The 2018 updates to the Quality Payment Program established by MACRA were published on June 30, 2017. In general, the Centers for Medicare & Medicaid Services (CMS) has lowered thresholds for participation and positive adjustments under the Merit-based Incentive Payment System (MIPS) in 2018 compared to the original plan, and in some cases delayed or eased other aspects of implementation.
MACRA is legislation that was passed with bipartisan support in 2015, and the proposed rule carries no suggestion that the foundation of payment adjustments or bonuses based on quality is going to change. Here are some highlights of the proposed rule that are likely to get finalized in the fall—and the possible impact on urology providers. (For more on this rule, see “Proposed MIPS rule modifies 2018 requirements.")
Payment, patient thresholds set for change
Providers who see few patients or payments from traditional Medicare fee for service may be exempt from MIPS. CMS has proposed to raise that threshold for exemption from $30,000 to $90,000 per year in 2018 and raise the patient threshold from 100 to 200 payments—thus excluding more providers from MIPS.
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Urologists should be aware that should they elect to report individually, rather than as a group, many non-physician providers (nurse practitioners, physician assistants) could fall below these thresholds and be exempt. On the other hand, the threshold is the same for individuals and groups, so group reporting would likely subject these low-volume providers to inclusion in MIPS. Low-volume providers may opt in to the MIPS program and may consider doing so if they feel confident in their ability to receive a positive adjustment.
CMS has proposed maintaining the same weights for the four categories that comprise the MIPS composite score in 2018: Quality, 60%; Cost, 0%; Advancing Care Information, 25%; and Improvement Activities, 15%. The Quality category will continue to contribute the majority of weight to MIPS in 2018, is arguably complex, and now will be reported for 12 months. The Cost category is perhaps the least understood and by statute must comprise 30% of the weight in 2019. Urologists should become familiar with their Quality Resource and Utilization Report available from CMS. This report is the closest approximation of a predictor for performance in the Cost category under MACRA and contains rich patient, physician, and hospital-level detail about patients attributed to each provider in the practice (by tax ID number).
CMS has delayed the required use of 2015 certified EHR technology until 2019 in the proposed rule. This welcome change means that practices may continue to use 2014 certified technology. Those that have already switched may receive a bonus under MIPS if the proposed changes are finalized. CMS has not suggested that it will abandon the 2015 certification standard—just delayed it.
In the 2018 proposed rule, CMS has clarified that the MIPS adjustment would apply to Medicare fee-for-service payments including, in those cases where they can be attributed to a provider, Part B drug payments. Inclusion of drug payments is a departure from traditional payment policy under the Physician Quality Reimbursement System and Meaningful Use program, and this provision may not be finalized in its current form. The impact on urology would not be as significant as on other specialties such as medical oncology (table).
Urologists projected to fare well
CMS has estimated that urologists as a group would fare well in the 2018 performance year/2020 payment year of MIPS. According to their participation assumptions modelled on experience with the Physician Quality Reporting System, 96% of urologists are projected to receive a neutral or positive adjustment, and 72% of urologists may receive an exceptional payment adjustment in 2020. Approximately 8,254 urology clinicians are projected to earn an aggregate $18 million and about 335 urology clinicians would be penalized an aggregate $3.4 million in 2020, according to these estimates.
These estimates do include payments for Part B drugs, which in aggregate amount to about 14% of Part B payments in urology but may vary widely depending on the practice.
An analysis of the 2015 Medicare Physician Aggregate payments file (available from CMS) indicates that the average total Medicare payments in that year were $192,000 per urology provider (National Provider Identifier). The adjustment in 2018 may range from –5% to +5%, so on average a typical urologist may gain/lose up to $9,600 (before an exceptional payment adjustment). Exclusion of drugs would again change these numbers.
Bottom line: CMS has proposed some relaxation in the implementation schedule for MACRA/MIPS, and most urologists are projected to perform well or even exceptionally in the early years of the program. Urologists may wish to take advantage of the delayed implementation to investigate their cost performance and prepare for the future when this category will contribute significantly to the Quality Payment Program.
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