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Stakeholders Seek Common Changes to Quality Payment Program

Stakeholders have called for numerous changes to the Quality Payment Program in 2018, many of which are similar.

Quality Payment Program

Source: Thinkstock

By Kate Monica

- CMS is currently gearing up to finalize the Quality Payment Program (QPP) proposed rule for 2018.

Released in June, the proposed rule seeks to simplify the second year of the program comprising the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) after scores of healthcare organizations had deemed the program overly-complex and burdensome for providers.

CMS listened to the concerns of providers across the country and care continuum and solicited feedback from over 100 stakeholder organizations to draft potential changes to existing program policies. 

The resulting 400-page proposal is aimed at easing provider concerns about certified EHR technology (CEHRT), promoting more collaboration between providers, and reducing MIPS reporting requirements for smaller practices — among other objectives.

Judging by initial responses from organizations such the American Hospital Association (AHA) and HIMSS, the proposed rule has met with success. Proposed changes to QPP hit on several areas in need of improvement, brightening prospects for providers — particularly those in small or rural practices — to meet reporting requirements and avoid being subject to penalties. 

READ MORE: MACRA’s Quality Payment Program to Support Health IT Progress

With the public comment period closing in the coming days, many organizations are taking a closer look at the proposed rule and providing final feedback, as well as recommendations on areas in need of further streamlining.

The following are some of the most frequently cited positive changes and recommendations to QPP from healthcare organization responses to the proposed rule:

Virtual groups

As part of the proposed rule, CMS suggested implementing virtual groups to encourage clinicians to work together to meet cost and quality requirements under MIPS.

Virtual groups are defined as a combination of two or more tax identification numbers (TINs) comprising a single practitioner or a group of 10 or fewer clinicians under one TIN that opts to form a virtual group with at least one other similar practitioner or group for one MIPS performance year.

Providers must formally create groups by December 1 prior to the start of the performance year they intend to go into effect. Additionally, virtual groups must establish a formal agreement between each member outlining expectations for the group.

READ MORE: CMS Opens Quality Payment Program Hardship Exception Application

Along with allowing for the simplified implementation of virtual groups, CMS also stated there will be no cap on the number of members in each group.

Healthcare associations both small and large have applauded this development.

In public comments submitted to CMS, the California Association of Physician Groups (CAPG) commended the decision to encourage collaboration between physician groups and lessen the load of quality and cost reporting requirements per group participant.

“CAPG strongly supports the creation of virtual groups with no limit on the overall size of the group,” wrote the association. “We have seen firsthand how successful and independent practice association model can be. Many of our IPA members have had strong outcomes in terms of improving quality and reducing cost trend in MA, while allowing clinicians to remain in their independent practices.”

Assisting independent practices in succeeding under MACRA is especially important considering physicians have pointed to federal regulations as one of the leading causes contributing to the downfall of the independent practice.

READ MORE: CMS Details Quality Payment Program Technical Assistance

 “We welcome the opportunity to begin to introduce this model in traditional Medicare and to allow clinicians to come together to take accountability for cost and quality as a group,” continued CAPG.

While CAPG is satisfied with the motion to implement virtual groups, the association sees opportunities for CMS to reduce the burden associated with establishing the groups. 

“We encourage CMS to simplify and streamline contracting and paperwork requirements for virtual groups to encourage their rapid formation,” it stated.

The National Committee for Quality Assurance (NCQA) also praised the federal organization’s efforts to simplify the implementation of virtual groups in its own comment submission. 

“This is a key step toward helping small practices advance toward accountable, team-based, patient-centered care models,” stated the committee in its letter to CMS.

Among the 11 recommendations detailed in its submission, the committee focused on the benefits of virtual groups as well as the additional changes CMS could make to reduce administrative burden for small and independent practices.

“We urge you to provide bonus points as incentive for clinicians to join Virtual Groups,” it continued. “We also urge you to encourage, rather than prohibit, low-volume clinicians’ participation in Virtual Groups.”

