MACRA Proposed Rule Summary: Impact for Oncologists

Published On: July 1st, 2017Categories: Issue Briefs & Overviews, Research & Publications

MACRA Proposed Rule Summary: Impact for Oncologists

On June 20, 2017, the Centers for Medicare and Medicaid Services (CMS) posted the 2018 Quality Payment Program (QPP) Proposed Rule (CMS-5522-P) which is updated annually as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The Community Oncology Alliance (COA) has compiled this summary overview for members to better understand the proposed rule and its potential impact. Formal comments on the proposed rule are due to CMS by 5 pm ET on August 21, 2017.

COA will be submitting formal comments based on feedback and input from practices. If you would like to submit feedback directly to CMS, instructions can be found in the official QPP proposal posting here (link). If you would like to share thoughts directly with COA for inclusion, please email them directly to Bo Gamble (bgamble@coacancer.org).

Download PDF Version

Access the Full CMS QPP Proposed Rule

Access the Fact Sheet on the QPP Proposed Rule Compiled by CMS

Submit Comments to COA on the QPP Proposed Rule

Key Takeaways from CY 2018 QPP Proposed Rule

The Proposed Rule for QPP Year 2 (2018) reflects not only a continued gradual ramp-up to the full implementation of the QPP, but there also is a deliberate tilt towards improving the efficiency of the operation of the program itself through proposals related to streamlining requirements and reducing clinician burden. This approach is perhaps most clearly reflected in the addition of a seventh objective to the agency’s QPP strategic objectives (see table) that is focused on maintaining operational excellence as the QPP develops and matures.

CMS states in the Proposed Rule that the Year 2 proposals have been designed to ease the burden on small and solo practices. The regulatory impact analysis included in the Proposed Rule estimates that at least 80 percent of clinicians in small practices (defined as 1-15 clinicians) will receive a positive or neutral payment adjustment as a result of the numerous proposed modifications.

Merit-Based Incentive Payment System (MIPS)

Recall, that under Merit-Based Incentive Payment System (MIPS) by statute, clinicians will be measured in four performance categories:

Quality
Cost
Clinical Performance Improvement Activities
Advancing Care Information (ACI)

A composite score will be calculated based on a weighted score in the four performance areas. For QPP Year 2, eligible clinicians can earn a positive, negative or neutral payment adjustment based on their performance in MIPS. Proposed performance weights are below:

MIPS Performance Weights (CY 2017 Final and 2018 Proposed)

Quality	ACI*	Improvement Activities	Cost
60 percent	25 percent	15 percent	0 percent

Low Volume Threshold

The original MACRA statute allows for a low-volume threshold exception for the MIPS program. Subsequent implementing regulations excluded from the program’s requirements would be any clinician who billed less than or equal to $30,000 to Medicare under Part B of the program, or who saw less than or equal to 100 beneficiaries. In response to stakeholder feedback on the challenges faced by solo practitioners, rural providers and small practice groups, CMS is now proposing to raise the low volume threshold bar to $90,000 or 200 beneficiaries.

Low Volume Threshold Qualifications for Exemption

CY 2017 Final Policy	CY 2018 Proposed Policy
≤ $30,000 in Part B allowed charges OR ≤ 100 Part B beneficiaries	≤ $90,000 in Part B allowed charges OR ≤ 200 Part B beneficiaries

CMS estimates that in 2018, 647,219 clinicians will be excluded from MIPS based on the low volume threshold exception.

CMS is also considering establishing an additional criterion for the low volume threshold exception which would be based on the number of items and services a MIPS eligible clinician provides to Part B beneficiaries.

For oncologists, this could result in a change to reflect “volume of therapy administration” or something similar. Specifically, CMS is considering defining items and services by using the number of patient encounters or procedures associated with a clinician. CMS is soliciting comments on methods to define items and services furnished by a clinician. Finally, CMS is also soliciting comments on a process for clinicians that meet the low volume threshold criteria to voluntarily opt-in to MIPS.

