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ASCRS and Medical Community Advocacy Prompts CMS to Continue MIPS Transition Flexibility in 2018 so Physicians Can Easily Avoid 2020 Penalties, But Unfortunately Increases Cost Category Weight to 10%

As we alerted you last evening, CMS released the 2018 Quality Payment Program (QPP) Year 2 final rule, which includes the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). CMS continued its efforts to reduce the regulatory burden through its “Patients Over Paperwork” initiative and finalized many of the proposals supported by ASCRS that would ease the transition to the MIPS program and reduce reporting burden, specifically for small practices. Disappointingly, CMS did not finalize its proposal to keep the 2018 Cost category weight at 0%, and instead the Category will count for 10% of the MIPS final score in 2018 to impact 2020 payments.

Transition Flexibility to Avoid Penalties

The final rule sets the 2018 MIPS performance threshold at 15 points. Following ASCRS and medical community recommendations, CMS elected to use the transition flexibility the MACRA statute offers for the first two years of the program to set a low threshold so most physicians will avoid a penalty by submitting minimal data. CMS is extending its 2017 policy to set a quality measure “floor” of three points, so a physician or group could avoid the 2020 5% MIPS penalty by submitting five quality measures each on one patient to meet the 15-point MIPS threshold. In addition, submitting one high-weighted improvement activity or a combination of the base score of the Advancing Care Information category and some quality measures would qualify to avoid a penalty. CMS finalized extending the performance period to a full year for the Quality and Cost measures, but maintained a 90-day performance period for Improvement Activities and ACI.

Cost Category

Despite widespread support for CMS’s original proposal not to include Cost in the 2018 score, CMS will increase the weight to 10% in an effort to create a more gradual transition to 2019, when the MACRA statute requires it be worth 30% of the MIPS final score. ASCRS and the medical community continue to oppose the measures included in this category, which were first used in the Value-Based Payment Modifier, because they are primary care-based, potentially hold physicians responsible for the cost of care they did not provide and they are not risk adjusted. CMS will not score physicians on the episode measures previously finalized in 2017 because new measures are currently being developed and tested, including for cataract surgery. Because of the attribution methodology that first attributes patients to a primary care provider, and if the beneficiary did not see a primary care provider in the performance year then attributes them to the physician who billed the plurality of E/M services, some ophthalmologists will not have enough beneficiaries attributed to them to meet the case minimums for one or both measures in the category. If a physician has no measures attributed in the Cost category, the 10% weight of the category is reassigned to the Quality category.

Reduced Burden for Small Practices

CMS clarified in the final rule that practice size determinations would only be made on the number of MIPS-eligible clinicians in the TIN. Therefore, any physicians excluded from MIPS because they are Advanced APM participants or are in their first year of practice will not be included in the group size. ASCRS and the medical community have been advocating for Congress to make a technical correction to the MACRA statute that would have addressed this, however, CMS determined it had the regulatory authority to make the change in the final rule. In addition, CMS will institute a small practice hardship exemption for the ACI category, and a small practice 5-point bonus on the MIPS final score.

Quality Category Reporting Threshold

In another reversal from the proposed rule, CMS will increase the Quality category data completeness thresholds to 60% of all patients for EHR and registry reporting and 60% of Part B patients for claims reporting. It is important to remember that based on the quality measure benchmarks, physicians will likely have to report on even higher thresholds of patients to achieve full credit in the category.

MIPS Eligibility Determinations and Payment Adjustments

In this final rule, CMS clarified that items and services furnished under Part B, including drugs administered in the physician's office, are included in the MIPS eligibility determinations and payment adjustments. Therefore, CMS will determine a physician's eligibility in MIPS on the total cost of items and services furnished and will make bonus payments or penalty reductions on all reimbursements including Part B drugs. ASCRS and the medical community oppose this policy and are seeking Congressional action to change the MACRA statute so only physician services are included in MIPS payment adjustments or eligibility determinations.

Interim Final Rule for Disaster Relief

Noting the extreme weather conditions experienced in CY 2017, which likely disrupted physician practices significantly, CMS included an interim final rule that creates an automatic MIPS hardship exemption, without having to submit an application, for physicians in disaster areas. Physicians in affected areas may still submit MIPS data and be scored, but will not be penalized if they do not submit data in 2017. In addition, the final rule extends the ability to apply for a disaster-related exemption for ACI into 2018.

Resources for ASCRS•ASOA Members

ASCRS•ASOA will continue to review this final rule and will also be updating our comprehensive guides for 2018. We will release them shortly. If you need additional information on the MACRA program, visit ASCRS•ASOA's MACRA Center web page, call the MACRA hotline at 703-383-5724, or email Allison Madson at