A Guide to Reporting on MACRA in 2018

On Nov. 2, 2017, CMS released a final rule with updates to 2018 reporting requirements under MACRA’s Quality Payment Program (QPP). Changes finalized for the 2018 QPP reporting period impact Medicare reimbursement penalties and incentives applied to the 2020 payment period for eligible clinicians.

In the rule, CMS projects that equal distributions of $118 million in positive and negative adjustments will be issued to providers reporting via the QPP’s Merit-based Incentive Payment System (MIPS). Another $500 million in additional incentives is available for clinicians who demonstrate “exceptional performance” under MIPS.

The 2018 final rule largely cements MIPS reporting provisions laid out in the proposed rule released earlier this year. According to CMS estimates, roughly 622,000 eligible clinicians will be required to report under MIPS in 2018. Another 540,000 clinicians are expected to fall below revised low-volume exemption thresholds set forth in the new rule, which exclude clinicians and groups receiving less than $90,000 in Medicare Part B reimbursement or treating fewer than 200 Part B beneficiaries.

While CMS extended several flexibilities designed to lessen provider participation burden, other updates in the rule decidedly push things forward. Changes to the QPP’s second reporting period include:

• Requirements that clinicians report a full year of quality metrics
• Introduction of the Cost category to MIPS scoring
• Overall performance threshold increase from 3 points in the 2017 transition year to 15 points in the 2018 reporting period

Providers who have been hesitant to embrace MACRA will have to act quickly to prepare for quality reporting for the full year in 2018. CMS’ decision to introduce Cost to 2018 MIPS scoring may surprise providers who were hopeful the category would be pushed back another year. MACRA mandates requiring that Cost account for 30 percent of overall MIPS scores by the 2019 reporting period likely prompted the 10 percent weighting in 2018 as a means to help providers acclimate to the new category.

MIPS Scoring in 2018: Per the final rule, MIPS scoring categories for the 2018 reporting are listed below, with several highlighted updates within each:  

Quality (50 percent)

• 9 new Quality measures adopted
• 6 topped-out Quality measures identified for the 2018 performance period
• Up to 10 percentage points available for Quality performance improvement from 2017 to 2018
• “Completeness of reporting” threshold on quality measures raised from 50 to 60 percent

Advancing Care Information (25 percent)

• Use of 2014 or 2015 Certified EHR Technology (CEHRT) allowed with bonus points applied for sole use of 2015 CEHRT
• ACI hardship exceptions extended to small practices, hospital and ambulatory-based clinicians, and those whose health records were decertified (ACI category weight added to Quality)

Improvement Activities (15 percent)

• New measures added for a total of 112 IA activities
• Patient-Centered Medical Home IA activity threshold set at 50 percent of practice sites certified

Cost (10 percent)

• Up to 1 percentage point available for Cost performance improvement from 2017 to 2018 (as calculated by CMS)
• CMS working to identify new measures to replace the 10 episode-based Cost measures adopted in the 2017 reporting period

Updates also introduced new specialty metrics and patient satisfaction measures. Facility-based scoring options for quality and cost categories (for clinicians whose primary responsibilities are in an inpatient hospital or emergency room setting) are delayed to 2019, as are allowances for multiple submission mechanisms per reporting category.

Additional provisions in the final rule affecting the MIPS reporting track include:

• Bonus points: Clinicians who treat complex patients and small practices (those with 15 or fewer clinicians) that submit data on at least one performance category will receive a five-point bonus to their overall score.
• Virtual groups: Two or more Taxpayer Identification Numbers (TINs)- including solo practitioners and groups of 10 clinicians or less - can come together “virtually” to participate in MIPS in 2018.
• Hardship exemptions: CMS established an “extreme and uncontrollable circumstances” policy to give reporting reprieve to providers impacted by natural disasters in the 2017 performance period.

CMS continues to walk the fine line between advancing value-based program initiatives and allowing clinicians time to adapt. Stakeholders have expressed concern that broader exclusions from participation due to revised Medicare volume thresholds may be slowing down adoption. Others are concerned that rolling into the 2018 reporting period prior to receiving feedback on 2017 performance may send providers down the wrong path. Payment adjustments for the 2020 payment year, as determined by 2018 MIPS reporting, will impact clinician Medicare reimbursement to the tune of plus or minus 5 percent.

About the AuthorKerri Wing, RN, brings over 16 years of clinical experience to her role as Director of Clinical Analytics for Advantum Health. Prior to joining Advantum, Kerri acted as a subject matter expert in Product Management at Greenway Health and as Director of Clinical Transformation at a 300-provider, multi-specialty practice group. Kerri’s areas of expertise include Meaningful Use, PQRS, MACRA, MIPS, clinical data collection and quality reporting, clinical requirements assessment, and analytics. She holds a Masters in Health Administration Informatics from the University of Maryland.

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