Performance Threshold for Payment in MIPS

Under the MIPS scoring system, a participant’s MIPS score ranges from 0 to 100 points, and the payment adjustment applied is based upon that score. The “performance threshold” represents the score that is needed to receive a neutral to positive payment adjustment for the year.

A score below the performance threshold will result in a negative payment adjustment; while a score above the payment threshold will result in a positive payment adjustment (a score at the payment threshold will result in a neutral payment adjustment).

For 2017, the performance threshold is three points, which can be earned by submitting a single Quality measure or attesting to performing one Improvement Activity for 90 consecutive days. CMS is now proposing to raise the performance threshold to 15 points for the 2018 Performance Period.

Continued Delay of the Cost Category

CMS assigned a zero weight to the cost category in 2017, due to implementation challenges, and to help clinicians ease into the QPP in Year 1.

For 2018, CMS proposes to maintain a zero percent weight on Cost on the Cost Performance Category. CMS explains that the MACRA statute requires a 30 percent weight for the Cost Performance category by 2021 that cannot be waived by the agency. As such, maintaining the zero percent weight for Cost for the 2018 Performance Period is expected to result in a sharp increase in the Cost Performance Category to 30 percent in Performance Period 2019. In order to avoid such a large change, CMS also seeks comments on an alternative approach of weighing the Cost category at 10 percent for 2018.

Virtual Groups

The MACRA statute allows CMS to establish “virtual groups” for purposes of reporting and measuring performance under MIPS. Virtual groups can be comprised of solo practitioners and small group practices that join together to report on MIPS requirements as a collective entity, and the members of a virtual group share the same financial adjustments as the result of that reporting. The statute envisioned this to be a way for smaller practices to pool resources and achieve efficiencies. CMS did not implement a virtual group option in 2017, but the agency is now proposing to do so for 2018.

CMS is proposing to allow solo practitioners and groups of 10 or fewer eligible clinicians to come together “virtually” with at least 1 other solo practitioner or group to participate in MIPS.

CMS notes that all National Provider Identifiers (NPIs) billing under the Tax Identification Number (TIN) joining the virtual group must participate. They are assessed collectively as a virtual group but only the NPIs that meet the definition of a MIPS eligible clinician would be subject to a MIPS payment adjustment.

Virtual groups may submit data through any of the mechanisms available to groups under the broader program requirements, such as a registry. While CMS did consider limiting the size of virtual groups, they are not proposing to put any limits on the number of TINs that may form a virtual group. Because of the lead-time needed to form a virtual group, CMS estimates the number of virtual groups will be very small in 2018 but will grow over time.

Advanced Alternative Payment Models (APMs)

Similar to the approach for MIPS, CMS largely maintains the framework for qualifying for the Advanced Alternative Payment Models (APMs) track while making minor modifications and expanding upon future program options. The most impactful changes included in this portion of the rule relate to (1) a minor modification in the nominal risk threshold requirement for the Medicare Medical Home track and (2) additional details on the forthcoming All Payer APM Option available beginning in 2021, including the qualifications and process for determining models that will count towards the Advanced APM participation threshold.

In the Proposed Rule, CMS reviews the requirements for qualifying for the Medicare APM Option, including the electronic health record utilization threshold, the quality measurement standard and the minimum threshold for meeting the nominal risk requirement. While the agency acknowledges that it intends to ramp-up the performance requirements in each of these categories eventually, it also notes that it believes eligible clinicians are still trying to understand how QPP works and advance towards the initial requirements. As such, the Proposed Rule maintains the 2017 requirements for the Medicare option under the Advanced APM track in 2018, specifically discussing the 8 percent threshold for the revenue-based nominal risk standard. However, the agency does seek comments on whether it should increase or decrease the revenue-based threshold in future years, as well as whether or not it should consider implementing a lower threshold for revenue-based, nominal risk for small or rural practices participating in APMs.