Similar to CAPG, NCQA also recommended ways CMS can improve its implementation of virtual groups.

“We urge you to provide bonus points as incentive for clinicians to join Virtual Groups,” it continued. “We also urge you to encourage, rather than prohibit, low-volume clinicians’ participation in Virtual Groups.”


 MIPS performance categories

MIPS performance categories in their current form have drawn criticism from several associations across the industry.

In particular, providers have inquired about the MIPS clinical improvement activities performance category.

As the only new performance category, providers are less familiar with improvement activities than with the other three MIPS performance categories.

To accommodate providers uncertain about this category, CMS has offered additional resources to clear up any lingering confusion regarding its requirements.

Improvement activities assess how often providers participate in activities geared toward improving clinical practices. Providers have the option to choose from a variety of activities to demonstrate their performance.

NCQA included a host of recommendations in its letter to CMS during the current public comment period.

Among them, NCQA requested that CMS offer full auto-credit to any practice that achieves NCQA Recognition by December 31 of a performance year, since NCQA requires practices seeking patient-centered medical home (PCMH) and patient-centered specialty practice (PCSP) status to perform improvement activities in alignment with CMS requirements for a minimum of 90 days.

In this way, these PCMH and PCSP groups demonstrate improvement activities requirements. By giving these groups auto-credit, CMS can reduce redundancies and streamline reporting for providers.

The Medicare Payment Advisory Committee (MedPAC) also submitted recommendations for potential adjustments to improvement activities.

In a letter to Congress, MedPAC highlighted that the degree of difficulty between MIPS performance categories varies widely. As a result, CMS may not meet their objectives if most physicians choose measures in which a high percentage of practices tend to score well.

"Many of these measures are poorly linked to outcomes of importance for beneficiaries and the program and, instead, reinforce the incentive in fee-for-service (FFS) Medicare to provide more services than are clinically necessary," stated MedPAC.

To resolve this issue, MedPAC recommended CMS use more population-based outcome measures and rely more on claims data and survey results than physician reporting.

Incorporating a focus on population health outcomes in the finalized QPP rule would offer CMS a more transparent look at participants’ clinical performance.

Streamlining and improving the effectiveness of MIPS performance categories has been a consistent objective of healthcare associations and federal organizations since MACRA implementation began.

Quality measures

In 2017, CMS required eligible clinicians to choose from nearly 275 quality measures to fulfill requirements that offer insight into how efficiently and thoroughly providers are administering care.

As part of the QPP proposed rule, CMS requires eligible clinicians to meet a data completeness requirement of at least 50 percent of all eligible patients per measure, which the organization intends to raise to 60 percent for the 2019 MIPS performance period.

NCQA supports this move, but requests CMS raise the bar higher even sooner for data completeness.

“We support the proposal to raise the measure data completeness requirement to at least 50% of all eligible patients per measure, and urge you to consider raising it further to 60% for CY 2018 and continuing to raise that threshold over time,” wrote the committee. “As outlined above, reporting on one hundred percent of eligible patients is critical to identification of topped out measures and prevention of gaming.”

Whereas NCQA wants CMS to elevate aspects of quality reporting and quality data completeness, physician-led organizations such as the American Academy of Family Physicians (AAFP) seek even more simplicity.

“Use only the core measure sets developed by the multi-stakeholder Core Quality Measures Collaborative to ensure alignment, harmonization, and the avoidance of competing quality measures among payers,” urged the Academy.  

Similar to MedPAC, AAFP also wants to see less variation in provider expectations.

“Require all physicians participating in the MIPS program to meet the same program expectations and report on the same number of measures,” the organization recommended.

The healthcare organizations, physician associations, and stakeholder groups that have responded to the CMS request for comment so far have called for further structural simplicity across the board. Additionally, responding organizations want an effort from CMS to fashion the program to be more transparently representative of the quality and value of provider performance, and less likely to lead to complacency on the part of clinicians.

With the comment period closing on Monday, CMS will have the resources necessary to finalize QPP requirements for 2018. 



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