and will continue to call for more condition- or specialty-specific cost measures as the MVP is developed.
  • Performance measures identified by CMS as “low-value” will be removed in response to ACP concerns about low validity and clinical accuracy. ACP continues to call for a sufficient number of patient-centered, actionable, appropriately attributed, and evidence-based measures available for all subspecialists and urges CMS to look to improve the accuracy measures when possible instead of removing them.
  • In the Promoting Interoperability Category, which measures how practices are using certified electronic health record technology, CMS removed the “Verify Opioid Treatment Agreement” measure and made the “Query of Prescription Drug Monitoring Program” measure optional and available for bonus points, as opposed to mandatory. ACP supported both changes due to reduced burden and increased flexibility for physicians.

ACP is raising the alarm about several 2020 changes that could increase burden on primary care physicians, especially those in small and rural practices. Specifically, ACP has the following concerns:

  • Increasing data completeness requirements in the Quality Category will increase reporting burden and reduce capacity to overcome temporary disruptions in data reporting.
  • Increasing the group reporting threshold for the Improvement Activities Category from a single clinician to half of the clinicians in the practice will drastically increase reporting burden, and does not consider scenarios in which the functioning of an entire practice can be improved by the actions of one or a few clinicians. However, in a reversal from the proposed rule, CMS will allow physicians to attest to the same activity over different 90-day periods throughout the performance period.
  • Increasing the regular and exceptional MIPS performance thresholds without additional flexibilities for small and rural practices could exacerbate the existing performance gap between small and large practices. The regular MIPS performance threshold determines whether a physician qualifies for a payment penalty or bonus under MIPS. If a physician meets the exceptional performance threshold, they would qualify for an additional bonus. ACP will continue to advocate for additional supports for small and rural practices under the MVP.

On another front, ACP fears that as a result of the rule, physicians will be prevented from qualifying as participants in Advanced Alternative Payment Models (APMs) and earning a five percent bonus. Among other changes to limit what constitutes financial risk, CMS will restrict private-sector medical homes from qualifying as Advanced APMs unless they formally align with Medicare. ACP believes this opposes congressional intent because it fails to reward clinicians who participate in innovative payment and delivery arrangements, including those in the private sector.

“It's more important than ever to address administrative burdens while ensuring quality patient care,” McLean said. “We need to promote participation in APMs and reduce MIPS reporting burden and not add to it – in order to improve patient care.”

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