Generally Applicable Nominal Amount Standards for Advanced APMs and Other Payer Advanced APMs Finalized in the CY 2017 Quality Payment Program Final Rule

Advanced APMs

Other Payer Advanced APMs

Generally Applicable Nominal Amount Standard

For 2017 and 2018, nominal amount of risk must be at least equal to either:

8 percent of average estimated total Medicare Part A and Part B revenues of all providers and suppliers in participating APM entities; or
3 percent of expected expenditures for which the APM entity is responsible

Nominal amount of risk must be:

Marginal Risk of at least 30 percent;
Minimum Loss Rate of no more than 4 percent; and
Total Risk of at least 3 percent of the expected expenditures for the APM Entity is responsible

Implications for Oncologists

Potential for Virtual Groups for small practices
Bonus point potential for Complex Patients or use of 2015 CEHRT
Possibility for Other Payer APM in 2019
Support for Small Practices

Quality Payment Program Small, Underserved, & Rural Support (QPP-SURS)

CMS recognizes that small practices with 15 or fewer clinicians, including those in rural locations, health care professional shortage areas, and medically underserved areas are a crucial part of the health care system but will need additional support in QPP and other quality initiatives.

Quality Payment Program – Small, Underserved, & Rural Support (QPP-SURS) is one of four technical assistance (TA) programs funded by CMS to assure that eligible clinicians have access to for the support they need to prepare for MIPS and APMs. The TA offered by QPP-SURS is free-of-charge.

Each state or territory has an assigned QPP-SURS. Find out how to connect with the QPP-SURS for your state below:

MACRA Proposed Rule Summary: Impact for Oncologists

Published On: July 1st, 2017Categories: Issue Briefs & Overviews, Research & Publications

MACRA Proposed Rule Summary: Impact for Oncologists

Download PDF Version

Access the Full CMS QPP Proposed Rule

Access the Fact Sheet on the QPP Proposed Rule Compiled by CMS

Submit Comments to COA on the QPP Proposed Rule

Key Takeaways from CY 2018 QPP Proposed Rule

Merit-Based Incentive Payment System (MIPS)

Recall, that under Merit-Based Incentive Payment System (MIPS) by statute, clinicians will be measured in four performance categories:

Quality
Cost
Clinical Performance Improvement Activities
Advancing Care Information (ACI)

MIPS Performance Weights (CY 2017 Final and 2018 Proposed)

Quality	ACI*	Improvement Activities	Cost
60 percent	25 percent	15 percent	0 percent

Low Volume Threshold

Low Volume Threshold Qualifications for Exemption

CY 2017 Final Policy	CY 2018 Proposed Policy
≤ $30,000 in Part B allowed charges OR ≤ 100 Part B beneficiaries	≤ $90,000 in Part B allowed charges OR ≤ 200 Part B beneficiaries

CMS estimates that in 2018, 647,219 clinicians will be excluded from MIPS based on the low volume threshold exception.

Performance Threshold for Payment in MIPS

Continued Delay of the Cost Category

CMS assigned a zero weight to the cost category in 2017, due to implementation challenges, and to help clinicians ease into the QPP in Year 1.

Virtual Groups

CMS is proposing to allow solo practitioners and groups of 10 or fewer eligible clinicians to come together “virtually” with at least 1 other solo practitioner or group to participate in MIPS.

Advanced Alternative Payment Models (APMs)

Generally Applicable Nominal Amount Standards for Advanced APMs and Other Payer Advanced APMs Finalized in the CY 2017 Quality Payment Program Final Rule

Advanced APMs

Other Payer Advanced APMs

Generally Applicable Nominal Amount Standard

For 2017 and 2018, nominal amount of risk must be at least equal to either:

8 percent of average estimated total Medicare Part A and Part B revenues of all providers and suppliers in participating APM entities; or
3 percent of expected expenditures for which the APM entity is responsible

Nominal amount of risk must be:

Marginal Risk of at least 30 percent;
Minimum Loss Rate of no more than 4 percent; and
Total Risk of at least 3 percent of the expected expenditures for the APM Entity is responsible

Implications for Oncologists